Percutaneous transcatheter aortic valve implantation for degenerated surgical bioprostheses: the first case series in Asia with one-year follow-up

<p><b>INTRODUCTION</b>Percutaneous transcatheter aortic valve implantation (TAVI) has become an established therapy for inoperable and high-surgical-risk patients with severe aortic stenosis. Although TAVI in patients with degenerated surgical aortic bioprostheses (i.e. valve-in-valve TAVI) is increasingly reported in Western studies, such data is lacking in Asian patients. We describe the initial experience of valve-in-valve TAVI in Asia.</p><p><b>METHODS</b>Eight patients who underwent valve-in-valve TAVI due to degenerated aortic bioprostheses were enrolled. The mechanism of bioprosthetic valve failure was stenotic, regurgitation or mixed. All procedures were performed via transfemoral arterial access, using the self-expanding CoreValve prosthesis or balloon-expandable SAPIEN XT prosthesis.</p><p><b>RESULTS</b>The mean age of the patients was 71.6 ± 13.2 years and five were male. Mean duration to surgical bioprosthesis degeneration was 10.2 ± 4.1 years. Valve-in-valve TAVI was successfully performed in all patients. CoreValve and SAPIEN XT prostheses were used in six and two patients, respectively. There were no deaths, strokes or permanent pacemaker requirement at 30 days, with one noncardiac mortality at one year. All patients experienced New York Heart Association functional class improvement. Post-procedure mean pressure gradients were 20 ± 11 mmHg and 22 ± 8 mmHg at 30 days and one year, respectively. Residual aortic regurgitation (AR) of more than mild severity occurred in one patient at 30 days. At one year, only one patient had mild residual AR.</p><p><b>CONCLUSION</b>In our experience of valve-in-valve TAVI, procedural success was achieved in all patients without adverse events at 30 days. Good clinical and haemodynamic outcomes were sustained at one year.</p>

Thoracic complications of radiofrequency ablation of recurrent hepatoma

<p><b>INTRODUCTION</b>Radiofrequency ablation (RFA) for unresectable primary or secondary hepatic malignancies have gained widespread availability and acceptance over the past 5 years. Complication rates have been reported to range from 0% to 27%.</p><p><b>CLINICAL PICTURE</b>We report a patient with symptomatic right pleural effusion due to a diaphragmatic fistula and another with biliptysis post-RFA, for recurrent hepatoma.</p><p><b>TREATMENT</b>Percutaneous drainage of both the pleural effusion and biloma was performed. However, surgical repair of the diaphragmatic fistula was only required for the former for persistent drainage.</p><p><b>OUTCOME</b>Both patients were successfully treated with minimal morbidity.</p><p><b>CONCLUSION</b>High index of suspicion is required for the early diagnosis and treatment of diaphragmatic fistulas. Simple catheter drainage can potentially obviate the need for surgery.</p>

Paradoxical orthodeoxia in a patient with a large thoracic aortic aneurysm

<p><b>INTRODUCTION</b>Orthodeoxia is a rare clinical syndrome characterised by dyspnoea and arterial deoxygenation that accompanies a change from a supine to erect position.</p><p><b>CLINICAL PICTURE</b>We describe an unusual case of "paradoxical orthodeoxia" in a 70-year-old man with a thoracic aortic aneurysm: arterial desaturation when supine that improved when erect.</p><p><b>TREATMENT AND OUTCOME</b>Non-invasive imaging revealed compression of the left pulmonary artery by the aneurysm (thoracic computed tomography) and patent foramen ovale (transesophageal echocardiography). Nuclear studies show decreased relative left lung perfusion attributable to the former, and right-to-left atrial shunt attributable to the latter. The degree of right-to-left shunt increases in the supine position: nuclear pulmonary shunt study shows shunt extent of 21% when supine versus 10% erect.</p><p><b>CONCLUSION</b>A physioanatomical explanation is proposed.</p>