RESUMO
Background Patent foramen ovale (PFO)-related stroke is a possible and not easily manageable occurrence in ≤60-years-old patients due to the presence of different comorbidities and in particular of diastolic dysfunction which is considered as a contraindication to PFO closure.The grade of diastolic dysfunction for which PFO closure is contraindicated and whether there are changes in diastolic dysfunction class after closure have not been investigated in deep yet.Methods We prospectively enrolled patients who were referred to our centre over a 12 months period for PFO transcatheter closure having echocardiographic demonstration of diastolic dysfunction (≤Ⅲ class diastolic dysfunction).Echocardiography was scheduled at 1,6 and 12 months in order to assess changes in haemodynamic parameters of left ventricle function.Results Thirteen out of 80 patients referred to our centre (16.2%,mean age 65 + 6.4 years) over a 24-month period were enrolled in the study (Table 1).Eighteen Amplatzer PFO Occluder 25 mm and one 35 mm,two Amplatzer 25/25 mm Cribriform Occluder and two 25 nun Premere Occlusion System were successfully implanted with no intraoperative complications.As collateral findings on ICE 8/12 patients (66.7 %) had hypertrophy of the interatrial septum (thickness of the rims ＞ 1.2 mm) probably imputable to hypertensive cardiomyopathy.Four patients developed atrial fibrillation during the first month post-implantation,all successfully treated with antiarrhythmic drugs.After a mean follow-up of 40±4.3 months left ventricle performance indices (ejection fraction and end-diastolic volume) and diastolic dysfunction parameters (E/A,deceleration time,diastolic dysfunction class) did not change significantly.Conclusion The present study suggests that PFO transcatheter closure may be safely performed in aged patients with diastolic dysfunction class 1-2.(J Geriatr Cardio12008;5:3-6.)
RESUMO
Background and Objective Elderly patients who have been submitted to coronary bypass grafting with the left internal mammary artery (LIMA) may develop a coronary-subclavian steal syndrome because of a left subclavian artery (LSA) stenosis. Usually stenting of LSA is performed by the standard femoral route with guiding catheter technique, but this technique can be particularly difficult in elderly patients who often have iliac-femoral kinking and aortic tortuosity. We compared a new ad hoc brachial artery approach technique with the standard guiding catheter technique through the femoral access. Methods Between January 2005 and September 2006, four patients underwent LSA stenting using the left brachial artery access obtained with a 6F or 7F 45-cm-long valved anti-kinking sheath as the Super Arrow Flex sheath (Arrow International, PA, USA). The sheath was positioned just before the LIMA graft ostium and a 0.035 inch 260-cm-long Storq guidewire (Cordis Inc., Johnson & Johnson, Warren, NJ) was advanced across the lesion to the descending aorta. A balloon-expandable Genesis (Cordis Inc., Johnson & Johnson, Warren, NJ) endovascular stent was easily deployed, and the correct position was checked by direct contrast injection through the long sheath. This small group of patients has been compared to a group of 5 age-matched patients with coronary steal syndrome in whom the procedure has been performed with standard technique including femoral approach and guide catheter. Results The procedure was successful in all patients; vertebral and LIMA ostia remained patent in all cases. In the control group, cannulation of the subclavian artery was difficult in two cases, while one patient developed a groin hematoma. Mean pretreatment gradient was 32 mm Hg with a range of 25 to 40 mm Hg (34 mmHg, range 26-43, in the control group, P=0.87) and fell to 2 mm Hg with a range of 0 to 4 mm Hg (3.1 mmHg, range 0 to 5, P=0.89) posttreatment. Mean contrast dose was 60±16 ml (138±26 ml in the control group, P＞0.01), whereas mean fluoroscopy and procedural time were 5.7±1.6 minutes (10.8±1.0 minutes in the control group, P＞0.01) and 15.7±6.3 minutes (28±7.1 minutes in the control group, P＞0.01). At a mean follow-up of 10±3.2 months all patients are alive and free from angina and residual induced ischemia. Conclusions Our brief study suggested that brachial artery access be considered the optimal route to treat coronary-subclavian steal syndrome in elderly patients because of clear advantages; these included no manipulation of catheter to cannulate the artery, perfect coaxial position of the catheter at the site of LSA stenosis, clear visualization of the LIMA and vertebral ostia, and easy access to these vessels in case of plaque shifting or embolic protection device deployment.