MICRA AV implantation after transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has evolved as a breakthrough therapy for patients with severe aortic valve stenosis. While TAVR has revolutionized the management of aortic valve disease, the procedure may be associated with the development of conduction disturbances requiring permanent pacemaker implantation. Traditionally, conventional transvenous pacemakers have been used to address these complications. However, the introduction of leadless pacemaker technology, such as the MICRA Transcatheter Pacing System (TPS), offers a novel alternative. MATERIALS AND METHODS: This was a retrospective single-center study where all patients who underwent TAVR at our center and subsequently required permanent pacemaker implantation within 30 days were reviewed. We included only the patients who underwent leadless pacemaker placement. We then conducted a retrospective chart review to identify patient and procedural characteristics, procedural details, and relevant clinical outcomes. RESULTS: A total of 9 patients were identified. All of the patients underwent MICRA AV placement within 30 days post-TAVR by an interventional cardiologist. The average age of the cohort was 79.6 years with an average STS score of 3.7 %. The majority of the patients received balloon-expandable valves (78 %). There were no procedural complications in any of the patients. At an average follow-up of 353 days, capture thresholds and lead impedance remained stable with an average RV pacing of 13 %. CONCLUSION: This small, retrospective cohort demonstrates that the use of MICRA AV leadless pacemakers is feasible after TAVR and is associated with low periprocedural complications. Leadless pacemakers provide stable pacing thresholds and AV synchrony.

Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator.

BACKGROUND: Prosthetic valve thrombosis during pregnancy is life-threatening for mother and fetus, and the treatment of this complication is unclear. Cardiac surgery in pregnancy is associated with very high maternal and fetal mortality and morbidity. Thrombolytic therapy has rarely been used in these patients. The aim of this study is to evaluate the safety and efficacy of low-dose (25 mg), slow infusion (6 hours) of tissue-type plasminogen activator for the treatment of prosthetic valve thrombosis in pregnant women. METHODS AND RESULTS: Between 2004 and 2012, tissue-type plasminogen activator was administered to 24 consecutive women in 25 pregnancies with 28 prosthetic valve thrombosis episodes (obstructive, n=15; nonobstructive, n=13). Mean age of the patients was 29±6 years. Thrombolytic therapy sessions were performed under transesophageal echocardiography guidance. The mean dose of tissue-type plasminogen activator used was 48.7±29.5 mg (range, 25-100 mg). All episodes resulted in complete thrombus lysis after thrombolytic therapy. One patient had placental hemorrhage with preterm live birth at the 30th week, and 1 patient had minor bleeding. CONCLUSIONS: Low-dose, slow infusion of tissue-type plasminogen activator with repeated doses as needed is an effective therapy with an excellent thrombolytic success rate for the treatment of prosthetic valve thrombosis in pregnant women. This protocol also seems to be safer than cardiac surgery or any alternative medical strategies published to date. Thrombolytic therapy should be considered first-line therapy in pregnant patients with prosthetic valve thrombosis.

Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: the TROIA trial.

OBJECTIVES: The aim of this prospective study was to identify the most effective and safest regimen among different thrombolytic treatment strategies. BACKGROUND: The best treatment strategies for prosthetic valve thrombosis have been controversial. METHODS: Transesophageal echocardiography-guided thrombolytic treatment was administered to 182 consecutive patients with prosthetic valve thrombosis in 220 different episodes (156 women; mean age, 43.2 ± 13.06 years) between 1993 and 2009 at a single center. These regimens chronologically included rapid (Group I), slow (Group II) streptokinase, high-dose (100 mg) tissue plasminogen activator (t-PA) (Group III), a half-dose (50 mg) and slow infusion (6 h) of t-PA without bolus (Group IV), and a low dose (25 mg) and slow infusion (6 h) of t-PA without bolus (Group V). The endpoints were thrombolytic success, in-hospital mortality, and nonfatal complication rates. RESULTS: The overall success rate in the whole series was 83.2%; it did not differ significantly among Groups I through V (68.8%, 85.4%, 75%, 81.5%, and 85.5%, respectively; p = 0.46). The overall complication rate in the whole series was 18.6%. Although the overall complication rate was similar among Groups I through IV (37.5%, 24.4 %, 33.3%, and 29.6%, respectively; p > 0.05 for each comparison), it was significantly lower in Group V (10.5%, p < 0.05 for each). The combined rates of mortality and nonfatal major complications were also lower in Group V than in the other groups, with all differences significant except for comparison of Groups IV and V. By multivariate analysis, the predictors of combined mortality plus nonfatal major complications were any thrombolytic therapy regimen other than Group V (odds ratios for Groups I through IV: 8.2, 3.8, 8.1, and 4.1, respectively; p < 0.05 for each) and a history of stroke/transient ischemic attack (odds ratio: 3.5, p = 0.011). In addition, there was no mortality in Group V. CONCLUSIONS: Low-dose slow infusion of t-PA repeated as needed without a bolus provides effective and safe thrombolysis in patients with prosthetic valve thrombosis. (Comparison of Different TRansesophageal Echocardiography Guided thrOmbolytic Regimens for prosthetIc vAlve Thrombosis; NCT01451320).

A case of myocardial infarction due to acute left main coronary artery occlusion presenting with peculiar electrocardiographic changes.

Myocardial infarction (MI) due to acute obstruction of the left main coronary artery (LMCA) occlusion is a medical emergency, requiring early and prompt diagnosis and revascularization, and unless it is treated, it will frequently result in cardiogenic shock, which has a high fatality rate. Our case focused on a patient, who was transferred to our hospital relatively late due to peculiar ECG. He had acute MI, and was in cardiogenic shock. ECG is the easiest diagnostic method in the early diagnosis of the acute coronary syndromes and in deciding on the early invasive intervention in the high risk group. Before he was sent to us, the patient had an ECG showing right bundle branch block (RBBB) and a AVR ST segment elevation. At the time of the urgent coronary angiography, it was noticed that the LMCA was totally occluded. This case has been presented in order to emphasize that peculiar changes might bring about devastating consequences as in our rare case, showing acute left main coronary artery occlusion, and ST segment elevation only in the AVR on the 12-lead ECG along with upward deflection of ST segment vector might be critical for accurate diagnosis.

Complete off-pump coronary revascularization in patients with dialysis-dependent renal disease.

Patients who have dialysis-dependent renal disease frequently present with coronary artery disease but are considered at high risk for coronary artery bypass grafting. From 1 September 2000 through 31 August 2003, we performed complete off-pump coronary revascularization in 6 patients who had end-stage dialysis-dependent renal failure, and we prospectively studied the perioperative and early postoperative results. The effect of off-pump coronary artery bypass grafting on mortality, morbidity, postoperative complications, and transfusion requirements in this group of patients was investigated. No perioperative deaths or ischemic cardiac events were observed after off-pump coronary artery bypass grafting. In all patients, anginal symptoms were relieved during the postoperative period. The mean duration of follow-up was 172 +/- 12.4 months. Patients with dialysis-dependent chronic renal failure who present with coronary artery disease should be thoroughly evaluated preoperatively for risk factors and coexistent severe diseases. We believe that in patients with end-stage dialysis-dependent chronic renal failure, off-pump coronary revascularization is a good alternative.