Transcatheter aortic valve replacement in a patient with pre-existing left ventricular pseudoaneurysm: the importance of pre- and intra-procedural imaging

An 85-year-old man with a history of myocardial infarction and coronary bypass surgery presented with severe symptomatic aortic stenosis. Echocardiography revealed pressure gradients of 73/40 mm Hg across the aortic valve, an aortic valve area of 0.74 cm2, and a 35% ejection fraction.

Traumatic transcatheter aortic valve replacement.

A 76-year-old female with severe symptomatic aortic stenosis underwent cardiac CT angiography imaging. Severe calcification of the ascending aorta (porcelain aorta) (Figures 1A and 1B) precluded surgical aortic valve replacement. The aortic annular area, perimeter, and diameter were 372 mm2, 68.5 mm, and 20 mm, respectively. Transcatheter aortic valve replacement (TAVR) was performed with direct implantation of a 23 mm Sapien S3 valve (Edwards Lifesciences). The valve was delivered via the right femoral artery and a pigtail catheter was delivered to the aortic root via the left femoral artery. The balloon ruptured during valve implantation (Video).

Strategy for Totally Percutaneous Management of Vascular Injury in Combined Transfemoral Transcatheter Aortic Valve Replacement and Endovascular Aortic Aneurysm Repair Procedures.

Minimally invasive treatment of severe aortic stenosis by transcatheter aortic valve replacement (TAVR) and infrarenal abdominal aortic aneurysm by endovascular aortic aneurysm repair (EVAR) requires large-bore vascular access. These percutaneous transfemoral interventions may be performed as a combined procedure, however, vascular injury may necessitate surgical vascular repair. We implemented a strategy designed to enable percutaneous vascular repair, with stent-graft implantation, if necessary, after these combined procedures. We identified all combined percutaneous TAVR and EVAR procedures which were performed at our institution. Patient and procedural characteristics and clinical outcomes were analyzed. Six consecutive patients underwent total percutaneous combined TAVR and EVAR procedures. In all cases, TAVR was performed first and was followed by EVAR. Both common femoral arteries served as primary access sites for delivery of the implanted devices and hemostasis was achieved by deployment of vascular closure devices. Secondary access sites included the right brachial artery in all patients and superficial femoral arteries in 50% of the patients. In all cases an "0.014" 300-cm length "safety" wire was delivered to the common femoral artery or descending aorta by way of a secondary access site to facilitate stent graft delivery. Successful device implantation was achieved in all cases. Vascular closure device failure occurred in 2 patients and was treated by stent graft implantation by way of the brachial and superficial femoral arteries, without need for surgical vascular repair. A strategy designed to facilitate percutaneous vascular repair after combined EVAR and TAVR procedures may enable a truly minimally invasive procedure.

Pericardial constriction with calcified cystic mass compressing the right ventricle and right coronary artery.

Constrictive pericarditis is characterized by fibrosis and calcification of the pericardium that progressively impair the diastolic filling of the heart, causing heart failure. Uncommonly, pericardial constriction may be localized leading to a focal cystic mass formation that may compress nearby cardiac structures. We describe a unique case of a patient presenting with right heart failure due to idiopathic calcific constrictive pericarditis that was associated with a large pericardial cystic mass compressing the right ventricular free wall. This led to reduced cardiac output and possibly severe focal stenosis of the proximal right coronary artery that was resolved after pericardiectomy, the only definitive treatment for chronic progressive constrictive pericarditis. .

Multimodality imaging in subclavian steal syndrome.

Subclavian steal syndrome is a rare vascular cause of recurrent effort-related syncope events, affecting ~2% of the general population. Here, we report a case of a 64-year-old male who was hospitalized because of recurrent effort-related syncope events. Physical examination revealed several characteristic clinical clues for subclavian steal syndrome. Indeed, through the use of multimodality imaging, the diagnosis was established. We demonstrate that the combination of history taking, thorough physical exam and subsequent imaging studies can establish a relatively rare diagnosis of recurrent syncope.

Five Hours of Resuscitation With 150 Electrical Shocks and Complete Recovery.

BACKGROUND: Myocardial ischemia may lead to lethal arrhythmias. Treatment of these arrhythmias without addressing the cause of ischemia may be futile. The length of resuscitation is an important parameter for determining when to stop resuscitation but with shockable rhythms and reversible cause of the cardiac arrest, the decision to terminate resuscitation is complex.  Case Summary: A patient with a three-month history of shortness of breath with effort developed pulseless ventricular tachycardia (VT) at the early stages of a stress test. In coronary angiography, a critical lesion in the right coronary artery (RCA) was observed and treated with two stents. During the procedure and for a total of five hours, the patient had more than 100 separate episodes of VT and ventricular fibrillation (VF) that were treated by 150 defibrillations, artificial ventilation, intra-aortic counter-pulsation balloon insertion, and multiple drugs. One hour after the initial stenting procedure, thrombosis of the RCA was demonstrated and treated successfully with angioplasty. Use of procainamide resolved the arrhythmias and the patient recovered completely without neurological deficit, ejection fraction of 45%, and is asymptomatic at one year following the event. DISCUSSION: Our case shows that with a revisable cause of cardiac arrest, resuscitation should be directed at maintaining perfusion of essential organs and treating the reversible cause. Without re-opening the RCA, we could not have saved the patient's life. The use of an extracorporeal membrane oxygenator, if available, should be considered in similar cases. Finally, the quality of cardiopulmonary resuscitation determines the neurological outcome regardless of the length of resuscitation, as was evident in our patient who recovered completely.

Lupus myocarditis in an octogenarian patient-a case report.

Lupus myocarditis is a relatively rare manifestation of systemic lupus erythematosus. The majority of patients who experience myocardial involvement are females of young age. Here, we report a case of an 87-year-old male who was hospitalized because of perimyocarditis 2 weeks after undergoing percutaneous coronary intervention. Despite standard therapy his condition worsened, biomarkers and inflammation indices remained elevated, and pericardial effusion accumulated. The use of cardiac magnetic resonance (CMR) imaging, along with thorough history taking and testing for relevant antibodies allowed to establish the unusual diagnosis of lupus myocaridits. We demonstrate that lupus myocarditis may occur even in elderly males, as supported by characteristic CMR features.

Clinical features and outcomes of revascularization in very old patients with left main coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) is often more extensive in older adults and may involve multivessel and left main coronary artery (LMCA) disease. Elderly patients are commonly excluded from clinical trials, and limited real-world data exist on the management of LMCA disease in the very old. We aimed to investigate clinical features and outcomes of very old patients undergoing revascularization due to LMCA disease. PATIENTS AND METHODS: A retrospective single-center analysis of patients at least 80 years (n = 139) who underwent revascularization owing to CAD involving unprotected LMCA stenosis more than 50% was conducted. Subsequent major adverse cardiovascular events (MACE: myocardial infarction, stroke, and all-cause death) and repeat revascularizations were recorded, and their relation to revascularization procedure was studied. RESULTS: Percutaneous coronary intervention (PCI) was performed in 74 patients and coronary artery bypass surgery (CABG) in 65. Most patients (80%) had multivessel disease involving at least 2 additional coronary arteries. PCI was associated with older age, higher rates of baseline disability, previous revascularization, reduced ventricular function, significant aortic stenosis, and presentation with acute coronary syndrome, compared with CABG. Cumulative 3-year MACE rates were higher in patients undergoing PCI versus CABG (P = 0.009). After multivariable adjustment, predictors of MACE included presentation with ST-segment elevation myocardial infarction (STEMI) [hazard ratio (HR) = 2.39; 95% confidence interval: 1.24-4.63; P = 0.010], revascularization by PCI compared with CABG [HR = 2.21 (1.18-4.15); P = 0.013], baseline disability [HR = 2.17 (1.20-3.91); P = 0.010], and distal LMCA disease [HR = 1.87 (1.04-3.38); P = 0.038]. The difference in 3-year MACE between PCI and CABG was not observed in a propensity-score analysis of 90 patients matched 1: 1 for baseline disability, STEMI, and aortic stenosis (P = 0.797). CONCLUSION: In very old patients undergoing coronary revascularization owing to LMCA disease, PCI was associated with worse cardiovascular outcomes compared with CABG, influenced by a more severe and comorbid population selected for PCI. Baseline disability, presentation with STEMI, and distal LMCA bifurcation disease were additional independent outcome predictors.

An Intervention to Reduce the Time Interval Between Hospital Entry and Emergency Coronary Angiography in Patients with ST-Elevation Myocardial Infarction.

BACKGROUND: Outcomes of patients with acute ST-elevation myocardial infarction (STEMI) are strongly correlated to the time interval from hospital entry to primary percutaneous coronary intervention (PPCI). Current guidelines recommend a door to balloon time of < 90 minutes. OBJECTIVES: To reduce the time from hospital admission to PPCI and to increase the proportion of patients treated within 90 minutes. METHODS: In March 2013 the authors launched a seven-component intervention program:  Direct patient evacuation by out-of-hospital emergency medical services to the coronary intensive care unit or catheterization laboratory Education program for the emergency department staff Dissemination of information regarding the urgency of the PPCI decision Activation of the catheterization team by a single phone call Reimbursement for transportation costs to on-call staff who use their own cars Improvement in the quality of medical records Investigation of failed cases and feedback. RESULTS: During the 14 months prior to the intervention, initiation of catheterization occurred within 90 minutes of hospital arrival in 88/133 patients(65%); during the 18 months following the start of the intervention, the rate was 181/200 (90%) (P < 0.01). The respective mean/median times to treatment were 126/67 minutes and 52/47 minutes (P < 0.01). Intervention also resulted in shortening of the time interval from hospital entry to PPCI on nights and weekends. CONCLUSIONS: Following implementation of a comprehensive intervention, the time from hospital admission to PPCI of STEMI patients shortened significantly, as did the proportion of patients treated within 90 minutes of hospital arrival.

Telemedicine for multiple sclerosis patients: assessment using Health Value Compass.

BACKGROUND: Telemedicine carries the potential of improving accessibility to health services, especially for disabled people. OBJECTIVE: To assess the health-related outcomes of short-term implementation of telemedicine (telemed) for MS patients. METHODS: A prospective study of 40 MS patients divided into a control group and a telemed group was conducted, in two stages: A. Six months' follow-up for measurement of baseline health-related variables; B. Implementation stage, adding home telecare to the telemed group. A Health Value Compass was applied to assess the outcomes of home telecare implementation. Clinical status, cost data, patients' self-assessment of Health Related Quality of Life (HRQoL) and satisfaction with telecare were studied. RESULTS: Patients in the telemed group demonstrated improved clinical outcome measured by symptoms severity. There was a decrease of at least 35% in the medical costs for 67% of the telemed group patients. Satisfaction with telecare was high and most patients would recommend this service to others. CONCLUSIONS: The present pilot study, applying Health Value Compass-based analysis, suggests that telecare is a powerful tool for monitoring MS patients at home, carries the potential to improve health care while reducing costs, and should be considered for implementation as part of the management of chronic neurological diseases.