Percutaneous Aspiration of Vegetation in Tricuspid Valve Infective Endocarditis: A Possible Novel Treatment Option.

A 35-year-old man with a history of active intravenous drug use presented with infective endocarditis and tricuspid valve vegetations. He was a poor candidate for open heart surgery as a result of persistent bacteremia and comorbidities, and he underwent successful aspiration therapy with a mechanical thrombectomy device for the vegetation. (Level of Difficulty: Intermediate.).

Minimally Invasive Endovascular Repair of Ascending Thoracic Aortic Aneurysm with Use of Local Anesthesia and Conscious Sedation.

Ascending thoracic aortic aneurysm (ATAA) is typically treated surgically. No commercially available device has been specifically designed for endovascular ATAA repair, and currently, multiple anatomic and technical challenges affect its feasibility. Previously, such repairs have been performed with the patients under general anesthesia. We describe a novel, minimally invasive approach to endovascular repair of ATAA, involving local anesthesia, conscious sedation, and 24-hour hospitalization. Two consecutive male patients (ages, 79 and 54 yr) who had comorbidities underwent percutaneous transfemoral endovascular ATAA repair with use of commercially available endografts. Patient 1 had a saccular aneurysm, and Patient 2 had a pseudoaneurysm consequent to recent surgical ATAA repair. The patients were discharged from the hospital 24 hours after technically successful, uncomplicated procedures. At 2 months, computed tomograms showed no endoleak or stent-graft migration. Our experience shows that minimally invasive endovascular ATAA repair is feasible for selected high-risk patients. We describe the procedure, access and closure devices, and challenges associated with this approach.

Aorto-Right Ventricular Shunt after TAVR: Rare Complication of Common Procedure.

BACKGROUND: The primary treatment of symptomatic aortic stenosis is aortic valve replacement. Instead of open chest surgery, transcatheter aortic valve replacement (TAVR) is an alternative intervention for high-risk surgical candidates. CLINICAL CASE: A 92-year-old male presented with progressive exertional dyspnea and recurrent syncopal attacks secondary to severe AS. The patient underwent successful transfemoral TAVR with 29 mm Edwards SAPIEN XT valve. His postoperative course was complicated by aorto-right ventricular shunt. The patient's clinical course was followed up for one year. CONCLUSION: This case reports the incidence and clinical course of one of the rare complications of TAVR, aorto-right ventricular fistula. Conservative medical management is appropriate in hemodynamically stable patients with this specific complication.

Endovascular Abdominal Aortic Aneurysm Repair by Means of the Chimney Technique in a Patient with Crossed Fused Renal Ectopia.

Crossed fused renal ectopia, a congenital anomaly in 1 of 7,000 individuals, presents a challenge during endovascular treatment of abdominal aortic aneurysm. Most treatment approaches in these patients have involved open surgical repair of the aneurysm or endovascular repair with coverage of the ectopic renal artery. We present what we think is the first case of endovascular abdominal aortic aneurysm repair with use of the chimney technique (parallel stent-grafting) to preserve an ectopic renal artery, in an 88-year-old man who was at high risk for open surgery. In addition to the patient's case, we discuss the relevant medical literature.

Endovascular Treatment of Superior Vena Cava Syndrome via Balloon-in-Balloon Catheter Technique with a Palmaz Stent.

Superior vena cava syndrome is a well-known disease entity that carries substantial rates of morbidity and mortality. Although most cases of superior vena cava syndrome are secondary to a malignant process, additional causes (such as mediastinal fibrosis, pacemaker lead implantation, or central venous catheter placement) have been reported. Multiple treatment options include percutaneous transluminal angioplasty, stent implantation, thrombolysis, mechanical thrombectomy, and venous grafting. We present a case of superior vena cava syndrome in a symptomatic 30-year-old woman who obtained complete relief of obstruction and marked symptomatic improvement through venoplasty and stenting, aided by our use of a balloon-in-balloon catheter system.

Aspergillus Mediastinitis after Orthotopic Heart Transplantation: A Case Report.

A 55-year-old woman was admitted for orthotopic heart transplantation. Her medical history was notable for multiple cardiovascular problems, including ischemic cardiomyopathy that necessitated circulatory support with a left ventricular assist device. Five weeks after undergoing orthotopic heart transplantation, she developed Aspergillus calidoustus mediastinitis, for which she underwent a prolonged course of antifungal treatment that comprised (in sequence) posaconazole for 11 days, voriconazole for 10 days, and amphotericin B for 42 days. During this period, she also underwent repeated mediastinal drainage and sternal débridement, followed by sternal wiring and coverage with bilateral pectoralis advancement flaps. Four months postoperatively, she was discharged from the hospital with a successfully controlled infection and a healed sternum. To our knowledge, only 3 previous cases of Aspergillus mediastinitis after orthotopic heart transplantation have been reported in the literature, none of which was Aspergillus calidoustus.

Isolated spontaneous celiac artery dissection in a 47-year-old man with von Willebrand disease.

Isolated spontaneous dissection of the celiac artery is rare, and its occurrence without aortic dissection is even rarer. The typical symptom of this dissection is acute-onset abdominal pain. Complications of the condition include aneurysm formation, rupture, and abdominal-organ ischemia or infarction, especially in the liver or spleen. We report the case of a 47-year-old man with von Willebrand disease who had an isolated spontaneous dissection of the celiac artery. We used computed tomography and computed tomographic angiography in the diagnosis and characterization of the dissection. To our knowledge, this is the first report of celiac artery dissection in a patient with von Willebrand disease.

A common electrocardiographic finding in an uncommon presentation.

Anterior ST-segment elevation is the hallmark electrocardiographic finding of acute anterior left ventricular infarction that is caused by occlusion in one of the branches of the left coronary artery. We report a case of marked ST-segment elevation in the precordial leads, with concomitant inferior ST-segment elevation that was caused by acute occlusion of the marginal branches of the right coronary artery (RCA) causing an isolated right ventricular myocardial infarction (RVMI) during coronary angioplasty. Isolated occlusion of the marginal branches of the RCA appears to be extremely rare. In the case presented, this was caused by an iatrogenic spiral dissection with subsequent stenting of the RCA. This case illustrates that diffuse ST-segment elevation in the precordial leads may occur due to the occlusion of the RCA or its branches. It is important to recognize this scenario, since the treatment of left ventricular myocardial infarction differs from that of RVMI, where maintaining adequate preload and avoiding vasodilators to preserve right ventricular stroke volume is crucial.