Mechanism and severity of mitral regurgitation by transesophageal echocardiography in patients referred for percutaneous valve repair.

Percutaneous mitral valve repair with the MitraClip has been shown to decrease mitral regurgitation (MR) severity, left ventricular volumes, and functional class in patients with severe (3+ or 4+) MR. Determination of which patients are optimal candidates for MitraClip therapy versus surgery has not been rigorously evaluated. Transesophageal echocardiography was prospectively performed in 113 consecutive patients referred for potential MitraClip therapy under the REALISM continued access registry. MR severity was assessed quantitatively in all patients. Mitral valve anatomy and feasibility of MitraClip placement were assessed by transesophageal echocardiography and clinical parameters. MR was degenerative (mitral valve prolapse) in 60 patients (53%), functional (anatomically normal) in 44 (39%), and thickened with restricted motion (Carpentier IIIB classification) in 9 (8%). MR was mild in 19 patients (17%), moderate in 27 (24%), and severe (3 to 4+) in 67 (59%) by Transesophageal echocardiography. MitraClip placement was performed in only 17 of 113 patients (15%); all were successful. Surgical mitral valve repair was performed in 25 patients (22%), mitral valve replacement in 12 (11%). Most patients (59 of 113, 52%) were treated medically, usually because MR was not severe enough to warrant intervention. In conclusion, most patients referred for MitraClip therapy do not have severe enough MR to warrant intervention. Of those with clinical need for intervention, surgery is more often recommended for anatomic or clinical reasons. Three-dimensional transesophageal echocardiography with quantitative assessment of MR severity is helpful in evaluating these patients.

Complementary utility of multislice computed tomographic coronary angiography for detection of high-grade lesions in patients with negative stress myocardial perfusion imaging.

Myocardial perfusion imaging (MPI) is a highly sensitive and specific test for noninvasive detection of coronary artery disease. Therefore, in patients with negative MPI results, further noninvasive testing is usually not pursued. We report a series of patients with negative MPI results in whom 64-slice computed tomographic coronary angiography accurately predicted flow-limiting coronary lesions requiring subsequent revascularization.

Measurement of right ventricular volumes before and after atrial septal defect closure using multislice computed tomography.

Volumetric measurements of the right ventricle are helpful in patients with atrial septal defects (ASDs) in estimating the degree of right ventricular (RV) failure. They also may be important in following patients postoperatively after ASD closure. Traditional imaging modalities used to obtain such measurements have had limitations in measuring the complex shape of the right ventricle. Multislice computed tomography (MSCT) is a technique that provides excellent spatial resolution of the moving heart. This study was conducted to assess whether MSCT could be used to evaluate RV end-diastolic volume (EDV) before and after the closure of an ASD. From June 2004 to March 2006, 10 patients with ASDs underwent MSCT to calculate their RV volumes. The patients then had their ASDs closed by either a percutaneous or a surgical approach. Three months later, the patients' MSCT scans were repeated, and RV volumes were recalculated. EDV was approximated using 3-dimensional volume-rendered models of the right ventricle. At a mean follow-up of 3 months, a significant reduction in mean RV EDV, indexed for body surface area, was demonstrated, from 131 +/- 31 to 83 +/- 22 cm(3)/m(2) (p = 0.0007). In conclusion, this report is the first to describe the utility of MSCT to demonstrate RV EDV reduction after ASD closure.

Migration of an amplatzer septal occluder device for closure of atrial septal defect into the ascending aorta with formation of an aorta-to-right atrial fistula.

The percutaneous closure of atrial septal defects is increasingly used. Serious complications of the procedure, such as cardiac perforation and tamponade, are rare and usually occur <72 hours after device placement. The investigators report the late development of the erosion of an Amplatzer septal occluder into the ascending aorta with associated aortic-to-right atrial fistula formation.

Effect on right ventricular volume of percutaneous Amplatzer closure of atrial septal defect in adults.

In adult patients with atrial septal defects (ASDs), right ventricular (RV) cavity size may return to normal after operative closure. This study demonstrated improved RV volumes and right atrial areas in 20 adult patients after successful transcatheter closure of large ASDs. RV volumes decreased by 22%, 30%, and 41% at 1 day, 1 month, and 6 months, respectively, after the procedure. Right atrial areas decreased by 5%, 23%, and 26%, respectively, over the same time.

Effect of bivalirudin on length of stay in the recovery area after percutaneous coronary intervention compared with heparin alone, heparin + abciximab, or heparin + eptifibatide.

Three hundred nine patients were followed during their recovery area stay after percutaneous coronary intervention. Recovery area times for patients who received bivalirudin during percutaneous coronary intervention showed an average reduction in total recovery area length of stay of 36 minutes (p <0.0001) compared with patients who received heparin alone. This reduction was also seen when compared with the heparin + abciximab group (46-minute reduction, p = 0.0007), and the heparin + eptifibatide group (35-minute reduction, p = 0.0005). Patients who received bivalirudin took significantly less time for the activated clotting time (ACT) to normalize despite significantly higher average ACTs and significantly fewer subtherapeutic ACTs.

Percutaneous closure of multiple atrial septal defects with three Amplatzer septal occluder devices.

We report on the successful closure of three atrial septal defects with three Amplatzer septal occluders in a 55-year-old woman.

Validation of the i-STAT handheld activated clotting time for use with bivalirudin.

Bivalirudin is being used more frequently as an anticoagulant in the cardiac catheterization laboratory. Newer devices, used to measure activated clotting time (ACT), have not been thoroughly tested for use with bivalirudin. One such device, the i-STAT ACT, measures the generation of activated thrombin to determine the level of anticoagulation. Our study demonstrated a high level of agreement between the i-STAT ACT and the Hemochron ACT in patients anticoagulated with bivalirudin. In addition, the i-STAT was shown to have an extremely high degree of reproducibility.

Pulmonary arteriovenous fistula discovered after percutaneous patent foramen ovale closure in a 27-year-old woman.

We report the case of a 27-year-old woman with history of a transient ischemic attack who was diagnosed with a large patent foramen ovale (PFO). After percutaneous PFO closure, it was discovered that the patient had a pulmonary arteriovenous malformation (PAVM) and a diagnosis of hereditary hemorrhagic telangiectasia was made. The PAVM was later coil embolized. This case illustrates the importance of evaluating PFO closure patients for other causes of right-to-left shunting.