Aortic stenosis. Indications and results of percutaneous aortic valve implantation (TAVI). / Estenosis aórtica. Indicaciones y resultados del implante de válvula aórtica percutánea (TAVI).

Aortic stenosis (AS) is the most common valvular heart disease in developed countries. Its prevalence increases progressively due the aging of the population. Transcatheter aortic valve implantation (TAVI), however, has revolutionised the treatment of AS. With the current data, we can confirm that TAVI is the treatment of choice for patients with severe symptomatic AS considered inoperable or with high surgical risk. In recent years, the use of TAVI has grown exponentially and is spreading to patients of intermediate surgical risk due to the procedure's good results, the reduced number of complications and the low incidence of prosthetic degeneration. The results appear to indicate that, in the medium term, TAVI will progressively substitute conventional surgery for treating most patients with severe AS.

Anaesthetic management of percutaneous aortic valve implants: Results of 100 cases. / Manejo anestésico para la implantación de una prótesis aórtica por vía percutánea. Resultados de 100 casos.

INTRODUCTION: Transfemoral transcatheter aortic-valve implantation represents a therapeutic alternative for patients with severe aortic stenosis who cannot undergo surgery due to high surgical risk. OBJECTIVE: The aim of this study is to describe the anaesthetic procedure for transfemoral transcatheter aortic-valve implantation and the results on 100 patients with symptomatic severe aortic stenosis. MATERIAL AND METHODS: A series of cases are presented with prospective data collected on 100 consecutive patients. The anaesthetic procedure consisted of continuous remifentanil and propofol infusions, for sedation or general anaesthetic. RESULTS: Almost two-thirds (65%) of the cases ended on sedation, and 35% on general anaesthetic (19% out of this total were elective and 16% were due to complications during the procedure). Complications occurred in 34% of the cases, with both vascular and complete atrioventricular block being the most frequent. Mortality within the first 24h was 5%. CONCLUSIONS: Implantation of transfemoral aortic prosthesis under remifentanil-propofol sedation can be considered a valid therapeutic alternative for patients with severe symptomatic aortic stenosis, and with a high surgical risk, and therefore not considered for conventional surgery.

Successful sealing of an angioplasty-related saphenous vein graft rupture with a PTFE-covered stent.

A patient developed severe hemodynamic compromise after saphenous vein graft rupture during high-pressure coronary stent deployment. Immediate balloon inflation followed by implantation of a polytetrafluoroethylene-covered stent solved the problem. The next day, follow-up angiography confirmed persistent sealing of the rupture site. Clinical and angiographic features of vessel rupture during coronary angioplasty as well as several therapeutic options for this complication are discussed.

Results (>6 months) of stenting of >1 major coronary artery in multivessel coronary artery disease.

Multivessel percutaneous transluminal coronary angioplasty (PTCA) is associated with a high requirement for further revascularization procedures. Although stenting can reduce restenosis and clinical events after 1-vessel intervention, little information is available after multivessel coronary stenting. We followed up 136 patients (9% of 1,481 undergoing stenting in our center) who had had stent implantation in at least 2 different major native coronary arteries and were followed-up for >6 months. Each patient had received a mean of 2.3 +/- 0.6 stents (1.13 +/- 0.4 stents per lesion) and procedural success was 95%. In-hospital complications included 1 death, 1 Q-wave infarction, 5 non-Q-wave myocardial infarctions, and 1 repeat PTCA. After a mean of 18 +/- 13 months, 7 patients died (3 of heart failure, 4 of noncardiac causes), 2 required coronary bypass surgery, 1 had a myocardial infarction, 13 target vessel repeat PTCA, and 4 non-target vessel PTCA. Survival free of major cardiac events was 75% at 3 years. A history of heart failure, dilation of a restenotic lesion, and 3-vessel dilation were independent negative predictors of event-free survival. Angiographic follow-up was available in 86 patients: 56 (65%) were restenosis free, 23 (27%) had 1-vessel restenosis, and 6 (7%) had 2-vessel and 1 patient 3-vessel restenosis. Restenosis per vessel was 23% (41 of 177). Reference diameter, past-PTCA minimal luminal diameter, and length of the stent were independent predictors of restenosis. We conclude that multivessel stenting provides good midterm results in selected patients with multivessel coronary artery disease. Midterm events are less frequent than previously reported after balloon PTCA.

[The performance of coronary angioplasties at centers without cardiac surgery. The recommendations of the Sociedad Española de Cardiología]. / Realización de angioplastias coronarias en centros sin cirugía cardíaca. Recomendaciones de la Sociedad Española de Cardiología.

During the early years of coronary interventions a rigorous on-site surgical stand-by was mandatory. The increased experience in coronary angioplasty both on total number of procedures and the experience gained by each operator, together with the technical improvements, namely since the introduction of stents has induced an evolution in the stand-by strategy, with new concepts such as "next available operating room" or coronary interventions "without on site" surgical facilities, are gaining widespread acceptance. With the aim of defining the requirements to perform coronary interventions at hospitals without coronary surgery, the following aspects are reviewed: a) complications following coronary angioplasty that require coronary surgery; b) the current status of coronary angioplasty without surgical stand-by in different countries. All this information allows us to advance some recommendations concerning the performance of coronary interventions at hospitals without on-site cardiac surgery. Different issues including hospital characteristics, operator and cardiac catheterization laboratory requirements, as well as lesion characteristics and the type of informed consent, should be taken into account.

[Future perspectives in coronary stenting]. / Perspectivas futuras del stent coronario.

Coronary stenting has made a significant difference in percutaneous coronary revascularization techniques, since it provides an effective treatment for procedural complications and prevents to some degree the incidence of restenosis. Presently, many different stents are available on the market, therefore most interventional cardiologist needs are well covered. Nevertheless, there are still some vessels/lesions unsuitable for coronary stenting, such as very distal lesions or lesions in small vessels. On the other hand, although restenosis is less frequent after stenting, its incidence is still significant posteriorly, representing a major health and economical problem. In the near future, new developments in stent technology such as polymeric coating, local drug delivery systems or intraarterial radiation may contribute to a further decrease in the incidence of restenosis. With better short- and long-term results indications for percutaneous coronary revascularization might be significantly expanded in the next few years.

[Percutaneous mitral valvotomy. The experience of the Hospital Universitario San Carlos of Madrid]. / Valvotomía mitral percutánea. Experiencia del Hospital Universitario San Carlos de Madrid.

Percutaneous mitral valvotomy is an alternative to surgery for the treatment of selected patients with mitral stenosis. With the purpose of reviewing our own experience and to determine the relationship of several variables with procedural success or complications rate, we have analyzed the immediate results of 335 consecutive procedures (90% with the Inoue balloon). Mean age was 51 +/- 12 years, 79% were female, 59% were in atrial fibrillation, 49% in NYHA class > or = III and 34% had mild mitral regurgitation. Mean echocardiographic score was 7.6 +/- 1.9 and up to 25% of patients had a total score > or = 8. Mean mitral valve area (Gorlin) increased from 0.94 +/- 0.2 to 1.87 +/- 0.5 cm2, with increments > or = 50% in mitral area in 88% and a final area > or = 1.5 cm2 in 85% of patients. Patients with an score > 8 obtained smaller mitral areas (1.64 +/- 0.4 vs 1.95 +/- 0.5 cm2. p < 0.01), and a higher percent of suboptimal (< 1.5 cm2) mitral area (22 vs 2%, p < 0.001) than patients with a lower score. Echocardiographic score (p = 0.009), balloon size (p = 0.01) and left atrial diameter (p = 0.04) were identified as independent predictors of a post-procedural mitral area > or = 1.5 cm2. Complications including cardiac tamponade (3 cases), cerebral ischemic events (1 case) and death (1 case) were rare. Mitral regurgitation increased by 2 or more grades in 14%, but regurgitation was severe in only 6% and early mitral surgery was required in 6 (2%) patients. No clinical, anatomical or procedural variables were found to be predictors of a significant increase in mitral regurgitation, a complication which occurred even in valves with a low echocardiographic score. In conclusion, percutaneous mitral valvotomy is a safe and effective procedure for the treatment of selected patients with mitral stenosis. Since complications, even if rare might be serious, the procedure should be performed only in symptomatic patients.

[The correlation between measurements performed by intravascular echography and quantitative digital angiography in large- and small-caliber arteries]. / Correlación de las medidas realizadas mediante ecografía intravascular y angiografía digital cuantitativa en arterias de gran y pequeño calibre.

Intravascular ultrasound is a new promising technique that appears as a very useful complement to standard angiography in the study of atherosclerosis. Specifically, intravascular ultrasound provides by itself, information of great value concerning vessel wall characteristics. Nevertheless, before taking any decision with the results provided by this new technique, we must validate this information with that provided by other more conventional techniques like standard angiography. Accordingly, we have analyzed in 25 patients, 50 images of the abdominal aorta and 77 images of the coronary arteries taken from arterial segments free of atherosclerotic involvement. With the use of a calibrated small grid located over the patient's thorax, we have analyzed "in the same points" the images obtained with intravascular ultrasound and those provided by contrast angiography using a quantitative angiographic analysis. In the abdominal aorta the vessel diameter measured by intravascular ultrasound and angiography was 17.8 +/- 0.39 mm vs 18.6 +/- 0.42 mm (NS), whereas in the coronary arteries it was 2.76 +/- 0.39 mm vs 2.98 +/- 0.37 mm (NS), respectively. The correlation between both techniques was good for both types of arteries (r = 0.93 in the abdominal aorta and r = 0.87 in the coronary arteries). We conclude, that in our experience and with the methodology used, there is a good correlation between the measurements of the vessel diameters obtained by both intravascular ultrasound and digital angiography in arteries of different sizes, being the correlation even better in large arteries.

[Guided coronary atherectomy: preliminary results]. / Aterectomía coronaria dirigida: resultados preliminares.

Coronary atherectomy implies removing atheromatous material from the diseased coronary arterial wall. This technique has emerged as an attractive alternative to conventional percutaneous transluminal coronary angioplasty procedures, in an attempt to diminish both initial procedural failure and restenosis rate. Among different technologies, the Simpson's atherotome provides a means of performing directional (i.e. selective) coronary atherectomy (DCA). This device implements a coaxial catheter which is advanced into the lesion over a steerable guidewire. Its distal tip includes a hollow metallic cylinder with a lateral window. Removal of the material is accomplished by a rotating cutter which can be moved distally, once the device's window has been orientated facing the lesion. We have performed 14 DCA in 14 patients. Mean age was 58 years and 12 patients were male. The technique was indicated for unstable angina (7 patients), stable angina (4 patients) and silent myocardial ischemia (3 patients). Fifteen lesions were attempted (13 original and two with restenosis), located as follows: nine in the left anterior descending coronary artery, three in the right coronary artery and three in the left circumflex artery. Eleven lesions were proximal and four were located in mid coronary segments. Twelve lesions (80%) were eccentric, and five (33%) were irregular. Initial angiographic success (residual stenosis less than 50%) was obtained in all 15 lesions (100%). Pre-DCA stenosis was 84 +/- 5% and post-DCA stenosis was 16 +/- 6%. There was no need for urgent coronary artery by-pass surgery and no patient developed an acute myocardial infarction in relation to the procedure. A 82-year-old woman died after the procedure in cardiogenic shock.(ABSTRACT TRUNCATED AT 250 WORDS)