Coronary angioplasty post TAVI: Is the solution outside the box?

Transcatheter aortic valve replacement (TAVR) has become the standard option for high risk patients with bioprosthetic valve degeneration. However, percutaneous coronary interventions after TAVR may be challenging as the manipulation and engagement of the guiding catheters is much more limited and difficult, due to the superimposition of the metallic frame of the TAVR valve upon the bioprosthetic cage. We describe a case of percutaneous coronary intervention in a patient with history of transcatheter aortic valve implantation after bioprosthetic valve degeneration and we describe a new method for accessing coronary arteries in cases of TAVR-in-surgical aortic valve replacement with a high-frame TAVR with a supra-annular leaflet position, by using the route outside the frame. 〈Learning objective: We describe a method for accessing coronary arteries in cases of transcatheter aortic valve implantation (TAVI)-in-surgical aortic valve replacement with a high-frame TAVI with a supraannular leaflet position, by using the route outside the frame.〉.

Cryptogenic stroke after percutaneous closure of an atrial septal defect.

We present the case of a patient who underwent a percutaneous secundum atrial septal defect (ASD II) closure with an undersized septal occluder device. One week and one month later she experienced two transient ischemic attacks. Three-dimensional transesophageal echocardiography (TEE) revealed a residual patent foramen ovale (PFO) with a positive Valsalva bubble test. She underwent a second procedure under the 3D TEE guidance and the PFO was successfully closed percutaneously using a PFO occluder device that was attached to the ASD device. Accurate ASD and PFO morphology assessment and appropriate device selection are the key factors in the success of percutaneous closure. 3D TEE is an innovative diagnostic technique, providing a complete description of the cardiac defect and improving spatial orientation. Real-time 3D TEE is the appropriate guidance for successful and accurate positioning of the device.

The use of the GuideLiner™ catheter as a child-in-mother technique: an initial single-center experience.

Recently, a new interventional guide catheter, the GuideLiner™ catheter, was introduced into the market as a strategy for tackling the problem of stent delivery failure. We implemented this simplified child-in-mother technique in a series of 16 challenging coronary interventions. Balloon and stent delivery was successfully achieved in all cases and the device was both simple to deploy and remove. Apart from two cases of vessel dissection that were managed successfully with stent implantation, no other serious procedural complications were reported.

Rheolytic thrombectomy in patients with acute coronary syndrome and large thrombus burden: initial and mid-term results from a single centre experience.

INTRODUCTION: The presence of a large intracoronary thrombus burden is a major complicating factor during percutaneous coronary intervention (PCI) in patients with an acute coronary syndrome (ACS). The use of rheolytic thrombectomy (RT) has been proposed to prevent thrombus-related complications, with conflicting results. The purpose of this study was to identify the feasibility and safety of this approach. METHODS: We conducted a single-centre, retrospective, observational case-control study, comparing the outcomes of PCI in 26 consecutive patients with ACS and a large thrombus burden who underwent RT to those of a control group of 26 patients, matched with regard to artery location and initial TIMI flow grade. RESULTS: Despite the higher prevalence of acute ST-elevation myocardial infarction and the larger thrombus burden in the RT group, there was less incidence of distal embolisation/no-reflow and less use of vasoactive intracoronary agents. The final TIMI flow was identical in both groups. There was no difference between the two groups in the in-hospital and mid-term incidence of major adverse coronary events. CONCLUSIONS: In this study, the use of RT in patients with a large thrombus burden during acute PCI was both feasible and safe and reduced the incidence of initial no-reflow phenomenon.

Left atrial function and work after surgical ventricular restoration in postmyocardial infarction heart failure.

INTRODUCTION: The purpose of the current study was to examine the effect of surgical ventricular restoration in left atrial (LA) performance and left ventricular (LV) diastolic function in patients with congestive heart failure after extensive anterior myocardial infarction. METHODS: Seventeen consecutive patients (age 63 +/- 9 years, 14 male, 4 with diabetes) were studied prospectively. All patients underwent surgical ventricular restoration and concomitant coronary artery bypass surgery. LA volumes were calculated, as were peak LA kinetic energy (LAKE) and LA ejection fraction (LAEF). LV diastolic filling patterns were also assessed. RESULTS: Follow-up period was 1 year. LA size and volumes did not change significantly during the follow-up period. Two distinct groups of patients were identified: group A, in which LAEF and peak LAKE increased, and group B, in which LAEF and peak LAKE decreased. In both groups, the LAEF and peak LAKE appeared to increase or decrease simultaneously and this became evident from the first month after the surgery. However, 1 year after the operation, diastolic filling pattern was significantly different between the two groups. LA function showed improvement only in patients who demonstrated an improvement in indices of diastolic filling pattern. CONCLUSIONS: Despite improvement in clinical status and indices of LV systolic function in all patients who underwent surgical ventricular restoration for treatment of congestive heart failure as a result of LV dilatation secondary to large myocardial infarction, improvement of LA function occurs in patients with improved LV diastolic function.

Papillary fibroelastoma of the cardiac valves: a rare cause of embolic stroke.

Papillary fibroelastomas are rare, primary, benign cardiac tumours most frequently located in the heart valves. They are a potential cause of systemic emboli, stroke, myocardial infarction and sudden death. We present two cases of papillary fibroelastomas located in the mitral and aortic valves of patients who had suffered multiple strokes. The fibroelastomas were diagnosed using transoesophageal echocardiography and the patients were treated surgically, with broad excision of the tumours and preservation of the valves. The echocardiographic and microscopic characteristics of the fibroelastomas are analysed and methods for their differential diagnosis from other cardiac tumours are discussed in the context of the available literature.

Medium-term results from the clinical and angiographic follow-up of patients after angioplasty and implantation of sirolimus-eluting stents.

INTRODUCTION: The aim of this study was to evaluate the medium-term clinical and angiographic results, as well as the occurrence and treatment of restenosis, following the implantation of sirolimus-eluting stents (SES) in patients undergoing coronary angioplasty. METHODS: All patients who have an SES implanted in our department are entered into a database, with a view to evaluating the use of such stents in everyday clinical practice. This study included patients who consented to repeat angiography 8+/-2.4 months after stent implantation. The study population consisted of 91 patients (63 men, mean age 58+/-8.1 years) with 116 stenoses in all. This represented 17.4% of all patients who had an SES implanted during the study period. All the angiographic examinations were analysed independently using quantitative coronary analysis in order to determine the relationship between clinical and angiographic data and restenosis and late lumen loss. RESULTS: The mean vessel diameter was 2.5+/-0.48 mm and the mean lesion length was 12.61+/-1.54 mm. The late lumen loss was 0.04+/-0.49 mm. Restenosis was seen in 10 patients (12 vessels), of whom 4 were diabetics. The restenosis was in-stent in 7 vessels, in-segment in 5, and was localised (length of restenosis <10 mm) in all patients. After repeat angioplasty and SES implantation all the patients with restenosis remained free of symptoms 8+/-1.5 months later. Diabetes mellitus was the only factor to be correlated with restenosis. CONCLUSIONS: Restenosis following implantation of SES is mainly localised and occurs with about the same frequency within and outside the stent. The incidence of major cardiac events and restenosis following SES implantation is low. However, their long term efficacy in everyday clinical practice must be proved in large randomised studies in order to confirm the results presented here.

Rheolytic thrombectomy combined with a protective filter and platelet glycoprotein IIb/IIIa receptor inhibitors in rescue angioplasty.

Rescue angioplasty is used in patients in whom thrombolysis has been unsuccessful, in order to achieve a better restoration of flow and to improve left ventricular function and the long term prognosis. However, patients who undergo rescue angioplasty have a higher rate of reocclusion of the vessel or distal embolism, resulting in increased mortality. Rheolytic thrombectomy, which reduces the quantity of thrombus and improves flow in the vessel, has been used successfully in such cases. We describe a case in which rheolytic thrombectomy was applied during late rescue angioplasty in order to achieve immediate restoration of flow in the vessel.

Left atrial volumes, function and work before and after mitral valve repair in chronic mitral regurgitation.

BACKGROUND AND AIM OF THE STUDY: Despite the effect of mitral valve repair in left ventricular (LV) function having been extensively studied, investigations of left atrial (LA) performance indices are minimal. This prospective study was undertaken to analyze LA volumes, function and work in patients with chronic mitral valve regurgitation (MR) who underwent mitral valve repair; the analyses were conducted both before and six months after surgery. METHODS: Twenty patients (15 males, five females; mean age 51.4 +/- 12.5 years) with severe MR (grade IV) due to floppy mitral valve/mitral valve prolapse (FMV/MVP; anterior, posterior or both) underwent mitral valve repair. LA volumes, maximal at mitral valve opening (LAmax); minimal at valve closure (LAmin); and at onset of atrial systole (P-wave on ECG, LAP); and transmitral Doppler A-wave velocity were measured before and six months after surgery. LA stroke volume (LASV) = LAP - LAmin; LA ejection fraction (LAEF) = LASV/LAP; LA kinetic energy (LAKE) = 1/2 x LASV x 1.06 (specific gravity of blood) x A2 (dyne x cm x 10(3)); LA and LV dimensions and functions were assessed at the same time. RESULTS: NYHA functional class was improved postoperatively by at least one grade. LV systolic and diastolic dimensions were reduced significantly in all patients (p <0.001). LA volumes (LAmax, LAmin and LAP) were decreased significantly in all patients (p <0.001); LASV remained unchanged. LAEF and LAKE were increased significantly (both p <0.001). The A-wave was also increased (p <0.001). CONCLUSION: Increased LA work (LAKE) after mitral valve repair, despite a decrease in LA volumes, suggests that LA muscle dysfunction was present before surgery. LA involvement may precede LV involvement. The determination of LA performance and work will help to optimize the timing of surgery in patients with FMV/MVP and MVR.