Ângelo Nobre

Hybrid closure of postinfarction ventricular septal rupture enlargement after transcathether closure with Amplatzer occluder

Ventricular septal rupture (VSR) is nowadays a rare complication of myocardial infarction (MI), but with a mortality rate still very high. Urgent surgical correction is recommended, although in specific cases percutaneous closure of a post-infarct VSR is a therapeutic option or a bridge to surgical correction. We report a case of an 80-year-old woman, with a subacute anterior MI with an antero-septal VSR. Rapid clinical deterioration in a high-surgical-risk patient led us to attempt percutaneous VSR closure at day 8 post MI. A 16-mm Amplatzer post-infarction (PI) muscular VSD closed the defect with intra-cardiac echocardiography guidance, that allowed conscious sedation. Clinical and haemodynamic improvement was immediate. Unfortunately, a small orifice distal to the device persisted, which enlarged to 8 mm over the following days, with a Qp/Qs shunt of 1.9. At day 17 post MI, the VSR was surgically closed by suturing the Amplatzer device to the septum. A residual shunt was evident, but with no progression, being the patient discharged in NYHA class I. Percutaneous closure of a post-MI VSR as a bridge to surgery is a therapeutic option in patients with high surgical risk, allowing haemodynamic stabilization and thus gaining time for a further surgical intervention if needed, improving these patients grim prognosis. Intra-cardiac echocardiography for monitoring the percutaneous procedure instead of a transoesophageal approach, as well as the surgical technique, make this case unique.

Combined MitraClip implantation and left atrial appendage occlusion using the Watchman device: A case series from a referral center

INTRODUCTION Patients referred for percutaneous transcatheter mitral valve repair using the MitraClip® system frequently have atrial fibrillation, which imposes additional challenges due to the need for oral anticoagulation. Left atrial appendage occlusion is currently regarded as a non-inferior alternative to anticoagulation in patients with non-valvular atrial fibrillation and both high thromboembolic and bleeding risk. Considering that both MitraClip implantation and left atrial appendage occlusion are percutaneous techniques that require transseptal puncture, it is technically attractive to consider their concomitant use. OBJECTIVES We aim to evaluate the feasibility of a combined approach with MitraClip implantation and left atrial appendage occlusion in a single procedure. METHODS We report the first case series regarding this issue, discussing the specific advantages, pitfalls and technical aspects of combining these two procedures. RESULTS Five patients underwent left atrial appendage occlusion with the Watchman® device followed by MitraClip implantation in the same procedure. All patients experienced significant reduction in mitral valve regurgitation of at least two grades, optimal occluder position, no associated complications and significant clinical improvement assessed by NYHA functional class (reduction of at least one functional class, with four patients in class I at one-month follow-up). CONCLUSION In selected patients rejected for surgical mitral valve repair, with atrial fibrillation and increased risk of bleeding and embolic events, a combined approach with MitraClip implantation and left atrial appendage occlusion in a single procedure is feasible, safe and effective.

Subacute Retrograde TAVI Migration Successfully Treated With a Valve-in-valve Procedure

© 2016 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Expanding the functional role of miRNAs in the establishment of permanent atrial fibrillation.

a University Hospital Santa Maria, Department of Cardiology, Lisbon Academic Medical Centre, CCUL, Lisbon University, Lisbon, Portugal b Programme for Advanced Medical Education, Fundação Calouste Gulbenkian, Ministry of Health and Foundation for Science and Technology, Lisbon, Portugal c Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal d University Hospital Santa Maria, Department of Cardiothoracic Surgery, Lisbon Academic Medical Centre, CCUL, Lisbon University, Lisbon, Portugal

Pericardite efusiva‐constritiva como manifestação de um diagnóstico inesperado

Constrictive pericarditis is a clinical condition characterized by the appearance of signs and symptoms of right heart failure due to loss of pericardial compliance. Cardiac surgery is now one of the most frequent causes in developed countries, while tuberculosis remains the most prevalent cause in developing countries. Malignancy is a rare cause but usually has a poor prognosis. The diagnosis of constrictive pericarditis remains a clinical challenge and requires a combination of noninvasive diagnostic methods (echocardiography, cardiac magnetic resonance and computed tomography); in some cases, cardiac catheterization is needed to confirm the diagnosis. The authors present the case of a 51-year-old man, hospitalized due to cardiac tamponade. Diagnostic investigation was suggestive of tuberculous etiology. Despite directed medical therapy, the patient developed effusive-constrictive physiology. He underwent pericardiectomy and anatomopathologic study suggested a neoplastic etiology. The patient died in the postoperative period from biventricular failure.

Trombosis intracardiaca estéril asociada a electrodo de marcapasos

of recent onset. Neurology. 2007;68:1563–70. 4. Mueller L, Gallagher RM, Ciervo CA. Vasospasm-induced myocardial infarction with sumatriptan. Headache. 1996;36:329–31. 5. Dalkara T, Nozari A, Moskowitz MA. Migraine aura pathophysiology: the role of blood vessels and microembolisation. Lancet Neurol. 2010;9:309–17. 6. O’Keeffe ST, Tsapatsaris NP, Beetham Jr WP. Increased prevalence of migraine and chest pain in patients with primary Raynaud disease. Ann Intern Med. 1992;116:985–9.

[Images in cardiology after clinical observation - aortic dissection in Marfan syndrome].

Abstract Introduction Stanford type A aortic dissection is a rare phenomenon with high short-term mortality and clinical manifestations that can make differential diagnosis a lengthy process requiring several diagnostic examinations. Objectives Based on a case report, the aim is to highlight the importance of physical examination in the initial management of these patients and of rapid access to a surgical center. A brief review follows on the diagnosis and treatment of ascending aortic dissection, and its specific nature in Marfan syndrome. Case report A 33-year-old man was admitted to the emergency department of a district hospital with chest and back pain associated with vomiting, 20 hours after symptom onset. Initial physical examination revealed an aortic systolic murmur and musculoskeletal morphological abnormalities compatible with Marfan syndrome. Given suspected aortic dissection, a transthoracic echocardiogram was immediately performed, which showed an extensive intimal flap originating at the sinotubular junction. He was transferred to the cardiothoracic surgery department of a referral hospital where he was treated by a Bentall procedure. Conclusion In this case, careful physical examination during initial assessment raised the suspicion that this patient was in a high-risk group for aortic dissection, thus avoiding unnecessary and lengthy exams. This diagnosis requires emergent surgical treatment, and so direct contact in real time between those making in the diagnosis and the surgeon is essential, as well as protocols governing immediate access to a surgical center.

An alternative approach for addressing mediastinal tumours through mini-invasive surgery

Highlights • Mini-Invasive surgery for mediastinal tumours.• New technique using inframammary approach.• Low coast and minimal learning curve.

Lymphangioma of the heart as a rare tumor: a case report

Highlights • Lymphangioma is a rare cardiac tumor.• Lymphangiomas are benign in nature.• Diagnosis based on imaging techniques is difficult.• Surgery may be needed for definitive diagnosis and treatment.

Surgical Epicardial CRT-D Implantation in a Patient with Complete Obstruction of the Superior Vena Cava

Current guidelines clearly define the subset of heart failure patients who benefit from device implantation.1 Although first-time trans-venous device implantation has a high success rate, some patients present complex and challenging technical problems.2