Christian Witzke

Impact of rapid ventricular pacing during percutaneous balloon aortic valvuloplasty in patients with critical aortic stenosis: Should we be using it?

Background: Rapid ventricular pacing (RP) during percutaneous balloon aortic valvuloplasty (BAV) facilitates balloon positioning by preventing the “watermelon seeding” effect during balloon inflation. The clinical consequences of RP BAV have never been compared with standard BAV in which rapid pacing in not used. We evaluated the immediate results and in‐hospital adverse events of patients with severe aortic stenosis (AS) undergoing BAV with and without RP. Methods: This is a retrospective study of patients with severe AS undergoing retrograde BAV. Patients who underwent BAV with RP were compared to those who did not receive RP during BAV. Procedural outcomes, complications, and in‐hospital adverse events were compared between both groups. Stratified analyses were performed to evaluate RP in pre‐specified subsets for confounding and effect modification. Results: Between January 2005 and December 2008, 111 consecutive patients underwent retrograde BAV at Massachusetts General Hospital. Sixty‐seven patients underwent BAV with RP. Nearly 90% of patients were NYHA class III or IV and the mean AVA was 0.64 cm2. Baseline characteristics and balloon sizes were similar in the two groups. The average post‐BAV AVA was smaller in the RP group compared to the no‐RP group (0.87 v. 1.02 cm2, p = 0.02). Pre and post‐cardiac output, in‐hospital mortality, myocardial infarction, stroke, frequency of cardiopulmonary arrest, vasopressor use, and major complications were similar in the two groups. Conclusions: 1) RP allows precise balloon placement during BAV. 2) RP BAV is associated with lower post‐BAV AVA. 3) RP BAV may be safely performed in patients with high‐risk cardiac features.

Coronary Artery Perforations in the Contemporary Interventional Era

BACKGROUND Coronary perforations represent a serious complication of percutaneous coronary intervention (PCI). METHODS We performed a retrospective analysis of documented coronary perforations at Massachusetts General Hospital from 2000 to 2008. Medical records review and detailed angiographic analysis were performed in all patients. RESULTS Sixty-eight cases of coronary perforation were identified from a total of 14,281 PCIs from March 2000 to March 2008 representing an overall incidence of 0.48%. The study cohort was predominantly male (61.8%), mean age 71+/-11 years with 78% representing acute cases (unstable angina: 36.8%, NSTEMI: 30.9%, STEMI: 10.3%). Coronary artery perforation occurred as a complication of wire manipulation in 45 patients (66.2%) with 88.9% of this group being hydrophilic wires, of coronary stenting in 11 (16.2%), of angioplasty alone in 6 (8.8%), and of rotational atherectomy in 8 (11.8%). The perforation was sealed with an angioplasty balloon alone in 16 patients (23.5%), and with stents in 14 patients (20.6%) (covered stents: 11.8% and noncovered stents: 8.8%). Emergency CABG was performed in 2 patients (2.9%). Five patients (7.4%) developed periprocedural MI. The in-hospital mortality rate was 5.9% in the study cohort. CONCLUSION Coronary artery perforation as a complication of PCI is still rare as demonstrated in our series with an incidence of 0.48%. The predominant cause of coronary perforations in the current era of PCI is wire injury.

Transient Left Ventricular Apical Ballooning

A 69-year-old woman presented with acute onset of chest pain and diffuse ST-segment elevation suggesting ischemia (Figure 1). The creatine phosphokinase–MB was elevated, and in view of ongoing chest discomfort, she was referred for urgent cardiac catheterization. Figure 1. Twelve-lead ECG showing normal sinus …

Suicide left ventricle following transcatheter aortic valve implantation

In some patients with aortic stenosis, dynamic intraventricular gradients like those seen in hypertrophic obstructive cardiomyopathy may develop secondary to left ventricular hypertrophy from chronic pressure overload. With the advent of transcatheter aortic valve implantation, many patients with aortic stenosis and advanced age who formerly would be considered “too high risk” for aortic valve replacement are getting treatment for their aortic stenosis. This case highlights the hemodynamic aberrations that can occur with TAVI leading to a cautionary note regarding implementation of this rapidly emerging technique in patients with left ventricles that may be at risk for suicide left ventricle.

Retrograde versus antegrade percutaneous aortic balloon valvuloplasty: Immediate, short- and long-term outcome at 2 years†

The short‐ and long‐term vascular risks and hemodynamic benefits of antegrade versus retrograde percutaneous aortic balloon valvuloplasty (PAV) have not been clearly established. With the advent of percutaneous aortic valve replacement strategies, more valvuloplasties are being performed. The antegrade approach may reduce vascular complications, particularly in patients with peripheral vascular disease (PVD). Comparing the clinical efficacy and complications of each technique is warranted.

Comparison of Procedural and In-Hospital Outcomes of Percutaneous Balloon Aortic Valvuloplasty in Patients >80 Years Versus Patients <80 Years

Percutaneous balloon aortic valvuloplasty (PBAV) is a procedure used for palliation, bridging to surgery, and as an integral step in the procedure for percutaneous aortic valve replacement. Older patients with severe aortic stenosis are thought to have greater risk for adverse perioperative events than younger patients. The aim of this study was to evaluate the outcomes of patients aged >80 years and those aged < or =80 years who underwent PBAV to identify factors associated with adverse clinical outcomes. This was a retrospective study of 111 consecutive patients with severe symptomatic aortic stenosis who underwent retrograde PBAV at Massachusetts General Hospital from December 2004 to December 2008. Forty-nine patients (44%) were men, and the mean age for the whole group was 82 +/- 8 years. Patients were divided into 2 age groups: those aged >80 years (n = 73) and those aged < or =80 years (n = 38). Procedural outcomes, complications, and in-hospital adverse events were compared. Multivariate logistic regression was used for the adjusted analysis. Nearly 90% of patients were in New York Heart Association class III or IV. Patients aged >80 years had lower baseline ejection fractions (43.5% vs 56.1%, p <0.01) and smaller aortic valve areas (0.59 vs 0.73 cm(2), p <0.01). Although the 2 age groups had a similar percentage of aortic valve area increase (55.5% vs 45.2%, p = 0.28), those aged >80 years had smaller post-PBAV aortic valve areas (0.89 vs 1.02 cm(2), p <0.05). Overall, in-hospital mortality was 8.1%, with no significant differences between the groups. Advanced age was not an independent predictor of in-hospital death, myocardial infarction, stroke, cardiac arrest, or tamponade; however, patients aged >80 years had a significantly higher incidence of intraprocedural emergent intubation and cardiopulmonary resuscitation compared to the younger group. New York Heart Association class was the only independent predictor of worse in-hospital outcomes. In conclusion, compared to younger patients, those aged >80 years had less favorable preprocedural characteristics for PBAV but similar overall in-hospital clinical outcomes. Patients aged >80 years had significantly higher incidence of emergent intubation and cardiopulmonary resuscitation during PBAV.

Imaging of atrial septal defects: echocardiography and CT correlation

Adult patients with atrial septal defects (ASDs) have variable clinical presentations that can range from dyspnoea on exertion to cerebral vascular accidents from paradoxical embolism. Currently echocardiography is the mainstay in the diagnosis and follow-up of patients with ASDs. As CT technology advances and low radiation techniques improve, cardiac CT is becoming a desirable method to evaluate patients with ASDs when echocardiographic evaluation is limited. Correct diagnosis and appropriate management of patients with patent foramen ovales (PFOs) and ASDs relies on an understanding of the embryologic development patterns that resulted in the malformation and associated anomalies. In this review, we illustrate the development of the interatrial septum and the foramen ovale. We discuss the diagnosis of PFOs and ASDs by echocardiography and highlight the incremental benefit of CT to further elucidate defect morphology, associated anomalies, and anatomy post-repair. The primary atrium starts as a common cavity.1 Starting at 5 weeks of gestation, the primordial single atrium begins dividing into right and left sides by formation and fusion of two septa: the septum primum and septum secundum (figure 1). Early in the fifth week of gestation the septum primum begins to form near the centre of the roof of the common atrium, growing downward to the endocardial cushions, and partially dividing the common atrium into right and left counterparts (figure 1, A-1 and A-2). The gap between the septum primum and endocardial cushions is known as the ostium primum. Before the septum primum and endocardial cushions fuse, perforations develop within the cephalic portion of the septum primum through apoptosis, creating a large window known as the ostium secundum. At the end of the sixth week the caudal free edge of the septum primum reaches the atrioventricular cushions and fuses with them, closing the ostium primum (figure 1, B-1 and …

Patients With Small Left Ventricular Size Undergoing Balloon Aortic Valvuloplasty Have Worse Intraprocedural Outcomes

To evaluate the impact of left ventricular (LV) chamber size on procedural and hospital outcomes of patients undergoing aortic valvuloplasty.

Effects of Staged Versus Adhoc Percutaneous Coronary Interventions on Renal Function—Is There a Benefit to Staging?.

AIM The purpose of this study is to determine whether ad hoc (same session) percutaneous coronary intervention, and staged (multiple session) percutaneous coronary intervention (PCI) have different renal outcomes. METHODS AND RESULTS This is a retrospective cohort study that compares the maximal decline in glomerular filtration rate (GFR) at various times points (3-6days, 1-4weeks, 4-12weeks) after either ad hoc or staged PCI. 115 patients undergoing staged PCI and 115 matched ad hoc PCI controls were included in the study. They were equivalent in baseline GFR, left ventricular ejection fraction and intra-procedural volume status based on LVEDP. The group undergoing staged PCI had greater cumulative fluoroscopy time, SYNTAX score and number of stents placed. Staged PCIs used less contrast per catheterization (155.0±5.6mL) but higher cumulative contrast dose (326.6±14.0mL) compared to ad hoc PCIs (193.4±7.2mL). Following intervention, there was a progressive decline in renal function that did not significantly differ between the ad hoc and staged groups. In the subgroup of patients with initial GFR ≤60cm3/min, staged PCI was associated with 2.6-fold greater decline in renal function 4-12weeks after the procedure compared to ad hoc. A propensity match analysis performed in patients with GFR ≤60cm3/min confirmed worse renal function in the staged group at 4-12weeks. CONCLUSIONS Staged PCI exposes patients to greater cumulative contrast agent loads. The decline in renal function observed in both groups did not differ significantly, however worse renal outcomes were observed in the staged PCI group with baseline GFR ≤60cm3/min.

Coronary in-stent restenosis following beta brachytherapy A histopathological examination

Two cases of in-stent restenosis of a coronary artery bypass vein graft following beta (beta) brachytheraphy are presented. Previously unreported histopathology of directed atherectomy specimens of such restenotic lesions and a discussion of their proposed significance form the basis of this report.