João Calisto

Mean pulmonary arterial pressure after percutaneous mitral valvuloplasty predicts long-term adverse outcomes

INTRODUCTION AND AIM Percutaneous mitral valvuloplasty (PMV) is an effective treatment option for mitral stenosis (MS), but its success is assessed on the basis of clinical and echocardiographic outcomes in studies with relatively short follow-up. We aimed to characterize a cohort of patients undergoing PMV with long-term follow-up and to determine independent predictors of post-PMV mitral re-intervention and event-free survival. METHODS We studied 91 consecutive patients with MS who underwent PMV with a median clinical follow-up duration of 99 months. Two endpoints were considered: post-PMV mitral re-intervention (PMV or mitral surgery) and a composite clinical events endpoint including cardiovascular death, mitral valve re-intervention and hospital admission due to decompensated heart failure. We compared patients who required post-PMV mitral re-intervention with those who did not during follow-up. RESULTS The study population included 83.5% females and mean age was 48.9±13.9 years. The 1-, 3-, 5-, 7- and 9-year rates of clinical event-free survival were 93.0±2.8%, 86.0±3.9%, 81.0±4.4%, 70.6±5.6%, and 68.4±5.8%, respectively. The 1-, 3-, 5-, 7- and 9-year rates of mitral re-intervention-free survival were 98.8±1.2%, 97.5±1.7%, 92.1±3.1%, 85.5±4.5%, and 85.5±4.5%, respectively. The median time to mitral re-intervention was 6.2 years. Patients who required mitral re-intervention during follow-up were younger (43.3 vs. 51.2 years, p=0.04) and had higher pre- and post-PMV mitral gradient (14.9 vs. 11.5 mmHg, p=0.02 and 6.4 vs. 2.1 mmHg, p<0.001) and higher post-PMV mean pulmonary artery pressure (mPAP) (30.0 vs. 23.2 mmHg, p=0.01). In a Cox proportional hazards model, mPAP ≥25 mmHg was the sole predictor of both mitral re-intervention (HR 5.639 [1.246-25.528], p=0.025) and clinical events (HR 3.622 [1.070-12.260], p=0.039). CONCLUSION In our population, immediate post-PMV mPAP was the sole predictor of post-PMV mitral intervention. These findings may help identify patients in need of closer post-PMV follow-up.

Pulmonary Hypertension in Mitral Stenosis: An Optical Coherence Tomography Study

A 65-year old woman with a prior history of surgical mitral comissurotomy 30 years ago presented with a 6-month history of worsening fatigue and exertional dyspnea. On physical examination, she had a mitral stenosis murmur, a loud P2, with an irregular pulse and mild peripheral edema. The electrocardiogram showed atrial fibrillation; the echocardiogram was notable for a fibro-calcified mitral valve, with severe restriction of leaflet mobility and an area of 1.1 cm. Biventricular function was normal. As the valve anatomy was considered suitable for percutaneous intervention, the patient was scheduled a balloon valvuloplasty. The pre-intervention right heart catheterization showed a pulmonary artery pressure of 45/17/29 mmHg. After successful mitral dilatation, optical coherence tomography (LightLab Imaging Inc., Westford, Massachusetts, United States) was performed on a distal segmental branch of the right pulmonary artery (Fig. 1). Optical coherence tomography images showed diffuse thickening of the distal pulmonary arterial wall (Figs. 2 and 3). We registered a pulmonary artery wall thickness between 0.28 mm and 0.31 mm, higher when compared to reports from subjects without pulmonary hypertension (0.16 [0.03] mm for vessels with 2.14 [0.33] mm of diameter). No complications arose during or after the procedure. Optical coherence tomography is a safe and potentially useful tool for characterize, with high resolution, the pulmonary vessels and may contribute to investigate the mechanisms of vascular remodeling in pulmonary hypertension.

Acute pneumopericardium: when echocardiography is not enough

A 46-year-old female with metastasized rectal adenocarcinoma complained of progressive exertional dyspnea. The physical exam was remarkable for low blood pressure (98/54 mmHg) and tachycardia (115 bpm). A severe pericardium effusion with right chambers’ collapse was identified, and the patient was submitted to echocardiography-guided pericardiocentesis by a subxiphoid approach, employing a handheld ultrasound device, with fluoroscopy available. The puncture was undertaken uneventfully, with prompt drainage of serous fluid (500 cc) through a 6Fr pigtail catheter paralleled by pericardial effusion reduction on echo. However, it was impossible to obtain an ultrasound window to visualize the heart at the end of the procedure. Diagnosis: Immediate fluoroscopy showed a pneumopericardium (image and video 1), which explained the imaging finding on transthoracic ultrasound. The air was instantly drained with a 50-cc syringe (video 2). The patient remained asymptomatic and the discharge chest radiography was normal. Pneumopericardium is a rare complication of pericardiocentesis, and we hypothesize that it was due to air leakage to the pericardial drainage system (1). Conservative management is reasonable in hemodinamically stable patients (2); however, we proceeded to aspiration as the catheter was in position. Fluoroscopy was crucial for this clinically inapparent diagnosis.

Heart transplant coronary artery disease: Multimodality approach in percutaneous intervention

Coronary artery disease is the most important cause of late morbidity and mortality after heart transplantation. It is usually an immunologic phenomenon termed cardiac allograft vasculopathy, but can also be the result of donor-transmitted atherosclerosis. Routine surveillance by coronary angiography should be complemented by intracoronary imaging, in order to determine the nature of the coronary lesions, and also by assessment of their functional significance to guide the decision whether to perform percutaneous coronary intervention. We report a case of coronary angiography at five-year follow-up after transplantation, using optical coherence tomography and fractional flow reserve to assess and optimize treatment of coronary disease in this challenging population.