John P. Sweeney

Transcatheter Amplatzer device closure of atrial septal defect and patent foramen ovale in patients with presumed paradoxical embolism.

OBJECTIVE To review our experience with, and profile the safety and efficacy of, the Amplatzer PFO (patent foramen ovale) occluder (APO) and Amplatzer septal occluder (ASO) used to close PFO and/or atrial septal defect (ASD) in patients with paradoxical embolism (PE). PATIENTS AND METHODS Between April 1998 and November 2002, 103 patients at the Mayo Clinic in Rochester, Minn, and Scottsdale, Ariz, mean age 52.4 years, with presumed PE (transient ischemic attack [n=22], stroke [n=77], or peripheral emboli [n=4]) underwent transcatheter device closure of PFO (n=81), ASD (n=12), and ASD/PFO (n=10) with 106 devices (APO [n=22] or ASO [n=84]). RESULTS All devices deployed successfully, and no patients died. Procedural complications included atrial fibrillation (n=2), vessel injury (n=3), profound sinus node dysfunction (n=1), and device embolization with successful retrieval (n=1). At 3 months, 7 of 95 monitored patients had trivial residual shunt; at 12 months, 2 of 28 monitored patients had trivial residual shunt. Three patients had recurrent events--2 transient ischemic attacks and 1 retinal artery occlusion--at a mean +/- SD follow-up of 8.3 +/- 8.1 months (range, 1-34 months). None of these 3 patients had residual shunt or evidence of intracardiac thrombus. The average annual recurrence of all events was 3.6% at 23 months. The overall mean +/- SD freedom from recurrence of all events was 98.9% +/- 1.2% and 83.8% +/- 10.2% at 12 and 29 months of follow-up, respectively. CONCLUSIONS Transcatheter device closure of PFO and/or ASD with use of APO/ASO in patients with presumed PE is effective and safe. Recurrent events may occur in the absence of a residual shunt.

Aneurysms of the inferior vena cava

Aneurysms of the inferior vena cava are very rare. We describe a case of a saccular aneurysm of the inferior vena cava that thrombosed after vigorous exercise. This presented as deep venous thrombosis associated with a retroperitoneal mass. Laparotomy with biopsy confirmed the benign nature of this lesion, and symptoms gradually resolved. It is hypothesized that the increased intraabdominal pressure during exercise led to the thrombosis of what is presumed to be a congenital aneurysm of the inferior vena cava.

Transcatheter, valve-in-valve transapical aortic and mitral valve implantation, in a high risk patient with aortic and mitral prosthetic valve stenoses

Transcatheter valve implantation continues to grow worldwide and has been used principally for the nonsurgical management of native aortic valvular disease-as a potentially less invasive method of valve replacement in high-risk and inoperable patients with severe aortic valve stenosis. Given the burden of valvular heart disease in the general population and the increasing numbers of patients who have had previous valve operations, we are now seeing a growing number of high-risk patients presenting with prosthetic valve stenosis, who are not potential surgical candidates. For this high-risk subset transcatheter valve delivery may be the only option. Here, we present an inoperable patient with severe, prosthetic valve aortic and mitral stenosis who was successfully treated with a trans catheter based approach, with a valve-in-valve implantation procedure of both aortic and mitral valves.

Paradoxical coronary artery embolism - A rare cause of myocardial infarction

Paradoxical coronary artery embolism is a rare, but often an underdiagnosed cause of acute myocardial infarction. It should be considered in patient who presents with chest pain and otherwise having a low risk profile for atherosclerosis coronary artery disease. We describe a case of paradoxical coronary artery embolism causing ST segment elevation myocardial infarction in a patient with upper extremity venous thrombosis. Echocardiography demonstrated a patent foramen ovale (PFO) with bidirectional shunt. In addition to treatment of acute coronary event closure of the PFO should be considered to prevent a recurrence.

Endovascular retrieval of a TrapEase permanent inferior vena cava filter from the aorta

Intra-aortic inferior vena cava filter placement is a rare event. We describe a case in which a permanent vena caval filter was retrieved from the aorta with endovascular techniques. Knowledge of filter design, catheters, and available wires is important to perform this procedure safely.

Subepicardial Aneurysm Evaluated by Multiplane 2D and Real-Time 3D Volumetric Transesophageal Echocardiography

A 76-year-old man with a history of hypertension, dyslipidemia, and 90 pack-year smoking, presented to his primary care physician with complaints of worsening dyspnea. His ECG finding did not show any pathological Q-wave or ST-T abnormalities (Online Figure I). A 2D transthoracic echocardiogram revealed normal left ventricular (LV) systolic function with inferior and inferolateral wall motion abnormalities. A suspicious aneurysm was also noted (Figure 1). His adenosine stress nuclear perfusion images showed a moderate-sized area of ischemia or jeopardized myocardium involving the infero-lateral LV (Online Figure II). He underwent cardiac catheterization, which revealed an occluded right coronary artery and significant left-to-right collaterals (Figure 2). Left ventriculography revealed a hypokinetic basal inferior wall and an aneurysm (Figure 3, Movie I). A follow-up transesophageal echocardiogram was performed using an x7–2t …

Relief of pseudostenosis using the transit exchange catheter

Pseudostenosis is a generally benign complication of percutaneous coronary intervention that is caused by the mechanical deformation of a tortuous artery by the guidewire. We describe two cases of a tortuous right coronary artery in which pseudostenosis was relieved by placing a Transit exchange catheter (Cordis) distally and subsequently removing the guidewire. This technique safely confirmed the diagnosis of pseudostenosis without losing guidewire position or requiring additional wires and balloons. Catheter Cardiovasc Interv 2004;63:457–461.

Turf wars and silos--the effect of disruptive technologic innovation in the treatment of cerebral and peripheral vascular disease.

It is with interest and enthusiasm that we read the editorial comment authored by Hopkins et al [1]. The authors describe the traditional organization of medicine, which has led to the creation of department silos. They very elegantly play out the problem of turf wars because of this silo system and correctly point out that this approach led to tremendous advantages and expertise in that physicians were able to concentrate their energy and efforts and become true specialists. The authors note that turf wars continue to exist today driven by a number of factors including actual and potential declining reimbursement, changes in training programs with increased interest in organ system rather than specific organs, development of miniaturization techniques and less invasive approaches, and the advances of imaging, which allow subspecialty physicians to perform and interpret images. We define all of these factors as disruptive technical innovations. These changes are not limited solely to health care. The business literature is laced with many classic case reports of companies that have both floundered and flourished because of disruptive technical innovations. One of the classic cases described in business schools is that of the company that transformed a disruptive technology to their advantage [2]. Crown Cork and Seal was a major producer of cork-lined bottle caps at the turn of the century. As disruptive technological innovations continued in the bottling business, this corporation had to make numerous decisions on how to proceed. Were they simply to remain a bottle cap maker or were they in the business of manufacturing containers—metal cans, glass bottles, bottle caps, and plastic bottles? They chose to respond to a changing market place and have evolved into a corporation with operations in 42 countries employing over 24,000 people and net sales of

Left Ventricular Septal Hypertrophy in Elderly Patients With Aortic Stenosis

6.9 billion. Are vascular surgeons going to continue to simply be surgeons? Will cardiologists continue to only care for the vessels of the heart? Will interventional radiologists continue to perform interventions in isolation without preoperative assessments and postoperative care? We believe that all disciplines involved in the care of cerebrovascular and peripheral vascular patients should respond to the challenges that disruptive technology presents and not simply remain isolated and stagnant in a turf battle. The question of how to overcome this turf war is a difficult one. In business, different approaches are available. One such approach is simply to acquire innovative technologies by purchasing another corporation. Another approach is joint ventures and mergers. The editorial comment by Hopkins et al. suggest that in the field of medicine and specifically in the field of cerebral vascular and peripheral vascular care, mergers would work best [1]. Not only would they be more efficient and streamline patient care, but they would also reduce the number of human errors that occur when treating these patients. The difficulties with close collaboration are potentially tremendous. Breaking down silos and avoiding turf wars is potentially a difficult problem—in some instances, an insurmountable problem. Although our situation is unique in that we are a large multispecialty group of salaried physicians, we describe how a merger was successfully accomplished at our institution. As was successfully pointed out by Hopkins and coauthors, the first potential step is communication. This was accomplished here by fortnightly ‘‘vascular’’ conferences. These multidisciplinary conferences helped reduce the animosity among the groups and increased proximity. Getting to know the perceived adversary went a long way to dispel preconceived notions. After analyzing some of the business literature, it became obvious that communication was only a first step. The next step was to recognize that the whole is significantly greater than the sum of its parts. This is not just a true emotional statement, but also a fiscal statement. By effectively utilizing all talents and facilities, the group benefited with increased volumes for all the subspecialties.

Meta-Analysis of Studies Comparing Dual- Versus Mono-Antiplatelet Therapy Following Transcatheter Aortic Valve Implantation

Left ventricular (LV) septal hypertrophy in aortic stenosis raises diagnostic and therapeutic questions. However, the etiology and clinical consequences of this finding have not been well studied. The aim of this study was to perform a morphologic evaluation of the LV in aortic stenosis and to investigate the contributing factors and consequences of septal hypertrophy.