Jorge Gaspar

Graded balloon dilation atrial septostomy in severe primary pulmonary hypertension. A therapeutic alternative for patients nonresponsive to vasodilator treatment.

OBJECTIVES We sought to investigate the acute hemodynamic effects of graded balloon dilation atrial septostomy (BDAS) and to define the long-term impact of this procedure on New York Heart Association functional class and survival in adult patients with primary pulmonary hypertension (PPH). BACKGROUND Current treatment strategies for patients with severe and refractory PPH are limited by either technical difficulties and high mortality or cost. METHODS We studied 15 patients with severe PPH. BDAS was successfully performed in all patients by crossing the interatrial septum with a Brockenbrough needle, followed by progressive dilation of the orifice with a Mansfield balloon in a hemodynamically controlled, step-by-step manner. RESULTS BDAS caused an immediate significant fall in right ventricular end-diastolic pressure and in systemic arterial oxygen saturation and an increase in cardiac index. One patient died, and 14 survived the procedure and significantly improved their mean functional class (from 3.57 +/- 0.6 to 2.07 +/- 0.3 [mean +/- SD], p < 0.001). Exercise endurance (6-min test) also improved from 107 +/- 127 to 217 +/- 108 m (p < 0.001). Because of spontaneous closure, BDAS was repeated in four patients. The survival rate among patients who survived the procedure was 92% at 1, 2 and 3 years, which is better than that for historical control PPH patients (73%, 59% and 52%, respectively). CONCLUSIONS With careful monitoring, BDAS is a safe and useful palliative treatment for selected patients with severe PPH.

Potentiation of coronary vasoconstriction by beta-adrenergic blockade in patients with coronary artery disease.

Although,β-adrenergic blocking agents reduce myocardial oxygen consumption and symptoms of myocardial ischemia in patients with coronary artery disease (CAD), propranolol has been reported to exacerbate coronary artery spasm in some patients with variant angina. To determine whether increased coronary vasomotor tone can be induced by β-adrenergic blockade, we measured the changes in coronary vascular resistance (CVR) during cold pressor testing (CPT) in 15 patients, nine with severe CAD and six with normal left coronary anatomy, before and after i.v. propranolol (0.1 mg/kg). Coronary blood flow was measured by coronary sinus thermodilution. CVR was calculated as mean arterial pressure divided by coronary sinus blood flow. Heart rate was maintained constant at a paced subanginal rate of 95 ± 5 beats/min.Before propranolol, CPT induced significant increases in coronary vascular resistance in patients with CAD (15.0 ± 2.2%, p < 0.02), but no increase in CVR in the normal patients. After propranolol, the CVR change during CPT was augmented for patients with CAD (29 ± 6%, p < 0.01) and for the normal population (9 ± 5%, NS). The potentiated increase in CVR occurred without significant changes in resting CVR or in the magnitude of the hypertensive response to CPT.We conclude that,β-adrenergic blockade with propranolol can potentiate coronary artery vasoconstriction in some patients with CAD, possibly mediated by unopposed α-adrenergic vasomotor tone. These changes may be important in patients in whom intense adrenergic stimulation may increase coronary artery tone and adversely influence the balance between myocardial oxygen supply and demand.

Combined Clot Fragmentation and Aspiration in Patients With Acute Pulmonary Embolism

BACKGROUND Massive angiographic pulmonary embolism (PE) with right ventricular dysfunction (RVD) is associated with a high early mortality rate. The therapeutic alternatives for this condition include thrombolysis, surgical embolectomy, or percutaneous mechanical thrombectomy (PMT). We describe our experience using PMT in patients with massive PE and RVD with unsuccessful thrombolysis, increased bleeding risk, or major contraindications for thrombolytic therapy. METHODS Clinical, hemodynamic, and angiographic parameters prior to and following PMT were evaluated. Our primary objective was to describe the incidence of in-hospital cardiovascular death, and of major and minor complications. Mid-term outcomes included analysis of occurrence of cardiovascular death, recurrent pulmonary embolism, change of New York Heart Association functional class, and hospital readmission. RESULTS From July 2004 to May 2007, 69 patients were referred to the cardiac catheterization laboratory with a diagnosis of acute PE, 18 of whom met the criteria for massive PE and are the subject of this study. All patients underwent thrombus fragmentation using a pigtail catheter that was complemented in 13 patients with thrombus aspiration. A percutaneous thrombectomy device (Aspirex; Straub Medical; Wangs, Switzerland) was used in 11 patients. Hemodynamic, angiographic, and blood oxygenation parameters improved after the procedure. A significant increase was observed for systolic systemic BP (74.3+/-7.5 mm Hg vs 89.4+/-11.3 mm Hg, p=0.001) [mean+/-SD], as was a decrease in mean pulmonary artery pressure (37.1+/-8.5 mm Hg vs 32.3+/-10.5 mm Hg , p=0.0001). The in-hospital major complications rate was 11.1%; one patient died from refractory shock, and one patient had intracerebral hemorrhage with minor neurologic sequelae. No cardiovascular deaths or recurrent pulmonary thromboembolism were documented during clinical follow-up (12.3+/-9.4 months). CONCLUSIONS In patients with massive PE, RVD and major contraindications to thrombolytic therapy, increased bleeding risk, failed thrombolysis, or unavailable surgical thrombectomy, PMT appears to be a useful therapeutic alternative.

Attenuation of coronary vascular resistance by selective alpha1,-adrenergic blockade in patients with coronary artery disease

Alpha-adrenergic-mediated coronary vasoconstriction during stress such as cold pressor testing may contribute to myocardial ischemia by increasing coronary vascular resistance in patients with severe coronary artery disease. Nonselective alpha-receptor blockade with phentolamine abolishes both the peripheral and coronary vasoconstriction during cold pressor testing, but causes reflex tachycardia and increased inotropy. To determine the role of selective alpha 1-receptor blockade, the changes in coronary vascular resistance during cold pressor testing were measured in 18 patients with coronary artery disease before and after intravenous administration of 100 mg of trimazosin. Cold pressor testing was performed at a constant paced subanginal heart rate of 95 +/- 5 beats/min (+/- 1 SD). Before trimazosin, cold pressor testing increased mean arterial pressure by 9 +/- 4% (102 +/- 14 to 111 +/- 14 mm Hg, p less than 0.001) with no change in coronary sinus blood flow, but significantly increased coronary vascular resistance by 15 +/- 19% (1.02 +/- 0.46 to 1.15 +/- 0.57 units, p less than 0.05). Five minutes after trimazosin, cold pressor testing increased mean arterial pressure by 6 +/- 5% (p less than 0.001) with a marked attenuation of the increase in coronary vascular resistance (6 +/- 11%, p = NS), which was significantly less than before trimazosin (p less than 0.02). Trimazosin did not increase plasma norepinephrine concentration at rest, suggesting that in the dosage used trimazosin caused selective alpha 1-receptor blockade.(ABSTRACT TRUNCATED AT 250 WORDS)

Phasic pressure gradients across coronary and renal artery stenoses in humans

Fluid-filled catheter-transducer systems have been developed for assessment of phasic pressure gradients across arterial stenoses. The two catheters we have employed are 3 French and 2 French in diameter. After the catheters are flushed with carbon dioxide and filled with degassed saline solution to remove microbubbles of air, the catheters are attached to a low-volume displacement transducer. The frequency response of both catheter-transducer systems is adequate to record phasic arterial pressures. The catheters are very flexible and radioopaque, and the ability to monitor phasic pressure continuously at the tip during passage across a stenosis enhances safety of their use. The catheters have been employed successfully to measure phasic pressure gradients across 36 coronary and five renal artery stenoses. Maximal pressure gradients were observed in early diastole for coronary stenoses and in systole for renal artery stenoses, consistent with known differences in phasic flow patterns in these vascular beds. The pressure gradients in patients with coronary stenoses could be markedly increased by injection of contrast medium (Renograffin 76). Relatively poor correlation was observed between the resting pressure gradients and the angiographically defined degree of coronary stenoses.

Endovascular treatment of type B dissection in patients with Marfan syndrome: mid-term outcomes and aortic remodeling.

To evaluate the mid‐term outcomes, and the aortic remodeling in Marfan syndrome (MFS) patients with type B dissection that were treated with endovascular repair.

Echocardiographic Evaluation of Patients with Primary Pulmonary Hypertension Before and After Atrial Septostomy.

Objectives: To characterize the early changes in right ventricular [right ventricle (RV)] geometry and function, as assessed by two‐dimensional (2‐D) and Doppler echocardiography, after balloon‐dilation atrial septostomy (BDAS) in patients with severe primary pulmonary hypertension (PPH). Background. Survival in PPH is to a great extent dependent on the functional status of the RV. BDAS recently has been shown to improve functional class and hemodynamics in patients with PPH nonresponsive to conventional vasodilator treatment. Methods: Ten patients with severe PPH who underwent BDAS were studied with transthoracic and transesophageal 2‐D and Doppler echocardiography. RV dimensions were measured in the apical four‐chamber view. Continuous‐wave Doppler echocardiography was used to obtain peak velocity of tricuspid regurgitation. Transesophageal echocardiography (TEE) primarily was used for the follow‐up of the atrial septal defects (ASDs). Results: In the early post‐BDAS studies, right atrial and ventricular dimensions significantly decreased in all patients (P < 0.05). Global right ventricular wall motion (RVWM) also improved. RV percent change in area after septostomy inversely correlated with the changes in RV systolic area (r =–0.75; P < 0.05) and also with the baseline (preprocedure) values of RV percent change in area (r =–0.77; P < 0.05). Neither RV wall thickness nor the degree of tricuspid regurgitation were modified significantly after the procedure. Conclusions: BDAS in the setting of severe PPH results in moderate and salutary changes in geometry and function of the RV as assessed by 2‐D echocardiography. These changes mainly appear to be the result of the decompression effect of atrial septostomy.

Effects of prostacyclin on coronary hemodynamics at rest and in response to cold pressor testing in patients with angina pectoris

To assess the effect of prostacyclin on the diseased coronary circulation basally and, in particular, on the coronary responses to the cold pressor test, a small dose of 4 ng/kg/min and a large dose of 8 to 10 ng/kg/min was infused in 11 patients with stable angina pectoris. Coronary blood flow was measured by coronary sinus thermodilution technique. The mean blood pressure decreased from 97 +/- 5 to 89 +/- 5 mm Hg during the low-dose infusion (p less than 0.005) and to 81 +/- 5 mm Hg during the high-dose infusion (p less than 0.001); the heart rate increased from 65 +/- 4 to 69 +/- 4 beats/min during the low-dose infusion (p less than 0.05) and to 78 +/- 5 beats/min during the high-dose infusion (p less than 0.001). Systemic vascular resistance decreased by 11 +/- 4% with small doses (p less than 0.05) and by 38 +/- 4% with large doses (p less than 0.001) of prostacyclin, and coronary vascular resistance decreased by 16 +/- 7% (p less than 0.05) with the small dose and by 29 +/- 6% (p less than 0.001) with the large dose of prostacyclin. Seven of 11 patients showed a baseline vasoconstrictor response to the cold pressor test (increase in coronary vascular resistance of 11 +/- 2%). This increase in coronary vascular resistance was not altered by either the small or the large dose of prostacyclin. Thus, prostacyclin causes marked coronary and systemic vasodilation, with no evidence of selective enhancement of the sensitivity of the diseased coronary circulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Start-up of the program of transcatheter aortic valve implantation using a balloon-expandable Edwards Sapien XT transcatheter heart valve: Description of the first case in Mexico

Degenerative aortic valve stenosis (AS) is the most common valvular heart disease. About two-thirds of all valve operations are for aortic valve replacement (AVR). After onset of symptoms (angina, syncope or heart failure) severe aortic stenosis has a poor prognosis with an average survival of two or three years and a high risk of sudden death. According to the ACC/AHA and the European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines for management of patients with heart valve disease, surgical aortic valve replacement is an indication class I in symptomatic patients with AS, and for patients with severe AS undergoing CABG or surgery of the aorta or other heart valves, and patients with severe AS and LV systolic dysfunction (ejection fraction < 50%). It is generally accepted that surgical AVR can improve the functional class and prolong survival. Nevertheless, 30% of elderly patients with symptomatic severe aortic valve stenosis do not undergo AVR, attributed to ‘‘inoperable’’ conditions or extremely high surgical risk, such as advanced age, pulmonary, renal, hepatic disease, prior cerebrovascular event, weakness or frailty, that increases the risk of poor outcomes. Recently, transcatheter aortic valve implantation (TAVI) has become a treatment option for patients with high or prohibitive surgical risk. The concept of transcatheter valve implantation was evaluated by Andersen in 1992 in a porcine model. In 2002 the first TAVI was accomplished by Dr. Alan Cribier, via a transeptal antegrade delivery technique using a balloonexpandable aortic valve. After this pioneering procedure, several registries and one multicenter randomized control trial have been published worldwide (Fig. 1). We describe the first case of TAVI performed in Mexico using a balloonexpandable Edwards Sapien XT transcatheter heart valve, Figure 1 Transcatheter aortic valve implantation.

Primary angioplasty limited to the culprit vessel in patients with multivessel disease: Impact on clinical outcomes

adverse events in patients with STEMI: meta-analysis of randomised controlled trials. Heart Feb 2012;98(4):303–11. [6] Vorobcsuk A, Konyi A, Aradi D, et al. Transradial versus transfemoral percutaneous coronary intervention in acute myocardial infarction systematic overview and metaanalysis. Am Heart J Nov 2009;158(5):814–21. [7] Lunn DJ, Thomas A, Best N, Spiegelhalter D. WinBUGS — a Bayesian modelling framework: concepts, structure, and extensibility. Stat Comput 2000;10:325–37. [8] Higgins Julian PT, Green Sally. Cochrane Handbook for Systematic Reviews of Interventions. Wiley-Blackwell ed. 2009.