Juan Alcibar

Implantación primaria de stent en la coartación de aorta: seguimiento a medio plazo

Introduccion El stent ha sido aceptado como modalidad de tratamiento en diversas cardiopatias congenitas. Los resultados de la angioplastia con balon en la coartacion y en la recoartacion pueden ser mejorados y reducirse sus complicaciones. Objetivo Describimos nuestra experiencia en el tratamiento con stent de la coartacion y recoartacion, implantados con tecnica primaria. Pacientes y metodo En el estudio participaron 14 pacientes con edad media de 20 ± 12 anos. Once presentaban coartacion nativa y 3 recoartacion posquirurgica, dos de ellos con cardiopatia asociada. Diez tenian una forma localizada-diafragmatica, uno de ellos con hipoplasia moderada del arco, 2 con distorsion de aorta y 2 con obstruccion completa de la luz. Cinco pacientes presentaban hipertension y uno obstruccion completa preshock cardiogenico y arritmias gravisimas por miocardiopatia. Se implantaron 7 P308 y 7 P4014 con tecnica primaria y proteccion con vaina. La relacion diametro balon/diametro de aorta en el diafragma fue de 1. En 2 casos con obstruccion completa describimos una tecnica especial. Resultados En los 14 casos el procedimiento fue efectivo. El diametro de la luz aumento de 4 ± 2 a 15 ± 2 mm (p Conclusiones a) El stent en la coartacion y recoartacion puede ser una alternativa al tratamiento quirurgico en ninos mayores, adolescentes y adultos; b) es una tecnica especialmente atractiva en casos de mayor dificultad/riesgo quirurgico; c) creemos que se limita el numero de complicaciones mediante la tecnica primaria, y d) aportamos una tecnica especial con circuito arterial humeral izquierda-femoral derecha y angioplastia con cateter coronario para los casos con obstruccion completa.

Experiencia con el stent de Palmaz en la estenosis de rama pulmonar

Introduccion y objetivos El stent de Palmaz(Johnson & Johnson Interventional Systems) expandiblecon balon se utiliza para el tratamientode las cardiopatias congenitas desde 1989. Este estudiodescribe los resultados y la tecnica de su implantacionpara el tratamiento de las estenosis derama pulmonar nativa y secundaria a la retraccioncicatrizal posquirurgica en nuestro medio. Materiales y metodos Desde el mes de febrerode 1995 a junio de 1996, hemos aplicado la tecnicaen 11 ninos/jovenes sintomaticos con estenosis derama pulmonar, con una edad media de 11 ± 2 anos.Se realizaron 14 procedimientos y se implantaron16 stents. Como patologia de base presentaban: 7 tetralogia de Fallot con correccion total previa,uno sindrome de Noonan con comunicacion interauricularoperada, uno aneurisma del tronco pulmonarcon estenosis valvular y de rama con cirugiaprevia, uno atresia pulmonar del septo integro convalvulotomia quirurgica y posterior valvuloplastiapercutanea con buen desarrollo ventricular posteriory uno atresia tricuspidea con Waterston previoque estenosaba la rama derecha con posterior Fontanmodificado y estrechamiento severo de ramapulmonar media e inferior derecha. Se encontrabanafectados los ostium de rama en 5 casos y uno deellos de forma bilateral con hipoplasia difusa derama derecha. Nueve de las estenosis fueron nativasy 4 secundarias a cirugia previa (2 Waterston, 1 Blalock-Taussig y 1 Fontan). La via de acceso fuela vena femoral derecha y/o izquierda en todos loscasos menos en 2, en los que se realizo via yugularinterna. Se siguio la tecnica descrita en la experienciaBoston-Houston, con guia de alto soporte yvaina de Mullins hasta el punto de la estenosis. Resultados El procedimiento fue efectivo en todoslos casos menos en uno. El diametro de la ramapulmonar fue de 11 ± 3 mm, el del balon de 14 ± 2mm y su relacion 1,2. El diametro de la estenosisaumento de 4,8 ± 1 a 11 ± 2 mm (p Complicaciones Migracion del stent en un casocon extraccion quirurgica. Conclusiones La implantacion del stent de Palmazes un procedimiento eficaz para el tratamientode la estenosis pulmonar nativa o posquirurgica. Esposible su aplicacion en formas hipoplasicas y ostiales.Se confirma la validez de la reexpansion amedio plazo.

Elective Implantation of Covered Stents for Coarctation and Recoarctation in Adolescents and Adults

INTRODUCTION AND OBJECTIVES Stent implantation is an effective therapy for aortic coarctation and recoarctation. However, in adolescents and adults, aortic wall rupture and dissection can occur, as well as aneurysms during follow-up. In order to reduce these complications, we electively implant covered stents. METHODS Since 2005, we have performed the procedure using femoral access in 17 patients (2 adolescents and 15 adults), 16 electively and 1 as a rescue procedure. We used the Mullins technique in all cases, implanting a NuMED(®) covered stent. RESULTS Good stent apposition was achieved in all 17 procedures; 8 patients required a distal flare. Gradient was reduced from 40 (16) mmHg to 2 (2) mmHg (P<.001) and lumen diameter increased from 4 (2) mm to 19 (3) mm (P<.001). Two exceptional cases are discussed: one patient with aortic wall rupture who underwent a rescue procedure using a stent within a covered stent and another patient with total obstruction and intercostal aneurysm in whom the outcome was fatal at 48 h postprocedure (autopsy is shown). Four-year clinical follow-up included Doppler echocardiography; an additional imaging technique was required in 13 patients. All patients recovered well and there were no complications. CONCLUSIONS Covered stents are effective in treating coarctation and recoarctation in adolescents and adults, are the treatment of choice in patients with complex anatomy, and must be available in the operating room as a rescue device when implanting a conventional stent.

Percutaneous Closure of Complex Fistula Between the Internal Mammary Artery and a Lobar Branch of a Pulmonary Artery

A through review of the literature identified only 20 reported cases of fistula involving the internal mammary (internal thoracic) artery and a lobar branch of a pulmonary artery. Surgical closure was frequently done to avoid complications associated with this anomaly. We report the first patient in whom percutaneous treatment was accomplished with a combined technique involving an Amplatzer Duct Occluder device and coils.

Cierre percutáneo de una fístula compleja entre la arteria mamaria interna y la arteria lobar pulmonar

Tras una revision exhaustiva de la literatura, hemos encontrado tan solo 20 casos reportados de fistulas entre la arteria mamaria interna (AMI) y las arterias pulmonares. Frecuentemente se indica su cierre quirurgico por las complicaciones que pueden acarrear. Presentamos el primer caso en el que el tratamiento se realiza de forma percutanea mediante una tecnica mixta con un dispositivo Amplatzer Duct Occluder (ADO) asociado a coils

OCLUSION DE LA VENA LEVOATRIOCARDINAL CON COILS DE GIANTURCO TRAS LA CIRUGIA DE FONTAN

Se presenta el caso de una nina de 6 anos con atresia mitral, ventriculo izquierdo hipoplasico y gran ventriculo derecho del que emergen los grandes vasos con relacion normal y obstruccion pulmonar, a la que se realizo Fontan modificado fenestrado con baffle de Gore-Tex. En la evolucion presento cianosis y desaturacion significativa en relacion con la presencia y desarrollo de una vena levoatriocardinal que fue tratada mediante coils de Gianturco eficazmente. Se comentan las posibilidades de cortocircuito derecha-izquierda post-Fontan, y su tratamiento percutaneo como alternativa a la cirugia y las caracteristicas tecnicas y angio graficas favorables del presente caso.

Pediatrics Spanish Registry of Percutaneous Melody Pulmonary Valve Implantation in Patients Younger Than 18 Years

INTRODUCTION AND OBJECTIVES A decade has passed since the first Spanish percutaneous pulmonary Melody valve implant (PPVI) in March 2007. Our objective was to analyze its results in terms of valvular function and possible mid-term follow-up complications. METHODS Spanish retrospective descriptive multicenter analysis of Melody PPVI in patients < 18 years from the first implant in March 2007 until January 1, 2016. RESULTS Nine centers were recruited with a total of 81 PPVI in 77 pediatric patients, whose median age and weight were 13.3 years (interquartile range [IQR], 9.9-15.4) and 46kg (IQR, 27-63). The predominant cardiac malformation was tetralogy of Fallot (n = 27). Most of the valves were implanted on conduits, especially bovine xenografts (n = 31). The incidence of intraprocedure and acute complications was 6% and 8%, respectively (there were no periprocedural deaths). The median follow-up time was 2.4 years (IQR, 1.1-4.9). Infective endocarditis (IE) was diagnosed in 4 patients (5.6%), of which 3 required surgical valve explant. During follow-up, the EI-related mortality rate was 1.3%. At 5 years of follow-up, 80% ± 6.9% and 83% ± 6.1% of the patients were free from reintervention and pulmonary valve replacement. CONCLUSIONS Melody PPVI was safe and effective in pediatric patients with good short- and mid-term follow-up hemodynamic results. The incidence of IE during follow-up was relatively low but was still the main complication.

Atresia bilateral de venas pulmonares

Rev Esp Cardiol 2002;55(6):671-2 671 Congenital atresia of the pulmonary veins is a rare anomaly that is not associated with other heart disease. It has a poor prognosis and patients die secondary to pulmonary hypertension, recurrent hemoptysis, pulmonary edema, or congestive cardiac insufficiency. We present a 5-year-old male patient admitted to the hospital for asthenia, anorexia, hemoptoic vomiting, and a severe cough. Marked dystrophy was observed, with a weight of less than the 3rd percentile, pale skin and mucous, and bilateral nystagmus. Cardiovascular examination did not reveal murmurs and the second heart sound was strong. With respect to echocardiogram data, on 4-chamber projection the connections of the left pulmonary veins and the right superior vein lobe to the left atrium were not seen; in the short axis projection the great vessels were in a normal relationship, with the diameter of the pulmonary artery being greater than the diameter of the ascending aorta, the IM AG E S I N C A R D I O L O G Y

Embolia pulmonar múltiple tras vertebroplastia con polimetilmetacrilato, con evolución fatal a pesar de la extracción percutánea de un microfragmento

A 74-year-old man with high blood pressure, dyslipidemia, and diabetes, who had been evaluated in our unit 13 months earlier for atrial fibrillation, underwent cardioversion with no apparent structural heart disease. One month later he was diagnosed with T4N3M0-stage adenocarcinoma of the lung and received chemotherapy and radiation therapy. In February 2011, the patient was hospitalized for intense lumbar pain of 10 days’ duration. Computerized tomography identified a compression fracture of the second lumbar vertebra (L2) due to metastasis. The neuroradiology team opted for vertebroplasty. With the patient under general anesthesia and prone decubitus, the procedure began with diagnostic vertebrography, immediately followed by bilateral transpedicular vertebroplasty in L2 introducing radiopaque bone cement (Biomet Bone Cement V, BIOMET). This is prepared by dissolving a powder containing methyl methacrylate (MMA), zirconium dioxide, and benzoyl peroxide in a 10 ml flask with MMA solution and dimethyl toluidine, which is then cooled. We obtained good results in the vertebra (Fig. 1A). However, we identified millimetric MMA fragments in both lungs and one larger, round fragment in a segmental branch of the inferior left lobule (Fig. 1B). We requested that the cardiac catheterization laboratory remove these. After positioning the patient in supine decubitus and using right femoral vein access, a 30 cm 20 Fr XLCFW 20.038-30 Endostent (COOK) delivery catheter–with 2 cuts made in the distal end–was deployed. With a multipurpose catheter, we accessed the pulmonary artery and performed selective angiography, enabling us to locate the cement fragment in the Rev Esp Cardiol. 2012;65(6):571–580

Implantación de stent en la fístula central aortopulmonar paliativa de las cardiopatías congénitas con hipoperfusión pulmonar. Experiencia de dos casos

Describimos la experiencia pionera de implantacion de stent en la fistula aortopulmonar central de politetrafluoroetileno microporoso expandido. Dos lactantes de 1 y 13 meses con cardiopatia cianogena y disfuncion de la protesis con hipoxia critica a las horas y a los 13 meses de su creacion. El cateterismo urgente demostro estenosis de la fistula en un caso y obstruccion completa en el otro. La angioplastia e implantacion de stent se realizo por via arterial retrograda y de forma libre en el primer caso (sin cateter guia) y con cateter guia coronario derecho de Judkins en el segundo con acceso venoso y paso desde el ventriculo derecho a la aorta. Se obtuvo mejoria de saturaciones mantenida. El primer caso fallecio por insuficiencia renal y se exponen los datos de la autopsia.