Juan Francisco Oteo

Fatal Pulmonary Embolization of a Right Atrial Mass During Transesophageal Echocardiography

Transesophageal echocardiography is a semi-invasive diagnostic technique with a very low incidence of significant complications. Only two deaths related to the procedure have been reported in the literature. We present the case of a 46-year-old man with a right atrial mass, presumably a cardiac myxoma. During attempts at esophageal intubation for a transesophageal echocardiography procedure, the mass fragmented and dislodged, causing massive pulmonary embolism and death. We believe that to avoid this potential complication, great care must be taken in the evaluation of patients with a right intracardiac mass by means of transesophageal echocardiography.

Coronary Artery Fistula as a Bypass of a Left Anterior Descending Coronary Artery Stenosis

We present a case of coronary artery fistula originating from the proximal left anterior descending coronary artery anterior to a critical atheromatous stenosis, draining into the main trunk of the pulmonary artery and with a third branch draining into the coronary vessel itself, distal to the lesion. The diagnosis was made when we were performing a diagnostic coronary arteriography on a patient with unstable angina. The possible association of the fistula and coronary atherosclerosis is discussed.

Analysis of diagnostic and therapeutic strategies in advanced cardiac light-chain amyloidosis

BACKGROUND Prognosis of advanced cardiac light-chain amyloidosis (ACAL) is ominous. Diagnosis of ACAL is frequently preceded by several biopsies of non-clinically affected tissues, which can result in dangerous treatment delays. Combinations of alkylators and steroids have a limited role in its therapy. Definitive efficacy of bortezomib in ACAL is not widely described. In this study we analyze the diagnostic yield of biopsies and compare the effect of bortezomib with other therapeutic strategies in ACAL patients. METHODS This study is a retrospective analysis of 40 consecutive ACAL patients treated at our hospital (2005 to 2015). For comparison purposes, the cohort was divided into 2 groups: patients treated with bortezomib (n = 23) and those treated with other therapeutic approaches (non-bortezomib, n = 8). RESULTS Sensitivity of biopsies of non-clinically affected organs was 23%, as compared with 97% for affected organ biopsies (p < 0.0001). The need for >2 biopsies resulted in an average delay in diagnosis of 4.1 months (p = 0.007). Hematologic response was observed in 96% of patients in the bortezomib group compared with 25% in the non-bortezomib group (relative risk = 3.8; 95% confidence interval 1.14 to 12.75; p = 0.0002). Cardiac response criteria were met by 60% of patients in the bortezomib group as compared with none in the non-bortezomib group (p = 0.005). Survival at 6 months and 1 and 2 years for bortezomib patients was 91%, 91% and 73%, as compared with 58%, 15% and 0% for non-bortezomib patients (log rank, p < 0.0001), respectively. CONCLUSION In our experience, the sensitivity of biopsies from non-affected organs in ACAL is poor and could result in diagnostic delay. Bortezomib was associated with higher hematologic and cardiac response rates as well as survival when compared with other therapies.

Magnetic Resonance for Noninvasive Detection of Microcirculatory Disease Associated With Allograft Vasculopathy: Intracoronary Measurement Validation.

INTRODUCTION AND OBJECTIVES Cardiac allograft vasculopathy affects both epicardial and microcirculatory coronary compartments. Magnetic resonance perfusion imaging has been proposed as a useful tool to assess microcirculation mostly outside the heart transplantation setting. Instantaneous hyperemic diastolic flow velocity-pressure slope, an intracoronary physiology index, has demonstrated a better correlation with microcirculatory remodelling in cardiac allograft vasculopathy than other indices such as coronary flow velocity reserve. To investigate the potential of magnetic resonance perfusion imaging to detect the presence of microcirculatory remodeling in cardiac allograft vasculopathy, we compared magnetic resonance perfusion data with invasive intracoronary physiological indices to study microcirculation in a population of heart transplantation recipients with macrovascular nonobstructive disease demonstrated with intravascular ultrasound. METHODS We studied 8 heart transplantation recipients (mean age, 61 [12] years, 100% male) with epicardial allograft vasculopathy defined by intravascular ultrasound, nonsignificant coronary stenoses and negative visually-assessed wall-motion/perfusion dobutamine stress magnetic resonance. Quantitative stress and rest magnetic resonance perfusion data to build myocardial perfusion reserve index, noninvasively, and 4 invasive intracoronary physiological indices were determined. RESULTS Postprocessed data showed a mean (standard deviation) myocardial perfusion reserve index of 1.22 (0.27), while fractional flow reserve, coronary flow velocity reserve, hyperemic microvascular resistance and instantaneous hyperemic diastolic flow velocity-pressure slope were 0.98 (0.02), cm/s/mmHg, 2.34 (0.55) cm/s/mmHg, 2.00 (0.69) cm/s/mmHg and 0.91 (0.65) cm/s/mmHg, respectively. The myocardial perfusion reserve index correlated strongly only with the instantaneous hyperemic diastolic flow velocity-pressure slope (r=0.75; P=.033). CONCLUSIONS Myocardial perfusion reserve index derived from a comprehensive dobutamine stress magnetic resonance appears to be a reliable technique for noninvasive detection of microcirculatory coronary disease associated with cardiac allograft vasculopathy.

Unusual Complications of Cardiac Catheterization Via the Radial Artery

Use of the radial artery for cardiac catheterization has significantly reduced the incidence and severity of complications at the access site. Nevertheless, occasionally unusual complications or atypical responses to treatment are observed. We describe two cases: a radial artery pseudoaneurysm that was unresponsive to compression treatment and a foreign-body inflammatory reaction at the radial artery access site. The characteristics, development and treatment of the 2 cases are described, and the pathogenic mechanisms are discussed.

Complicaciones inusuales del cateterismo por vía radial

El uso de la via transradial para el cateterismo cardiaco ha reducido drasticamente la incidencia y la gravedad de las complicaciones relacionadas con el acceso. No obstante, en ocasiones se producen complicaciones inusuales o cuya respuesta al tratamiento es atipica. Describimos 2 casos: un seudoaneurisma radial refractario al tratamiento compresivo y una reaccion inflamatoria a cuerpo extrano en el lugar de la puncion arterial. Se ilustran ambos casos, se detallan su evolucion y tratamiento y se discute su mecanismo patogenico.

Implicaciones pronósticas de la morfología asimétrica en la implantación de prótesis aórticas transcatéter: A propósito de un caso

Transcatheter implantation of aortic valve prostheses is being performed with increasing frequency in patients with severe symptomatic aortic stenosis who are at high surgical risk. Either a transfemoral or a transapical approach is employed. Complications related to the procedure are relatively uncommon, but they provide information that is very useful for broadening our knowledge of the pathophysiology of prosthesis dysfunction. A 76-year-old man with severe aortic stenosis underwent transcatheter aortic valve implantation because of high surgical risk due to ischemic heart disease and severe chronic obstructive pulmonary disease. Intraoperative transesophageal echocardiogram (TEE) performed prior to the procedure revealed a severely calcified aortic valve, especially left coronary (Thebesian) valve; the ejection fraction was 42%. Balloon valvuloplasty was carried out, followed by implantation of a 26-mm SAPIEN valve (Edwards Lifesciences; Irvine, California, USA), performed without complications. Immediately after inflation, TEE confirmed that the aortic prosthesis was well positioned, with adequate valve mobility. However, probably due to the severe eccentric calcification, the prosthesis had an asymmetric morphology, with an oval shape and abnormal stretching of the valve, which was oriented along the major axis (Fig. 1). Despite this appearance, the results of the procedure were considered to be satisfactory because the prosthesis appeared to be functioning normally, with mild central and minimal paravalvular regurgitation. Initially, the patient progressed well and was extubated on the first day; however, the next day he developed acute pulmonary edema, with rapid clinical deterioration. An emergency echocardiogram revealed severe aortic regurgitation, and the patient underwent an emergency intervention involving extracorporeal surgery with implantation of a Perimount bioprosthesis (Edwards Lifesciences; Irvine, California, USA). The patient died of cardiogenic shock during the postoperative period. Visual inspection of the explanted SAPIEN valve showed an elliptical morphology with a major diameter of 27 mm and a minor diameter of 20 mm, measurements that agree with those made by means of TEE during the procedure (Fig. 2). Moreover, as documented with TEE, one of the valves was abnormally taut and elongated, with limited mobility. The Edwards-SAPIEN valve is a prosthesis made of bovine pericardium mounted on an expandable stent that is placed in subcoronary position. Nine years after the first case in humans, favorable results have been reported for both the transfemoral and the transapical approach. The complete and symmetric expansion of the prosthesis in the aortic annulus is very important for its normal function and the aim should be to achieve this in every case. In fact, when the valve has a circular aspect, a success rate of 98% can be expected, whereas an oval morphology is associated with suboptimal function and durability. In our case, the massive presence of eccentric calcium in the left coronary valve of the native valve presumably provoked abnormal stress in the anteroposterior direction and impeded uniform circular expansion. In fact, the major diameter of the prosthesis was greater than the nominal diameter, which indicates that the problem was not an insufficient inflation pressure, but the lack of deformability of the annulus in a given direction. The consequence was an abnormal tautness in the valve oriented along the major axis, which resulted in limited mobility, inadequate coaptation, and finally, severe aortic regurgitation. Although this aortic insufficiency was considered to be mild at the end of the procedure because of the narrow width of the jet, the abnormal geometry of the prosthesis may have been what caused the progression to severe regurgitation during the postoperative period. Severe asymmetric valve calcification is a risk factor for incomplete expansion of the prosthesis and requires special attention to technique, even balloon oversizing. The failure to

Failure of Percutaneous Closure of Prosthetic, Aortic Paravalvular Leak

We report the progression of aortic insufficiency after percutaneous closure of an aortic prosthesis paravalvular leak with the Amplatzer vascular plug (AGA Inc, Golden Valley, MN). Removal of the device and replacement of the aortic prosthesis was successfully performed. Based on operative findings, we hypothesize that shape mismatch between the occluder system and the leak might promote tearing at the end of slanted defects further enhancing the regurgitant area.

Radial Artery Pseudoaneurysm Following Cardiac Catheterization: Clinical Features and Nonsurgical Treatment Results

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Trasplante cardíaco en un paciente con artritis reumatoide

Una mujer de 56 anos con artritis reumatoide(AR) fue diagnosticada de miocardiopatia dilatadaidiopatica. Curso con insuficiencia cardiaca progresiva.Se realizo trasplante cardiaco a pesar de lacontroversia existente sobre su realizacion en pacientescon enfermedades sistemicas. La evoluciona los 33 meses ha sido favorable, tanto del injertocomo de la AR. La medicacion inmunosupresoraobligada en el trasplante ayudo al control de su enfermedadarticular.