Manuel Oliveira-Santos

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.

Subclinical thrombosis of a chronically lost stent

A 69-year-old man presented with stable angina and ischaemia on a treadmill test. He had a left internal mammary artery (LIMA) to left anterior descending artery (LAD) bypass graft seven years earlier. After 4 years, he had a percutaneous coronary intervention (PCI) of the right coronary artery (RCA). Coronary angiography showed LAD occlusion and patent LIMA graft. The RCA was calcified with good result of the previous ostial intervention but there was a linear radiopaque image in the mid segment (Panels A and A’, arrows; Supplementary ma terial online, Video S1). We suspected an unexpanded stent was lost inside the RCA and performed optical coherence tomography (OCT) to clarify the situation. OCT revealed the presence of a metallic tubular structure suggestive of an ‘abandoned’ stent (Panel B; Supplementary material on line, Video S2). Noticeably, there was red thrombus (Panel C, asterisk) adherent to the distal part of the unexpanded stent (Panel C, arrow) resulting in significant decrease of luminal area. Therefore, we decided to crush the stent to the arterial wall with a drug eluting stent (Panel D, arrows; Supplementary material online, Video S3). Patient angina was relieved and subsequent follow-up was uneventful. Unnoticed loss of an unexpanded stent is a known infrequent complication of PCI. This case emphasizes that, after three years, a lost coronary stent will not lead to endothelialization and may have adherent thrombus, even in a non-acute setting. Therefore, crushing the stent should be considered to relieve symptoms and to reduce the risk of stent thrombosis.

Aortic Valve Disease and Vascular Mechanics: Two‐Dimensional Speckle Tracking Echocardiographic Analysis

Degenerative aortic valve disease (AVD) is a complex disorder that goes beyond valve itself, also undermining aortic wall. We aimed to assess the ascending aortic mechanics with two‐dimensional speckle tracking echocardiography (2DSTE) in patients with aortic regurgitation (AR) and hypothesized a relationship with degree of AR. Aortic mechanics were then compared with those of similarly studied healthy controls and patients with aortic stenosis (AS); finally, we aimed to assess the prognostic significance of vascular mechanics in AVD.