Neeraj Jolly

Percutaneous transatrial mitral commissurotomy: Immediate and intermediate results

OBJECTIVES The purpose of this study was to evaluate the immediate and follow-up results of percutaneous transatrial mitral commissurotomy in 600 patients with rheumatic mitral stenosis. BACKGROUND Percutaneous transatrial mitral commissurotomy has emerged as an effective nonsurgical technique for patients with symptomatic mitral stenosis. Several studies have shown that the immediate results are comparable to closed and open mitral valvotomy. METHODS Percutaneous transatrial mitral commissurotomy was performed in 600 patients with rheumatic mitral stenosis by the double-balloon (290 patients [48.3%]) and flow-guided Inoue balloon (310 patients [51.7%]) techniques. There were 154 male (25.6%) and 446 female (77.4%) patients with a mean [+/- SD] age of 27 +/- 8 years (range 8 to 60). Atrial fibrillation was present in 26 patients (4.3%), mitral regurgitation < or = grade 2 in 62 (10.3%) and densely calcific valve in 12 (2%). All patients had clinical and echocardiographic (two-dimensional, continuous wave Doppler, color flow imaging) follow-up at 3-month intervals. RESULTS Percutaneous transatrial mitral commissurotomy was successful in 589 patients (98.1%), and optimal commissurotomy was achieved in 562 (93.6%), with an increase in mitral valve area from (mean +/- SD) 0.75 +/- 0.18 to 2.2 +/- 0.38 cm2 (p < 0.001) and a decrease in transmitral end-diastolic gradient from 27.3 +/- 6.1 to 3.8 +/- 4.2 mm Hg (p < 0.001). Mitral regurgitation developed or increased in 208 patients (34.6%). Six patients (1%) with mitral regurgitation required mitral valve replacement. Cardiac tamponade occurred in 8 patients (1.3%). Six patients (1%) died. Restenosis developed in 10 patients (1.7%) during a mean follow-up period of 37 +/- 8 months (range 6 to 66). CONCLUSIONS Percutaneous transatrial mitral commissurotomy is an effective, safe procedure with gratifying intermediate results. It should be considered the treatment of choice for rheumatic mitral stenosis.

Percutaneous closure of a ruptured sinus of Valsalva aneurysm using the Amplatzer duct occluder

Sinus of Valsalva aneurysms are rare congenital anomalies. When they rupture, they can lead to the development of biventricular failure as a result of systemic‐pulmonary shunting. Surgical repair has been the traditional treatment for these aneurysms. We present a case of a 54 year old man in whom a ruptured sinus of Valsalva aneurysm was successfully closed using a catheter‐based approach with the Amplatzer Duct Occluder. Cathet Cardiovasc Intervent 2003;58:406–411.

Pulmonary venous flow dynamics before and after balloon mitral valvuloplasty as determined by transesophageal Doppler echocardiography

The pattern of left atrial filling was studied in 14 patients with severe mitral stenosis in sinus rhythm before and immediately after successful balloon mitral valvuloplasty by transesophageal pulsed Doppler echocardiography of the left superior pulmonary vein. Mean mitral valve orifice area increased from 0.8 +/- 0.1 to 2.2 +/- 0.3 cm2 (p less than 0.0001), and left atrial mean pressure decreased from 30 +/- 5 to 12 +/- 4 mm Hg (p less than 0.0001) after the procedure. After balloon mitral valvuloplasty, significant increases in peak systolic pulmonary velocity (35 +/- 16 to 44 +/- 10 cm/s; p less than 0.01), systolic flow velocity time integral (3.3 +/- 1.5 to 5.9 +/- 2.0 cm; p less than 0.001) and the ratio of systolic/diastolic pulmonary venous flow velocity time integrals (0.8 +/- 0.4 to 1.4 +/- 0.5; p less than 0.001) were observed. An acute increase in mitral valve orifice area caused no significant changes in peak diastolic forward flow velocity (40 +/- 7 to 41 +/- 9 cm/s; p = not significant [NS]), diastolic forward flow velocity time integral (4.3 +/- 1.7 to 4.6 +/- 1.8 cm; p = NS) and atrial flow reversal velocity (30 +/- 3 to 35 +/- 3 cm/s; p = NS) compared with at baseline. The results suggest that in patients with severe mitral stenosis and sinus rhythm, left atrial filling is biphasic with a diastolic preponderance, and successful mitral valvuloplasty is associated with an immediate increase in pulmonary venous systolic forward flow.

Rheolytic percutaneous thrombectomy for acute pulmonary embolism in a pediatric patient.

Acute massive pulmonary embolism can have significant hemodynamic effects in both adults and children. We describe the case of a 10‐year‐old boy who developed cardiogenic shock after suffering a massive pulmonary embolism. A significant thrombus burden was removed using a catheter‐based strategy of rheolytic thrombectomy, leading to stabilization of the patient.

Subclavian artery access for ambulatory balloon pump insertion.

Intraaortic balloon pump insertion is traditionally performed through the femoral artery in the groin. However, this restricts the patient to bed rest, and prolonged implantation can be associated with infections in the groin crease. We describe a technique of insertion of a balloon pump through the subclavian artery, which allows the patient to ambulate. This technique can also be performed under local anesthesia in the cardiac catheterization laboratory.

Successful Percutaneous Retrieval of an Inferior Vena Cava Filter Migrating to the Right Ventricle in a Bariatric Patient

The use of an inferior vena cava filter has an important role in the management of patients who are at high risk for development of pulmonary embolism. Migration is a rare but known complication of inferior vena cava filter placement. We herein describe a case of a prophylactic retrievable vena cava filter migrating to the right ventricle in a bariatric patient. The filter was retrieved percutaneously by transjugular approach and the patient did well postoperatively. A review of the current literature is given.

Interchangeability of activated clotting time values across different point-of-care systems.

Significant variability in activated clotting time (ACT) measurement exists based on the type of point-of-care system used. We sought to determine the degree of agreement in ACT measurements by the Hemochron Response and the Hemochron Signature Elite Whole Blood coagulation systems and whether these 2 systems can be used interchangeably. We prospectively compared 126-paired samples in 77 patients undergoing percutaneous coronary intervention. ACT was measured for each sample using the Hemochron Response system with glass test tubes and the Hemochron Signature Elite system with low-range ACT cuvettes simultaneously. We used correlation and Bland-Altman analyses. Mean age of the study cohort was 67 ± 11 years, 49% were women, and 65% of measurements were made after systemic anticoagulation. There was a significant correlation between the Hemochron Response and Hemochron Signature Elite systems (r = 0.84, p <0.01). However, the mean bias for the ACT measurement was 9 seconds (95% confidence interval -69 to 86). In the therapeutic range of ACT measurements, the mean bias was 15 seconds (95% confidence interval -60 to 91). Thirty-three percent of total samples had >10% disagreement and 8% of samples had >20% disagreement in the ACTs measured with the Hemochron Response compared to the Hemochron Signature Elite. In conclusion, the Hemochron Response and Hemochron Signature Elite ACT values cannot be used interchangeably. Institutions using these 2 devices should be cognizant of this difference for ensuring patient safety.

Diastolic coronary artery compression in a cardiac transplant recipient: Treatment with a stent: Stenting in Diastolic Artery Compression

Myocardial bridges, with resultant systolic compression of the coronary artery, are common inborn anomalies that generally have a benign course. Diastolic compression of the coronary artery, however, is a rare finding that is believed to be an acquired lesion. It can be hypothesized that during diastole, when left ventricular filling occurs, the coronary artery is compressed against epicardial scar tissue or a noncompliant pericardium. This can then lead to diminished intracoronary blood flow. We present a case of functionally significant diastolic coronary artery compression in a cardiac transplant recipient who was successfully treated with intracoronary stent placement.

Factors Associated with the Use of Drug-Eluting Stents in Patients Presenting with Acute ST-Segment Elevation Myocardial Infarction.

Background. Drug-eluting stents (DES) have proven clinical superiority to bare-metal stents (BMS) for the treatment of patients with ST-segment elevation myocardial infarction (STEMI). Decision to implant BMS or DES is dependent on the patients ability to take dual antiplatelet therapy. This study investigated factors associated with DES placement in STEMI patients. Methods. Retrospective analysis was performed on 193 patients who presented with STEMI and were treated with percutaneous coronary intervention at an urban, tertiary care hospital. Independent factors associated with choice of stent type were determined using stepwise multivariate logistic regression. Odds ratio (OR) was used to evaluate factors significantly associated with DES and BMS. Results. 128 received at least one DES, while 65 received BMS. BMS use was more likely in the setting of illicit drug or alcohol abuse ([OR] 0.15, 95% CI 0.05–0.48, p ≤ 0.01), cardiogenic shock (OR 0.26, 95% CI 0.10–0.73, p = 0.01), and larger stent diameter (OR 0.28, 95% CI 0.11–0.68, p ≤ 0.01). Conclusions. In this analysis, BMS implantation was associated with illicit drug or alcohol abuse and presence of cardiogenic shock. This study did not confirm previous observations that non-White race, insurance, or income predicts BMS use.

Diastolic coronary artery compression in a cardiac transplant recipient: Treatment with a stent

Myocardial bridges, with resultant systolic compression of the coronary artery, are common inborn anomalies that generally have a benign course. Diastolic compression of the coronary artery, however, is a rare finding that is believed to be an acquired lesion. It can be hypothesized that during diastole, when left ventricular filling occurs, the coronary artery is compressed against epicardial scar tissue or a noncompliant pericardium. This can then lead to diminished intracoronary blood flow. We present a case of functionally significant diastolic coronary artery compression in a cardiac transplant recipient who was successfully treated with intracoronary stent placement.