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Long-term Follow-up After Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis

INTRODUCTION AND OBJECTIVES Transcatheter aortic valve implantation is used as an alternative to surgical valve replacement in patients with severe aortic stenosis who are considered high-surgical-risk or inoperable. Two of the main areas of uncertainty in this field are valve durability and long-term survival. METHODS This prospective single-center registry study from a tertiary hospital included all consecutive patients who underwent percutaneous aortic valve implantation between 2008 and 2012. Clinical follow-up lasted a minimum of 2.5 years and a maximum of 6.5 years. Valve Academic Research Consortium-2 definitions were used. RESULTS Seventy-nine patients were included, with an immediate success rate of 94.9%. The median survival was 47.6 months (95% confidence intervals, 37.4-57.9 months), ie, 4 years. One quarter of deaths occurred in the first month, and most were of cardiovascular cause. After the first month, most deaths were due to noncardiovascular causes. The mean values of valve gradients did not increase during follow-up. The cumulative rate of prosthetic valve dysfunction was 15.3%, with no cases of repeat valve replacement. CONCLUSIONS Half of the patients with aortic stenosis who underwent transcatheter aortic valve implantation were alive 4 years after the procedure. There was a 15.3% prosthetic valve dysfunction rate in cumulative follow-up, with no cases of repeat valve replacement.

Unilateral pulmonary edema and shock: a diagnostic challenge

Unilateral pulmonary edema (UPE) is a recurrent cause of misdiagnosis. The differential diagnosis includes any cause of pulmonary infiltrates: pneumonia, aspiration, alveolar hemorrhage, neoplasm, lung infarction, atelectasis or bronchial obstruction [1, 2]. UPE is more frequent in the upper right lung, and it has been reported in mitral regurgitation (MR), intracranial shunts, pulmonary vein obstruction and myocardial infarction without MR [3]. A 70-year-old female with no relevant clinical history presented to the emergency department complaining of dyspnea, pleuritic chest pain and myalgia. Physical exploration revealed a mild cardiac murmur at the apex, third cardiac sound and hypoventilation in the right lung with basal rales. The body temperature was normal, arterial pressure was 123/82 mmHg, and heart rate was 110 bpm. Blood tests showed slight leukocytosis (11,500 9 10/L) with normal formula and partial respiratory failure (pO2 49 mmHg, pCO2 28 mmHg, normal pH and bicarbonate). Chest radiography (Fig. 1a) was informed as consolidation in the upper right lobe with an air bronchogram, lower right lobe infiltrates and bilateral hilar enlargement. The patient was admitted with the diagnosis of multilobar bronchopneumonia, and antibiotics were initiated. Twenty-four hours later the clinical situation worsened with hypotension, tachycardia, severe tachypnea and lung rales. The patient required intubation and was transferred to the intensive care unit. Medical treatment was aimed at septic shock, starting fluid infusion and noradrenalin. Hemodynamic and respiratory parameters progressively worsened, and an echocardiogram was requested. Transthoracic and transesophagueal echocardiogram was performed, finding a flail mitral leaflet causing acute severe MR with an asymmetric jet directed to the septal wall of left atrium (Fig. 1b–c, Supplementary Movies 1–3). The mitral valve had myxoid degeneration, and there was a prolapse of the middle scallop (P2) of the posterior leaflet because of spontaneous rupture of chordae tendinae. Pulmonary pressure estimated from the tricuspid gradient was equalized with systemic pressure. Biventricular function was normal, and no other pathological evidence was found. Antibiotics were withdrawn, and treatment with intravenous diuretics and nitroglycerin was started, but refractory shock persisted. Subsequently, an intra-aortic balloon pump (IABP) was implanted, and finally hemodynamic and respiratory stability was achieved. The patient underwent emergent cardiac surgery. The surgeons confirmed the echocardiogram findings. Due to the severe myxoid degeneration of the valve, mitral repair was rejected, and a bioprosthesis was implanted. The patient progressed adequately and was discharged 7 days after the intervention. Eight months later, an echocardiogram was performed, finding normal function of the mitral prosthesis and

Tomografía de coherencia óptica en la disección coronaria espontánea y en las complicaciones derivadas de su tratamiento percutáneo

A 53-year-old man who had recently abandoned triple antihypertensive therapy was referred by his healthcare center following a first episode of angina at rest, which coincided with a significant increase in blood pressure (180/100 mmHg) and was accompanied by diffuse transitory ST-segment depression. Coronary angiography showed tapering of the proximal-middle segment of the median branch, which intracoronary nitroglycerin failed to modify (Fig. 1A). As spontaneous coronary dissection (SCD) was suspected, optical coherence tomography (OCT) was used to study the vessel after unfractionated heparin (85 U/kg) was administered. The OCT confirmed focal intimal rupture (Fig. 1Aa) and revealed a double lumen proximally (Fig. 1Ab) and a subocclusive intramural hematoma more distally (Fig. 1Ac). Given that the patient had experienced several episodes similar to that for which he was admitted while receiving optimal medical treatment (acetylsalicylic acid, clopidogrel, fondaparinux, beta blockers and nitroglycerin), as well as the elevated troponin T observed (11 ng/mL), and his good median branch caliber, the treatment of choice was percutaneous revascularization with a direct drug-eluting stent (3 38 mm at 14 atm), which would completely cover the hematoma and intimal rupture (Fig. 1B). Using OCT, we confirmed the adequate seal and stent placement (Fig. 1Ba), although OCT also disclosed distal progression of the dissection, causing substantial obstruction of the vessel (Fig. 1Bb) and the distal deployment of our guidewire in the false lumen (Fig. 1Bc). After relocating the guidewire in the true lumen (Fig. 1Bd), a second drug-eluting stent was overlapped distally. Subsequent angiography revealed proximal progression of the hematoma causing severe lumen reduction in the median branch ostium and circumflex artery (Figs. 2A and Aa), which required 2 drug-eluting stent implants (Figs. 2Ab and Ac). We finally confirmed satisfactory angiographic results for the intervention (Fig. 2B) when OCT visualized adequate stent placement at the ostial level–which did not protrude into the left main coronary artery–and showed that the dissection had not progressed this far (Fig. 2Ba) or to the left anterior descending coronary artery (Fig. 2Bb). The patient was discharged with no new complications. From our point of view, the patient and his clinical course raise several interesting issues. Firstly, although SCD has typically been described in young women with no cardiovascular risk factors we should not forget that it also affects middle-aged men (<20%-30% of patients). The (unclear) pathophysiology of SCD has been attributed to intramural hematoma formation originating in inflammatory atherosclerotic processes, rupture of vasa vasorum,

Percutaneous alcohol septal ablation for hypertrophic obstructive cardiomyopathy, Technical review and long-term clinical and echocardiographic outcomes

BACKGROUND Percutaneous septal ablation by alcohol-induced septal branch occlusion was introduced as a new treatment option in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Our aim was to evaluate procedural and long-term clinical and echocardiographic outcomes in patients with HOCM treated by alcohol septal ablation (ASA) at our center. METHODS This single-center retrospective study included 14 consecutive HOCM patients undergoing percutaneous ASA (66.4 +/- 12.1 years, 71.4% female). At baseline all patients presented persistent symptoms despite optimized medical treatment, left ventricular outflow tract (LVOT) obstruction with a peak gradient > 50 mmHg, systolic anterior motion of the mitral valve, and ventricular septal thickness > or = 15 mm. ASA was considered successful when the LVOT pressure gradient fell to less than 50% of baseline value. All patients had echocardiographic evaluation at baseline, intraprocedure and at follow-up, and a long-term clinical follow-up (25 +/- 38 months) with evaluation of functional class and occurrence of symptoms or cardiovascular events. RESULTS Percutaneous ASA achieved a 71.4% acute and 85.7% long-term success rate. Peak LVOT gradient decreased from 104 +/- 40 mmHg at baseline to 58 +/- 30 mmHg intraprocedure (p = 0.03) and 35 +/- 26 mmHg at follow-up (p = 0.001); total gradient decrease was 75 +/- 43 mmHg. Ventricular septal thickness and mitral regurgitation also presented significant decreases during follow-up (from 24 +/- 5 mm to 18 +/- 4 mm, p = 0.02, and from grade 2.4 +/- 0.6 to 1.4 +/- 0.5, p < 0.001, respectively). A tendency for long-term improvement in NYHA functional class (from 2.6 +/- 1.1 to 1.8 +/- 1.4, p = 0.09) was observed. Procedural complications occurred in 6.7% of patients; two deaths and one transient ischemic attack occurred in-hospital, but no long-term clinical events were recorded. CONCLUSIONS Percutaneous ASA is an effective treatment for symptomatic patients with HOCM, obtaining a marked decrease in LVOT pressure gradient and symptomatic improvement. Despite the occurrence of a significant number of procedural complications, the favorable long-term outcomes underline the potential of ASA as a percutaneous alternative to surgical myectomy.

Demostración ecocardiográfica de la contracción mecánica auriculoventricular en el flutter auricular común

We present the case of a 54-year-old patient with no history of heart disease who underwent transesophageal echocardiography (TEE) to rule out the presence of thrombus in the left atrial appendage (LAA) prior to programmed electrical cardioversion for common counterclockwise atrial flutter with 2:1 ventricular response at 150 bpm. The TEE confirmed good biventricular function, no thrombus in LAA, and slight dilatation of both atria. In the mid-esophageal plane we obtained pulsed-wave Doppler echocardiograms of the LAA at 608 (Fig. 1A) showing organized flow with waves 200 ms