Sebastián Carrizo

Percutaneous Balloon Pericardiotomy as the Initial and Definitive Treatment for Malignant Pericardial Effusion

INTRODUCTION AND OBJECTIVES Malignant pericardial effusion has a high recurrence rate after pericardiocentesis. We sought to confirm the efficacy of percutaneous balloon pericardiotomy as the initial treatment of choice for these effusions. METHODS Retrospective analysis of the clinical, echocardiographic, and follow-up characteristics of a consecutive series of percutaneous balloon pericardiotomies carried out in a single center in patients with advanced cancer. RESULTS Seventeen percutaneous balloon pericardiotomies were performed in 16 patients with a mean age of 66.2 (15.2) years. Fourteen patients had pathologically confirmed metastatic neoplastic disease, 3 had previously required pericardiocentesis, and in the remaining patients percutaneous balloon pericardiotomy was the first treatment for the effusion. All patients had a severe circumferential effusion, and most presented evidence of hemodynamic compromise on echocardiography. In all cases, the procedure was successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications during follow-up (median, 44 [interquartile range, 36-225] days). One patient developed a large pleural effusion that did not require treatment. Three patients needed a new pericardial procedure: 2 had elective pericardial window surgeries and 1 had a second percutaneous balloon pericardiotomy. CONCLUSIONS Percutaneous balloon pericardiotomy is a simple, safe technique that can be effective in the prevention of recurrence in many patients with severe malignant pericardial effusion. The characteristics of this procedure make it particularly useful in this group of patients to avoid more aggressive, poorly tolerated approaches.

Utility of optical coherence tomography and intravascular ultrasound for the evaluation of coronary lesions

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are imaging methods used in the diagnosis of coronary lesions. IVUS is widely used in interventional cardiology laboratories, but OCT is now increasingly used. Conventional coronary angiography can identify different types of coronary lesions but sometimes is unable to diagnose them correctly. Both intravascular imaging methods are useful for better interpretation of these lesions, and can accurately diagnose ruptured plaques, thrombosis, stent restenosis and hazy images. However, the resolution of OCT is ten times higher than IVUS, and so an accurate diagnosis cannot always be achieved with ultrasound imaging. We present three cases in which IVUS was unable to identify the lesion causing the condition and OCT was required to obtain clearer images that helped to confirm the diagnosis. The advantages and disadvantages of each method are then discussed.

Update in Pharmacological Management of Coronary No-Reflow Phenomenon

The no-reflow phenomenon (NRP) is defined as the lack of adequate myocardial tissue perfusion despite a patent epicardial coronary artery. The incidence of NRP varies between 2-5% of elective percutaneous coronary interventions (PCI) and 30% in primary PCI. Clinically, it is an independent predictor of myocardial infarction, in-hospital mortality, and long-term mortality. It may be categorized in interventional (after PCI, especially in saphenous venous grafts) or reperfusion NRP (after re-opening of a totally occluded coronary artery, usually during primary PCI or thrombolysis). There are many physiopathological factors implicated: distal microembolization, interstitial and intracellular edema, coronary spasm and capillary plugging. Although reperfusion and no reflow is a field of intense research, no single mechanical or pharmacological therapy has demonstrated a clear efficacy against NRP, probably due to its multifactorial nature. Once established, the treatment of NRP is based on vasodilators like adenosine, verapamil, nitroprusside or nicorandil. However, the efficacy of these measures is poor, so every effort should be made to prevent the apparition of NRP. The objective of this report is to provide an update of the pharmacological armamentarium available for the prevention and treatment of NRP, and suggest a systematic approach of the management of NRP according to the different possible clinical scenarios.

Utility of Optical Coherence Tomography to Assess a Hazy Intracoronary Image after Percutaneous Coronary Intervention

Although its use in daily practice is not common, optical coherence tomography (OCT) is a powerful research tool in invasive cardiology. This report describes a hazy angiography image after percutaneous coronary intervention that has been assessed using OCT. Based on the results of the OCT, the patient underwent an elective coronary angioplasty with standard anticoagulation. After implantation of the stent, an intracoronary hazy image was seen on angiography. The use of OCT permitted a correct diagnosis and a successful treatment. This paper provides a discussion of the advantages and disadvantages of OCT, and a comparison with intravascular ultrasound.

Functional assessment of coronary artery disease by intravascular ultrasound and computational fluid dynamics simulation.

Clinical trials have shown that functional assessment of coronary stenosis by fractional flow reserve (FFR) improves clinical outcomes. Intravascular ultrasound (IVUS) complements conventional angiography, and is a powerful tool to assess atherosclerotic plaques and to guide percutaneous coronary intervention (PCI). Computational fluid dynamics (CFD) simulation represents a novel method for the functional assessment of coronary flow. A CFD simulation can be calculated from the data normally acquired by IVUS images. A case of coronary heart disease studied with FFR and IVUS, before and after PCI, is presented. A three-dimensional model was constructed based on IVUS images, to which CFD was applied. A discussion of the literature concerning the clinical utility of CFD simulation is provided.

Case reportFunctional assessment of coronary artery disease by intravascular ultrasound and computational fluid dynamics simulationAvaliação funcional da doença arterial coronária com ultra-som intravascular e simulação computorizada de dinâmica de fluidos

Clinical trials have shown that functional assessment of coronary stenosis by fractional flow reserve (FFR) improves clinical outcomes. Intravascular ultrasound (IVUS) complements conventional angiography, and is a powerful tool to assess atherosclerotic plaques and to guide percutaneous coronary intervention (PCI). Computational fluid dynamics (CFD) simulation represents a novel method for the functional assessment of coronary flow. A CFD simulation can be calculated from the data normally acquired by IVUS images. A case of coronary heart disease studied with FFR and IVUS, before and after PCI, is presented. A three-dimensional model was constructed based on IVUS images, to which CFD was applied. A discussion of the literature concerning the clinical utility of CFD simulation is provided.

Utilidade prática das técnicas de diagnóstico intracoronário no tratamento percutâneo da reestenose intrastent

We report a case of very late bare-metal stent restenosis, in which assessment by two intracoronary imaging techniques (intravascular ultrasound and optical coherence tomography) revealed the underlying mechanism (neoatherosclerosis) and facilitated percutaneous treatment (direct bare-metal stent-in-stent). We also take the opportunity to briefly describe the advantages and limitations of both techniques in this pathology.

Stent Thrombosis in Ostial Lesion: Diagnosis and Treatment Guided by Optical Coherence Tomography

Optical coherence tomography (OCT) is an intracoronary diagnostic technique of particular interest for characterization of the atheromatous plaque and assessment of the outcome of stenting by percutaneous coronary intervention. We present a case of stent thrombosis in which OCT provided very useful information for arriving at the diagnosis, understanding the thrombotic mechanism, deciding on the most appropriate therapeutic strategy, and guiding percutaneous coronary intervention. The patient was a 65-year-old man, referred for primary angioplasty due to inferolateral acute myocardial infarction with onset 3 h earlier. He had completely discontinued double antiplatelet therapy 1 week earlier. Eight months earlier, he had experienced a non-Q-wave acute myocardial infarction for which 2 overlapping drug-eluting stents were placed in the second obtuse marginal branch. Another drug-eluting stents was placed in the ostium of the first obtuse marginal branch with adjustment by simultaneous balloon deployment in the proximal circumflex artery (Figs. 1A and B). The only finding in the coronary angiography performed during inferolateral stent thrombosis elevation was the presence of a small filling defect in the proximal circumflex artery (Fig. 1C). OCT confirmed the presence of a thrombus in the proximal end of the stent in the first obtuse marginal branch. Moreover, this stent protruded into the lumen of the circumflex artery itself. Several stent struts lacked neointimal coating and there was a thrombus adhered to its surface. The technique also showed that, on advancing towards the distal segments of the second obtuse marginal branch, our guide had crossed through this stent’s cells (Fig. 2A). We therefore advanced a second guidewire and it was confirmed that this time, it had gone beyond the stent (Fig. 2B), and so stent crushing could be performed (Fig. 1D). After administering an intracoronary abciximab bolus, we placed another drug-eluting stents in the proximal circumflex artery and inflated a kissing balloon at the circumflex artery and the first obtuse marginal branch (Figs. 1E and F). As seen in our case, the angiographic appearance of stent thrombosis is sometimes subtle and may go unnoticed. In the face of clinical suspicion, intracoronary diagnostic techniques are of great help for confirming or ruling out diagnosis and contributing to an understanding of its causal mechanism. Thus, OCT is extremely useful in view of its high sensitivity for identifying the thrombus and stent-related factors (lack of endothelialization, infraexpansion, malapposition, neoatherosclerosis, etc.) that may be implicated in thrombosis. Identification of the thrombus and stent-related factors is essential when deciding on therapeutic strategy, which may range from manual extraction only of the thrombus or intensification of antithrombotic treatment to balloon dilatation, with or without the need for repeat stenting. In our patient, in addition to discontinuation of antiplatelet therapy, we discovered the presence of a determinant mechanical factor: a smalldiameter partially endothelialized stent that protruded into a larger diameter vessel. This finding was essential when making the decision to perform stent crushing. Recently, it has been shown that OCT could be of use in percutaneous coronary intervention in bifurcation lesions, particularly when recrossing the angioplasty guidewire through the struts, as angiography and intravascular ultrasound may be of more limited value in this situation. As we show, an exact knowledge of the position of the guidewire relative to the previously placed stents may be of additional value, as it allows the desired bifurcation technique to be performed and avoids suboptimal angiographic outcomes with an increased risk of future adverse events. Although there is a lack of solid studies that demonstrate the clinical benefits of OCT-guided percutaneous coronary intervention, we believe that this case illustrates that OCT may be of use in Rev Esp Cardiol. 2013;66(7):586–597

Initial management of severe malignant pericardial effusion with percutaneous balloon pericardiotomy

Purpose: Malignant pericardial effusion (MPE) is associated with adverse outcomes and presents a high rate of recurrence after pericardiocentesis. Various approaches have been reported for prevention of recurrences. However most of them are associated with significant morbidity or even mortality and required unnecessarily prolonged hospital stay. We sought to confirm the efficacy of percutaneous balloon pericardiotomy (PPB) as the initial treatment of choice for MPE. Methods: Retrospective analysis of the clinical, echocardiographic and follow-up characteristics of a consecutive series of PPB carried out in a single center in patients with advanced cancer. Results: Twenty-one PPB were performed in 19 patients with a mean age of 65±15 years. Seventeen patients had pathologically confirmed metastatic neoplastic disease and in another two patients there was a high radiological suspicion of it. Three patients had previously required pericardiocentesis, and in the remaining patients PPB constituted the first treatment for the MPE. All patients had a severe (>20mm) circumferential effusion and only one patient did not have evidence of hemodynamic compromise on echocardiography. In all cases the procedure was initially successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications, and just one patient developed a large pleural effusion that did not require treatment. During the follow-up (median 74 [IQR 31.5-207.5] days), four patients required a new pericardial procedure: 2 elective pericardial window surgeries and 2 new PPB. Conclusions: PPB is a simple, safe procedure that can be effective in the prevention of recurrences in many patients with MPE. Based on the results and the poor prognosis of these patients we believe that PPB might be considered the initial treatment of choice for most MPE.