Ulises Ramírez

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

Extensive Chest Wall Destruction Secondary to a Large Ventricle Pseudoaneurysm: A Surgical Challenge

Left ventricular pseudoaneurysms have become a rare complication of acute myocardial infarction, occurring in approximately 2% of cases and even less frequently when primary percutaneous intervention can be performed. Regardless of treatment strategy, left ventricle pseudoaneurysms are associated with a high mortality rate. We report on the extremely rare occurrence of a patient surviving two episodes of free wall rupture associated with extensive chest wall destruction and secondary traumatic rib fractures. The key to success in this case is related to both the cardiac and chest wall repair.