RESUMEN
Dehiscence of a prosthetic heart valve or excessive rocking during the cardiac cycle is thought to preclude percutaneous paravalvular leak closure. However, surgical repair of paravalvular leak is associated with recurrent dehiscence and poor outcomes. We present the case of a symptomatic 74-year-old man in whom we performed percutaneous anchoring, involving multiple plugs and multimodal imaging, to stabilize a rocking mitral valve and close a substantial paravalvular leak caused by dehiscence. To our knowledge, using this technique to correct both conditions is novel.
Asunto(s)
Cateterismo Cardíaco/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Anciano , Procedimientos Quirúrgicos Cardíacos/métodos , Ecocardiografía Transesofágica , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/diagnóstico , Falla de Prótesis , ReoperaciónRESUMEN
OBJECTIVE: We investigated radioprotective strategies for the interventional echocardiographer (IE) during structural heart interventions in comparison with the interventional cardiologist (IC). BACKGROUND: Structural heart interventions are expanding in complexity with increased reliance on IE. Recent reports have demonstrated concerning exposure and higher radiation to the IE. METHODS: We monitored 32 structural interventions - 19 transcatheter aortic valve replacements (TAVR), 6 transcatheter mitral valve repairs, 5 paravalvular leak closures, and 2 atrial septal defect closures. Seventeen utilized transesophageal echocardiography (TEE) while 15 used transthoracic echocardiography (TTE). Members of the IC and IE teams wore multiple dosimeters on different sites of the body to measure radiation dose to the total body, lens of the eye, and hand. During each case, IE utilized dedicated radiation shielding. RESULTS: Mean doses were higher for the primary IC than the primary IE: IC#1-99, 222, 378; IE#1-48, 52, 416 (body, lens, and hand doses in µSv). IE radioprotective strategies were able to reduce body and lens doses compared to IC during both TTE and TEE-guided procedures. Hand equivalent dose remained higher for the IE driven by exposure during TEE-guided procedures (IC#1 294 vs. IE#1 676 µSv). In a subgroup using radioprotective drapes during TTE-guided TAVR, IC dose was reduced without effect on the IE. CONCLUSIONS: Radiation exposure during structural heart interventions is concerning. With dedicated shielding, IE received lower doses to the body and lens than IC. Further optimization of structural suite design and shielding is needed.
Asunto(s)
Ecocardiografía , Cardiopatías/terapia , Exposición Profesional/prevención & control , Dosis de Radiación , Exposición a la Radiación/prevención & control , Protección Radiológica/métodos , Radiografía Intervencional , Ultrasonografía Intervencional , Ecocardiografía/efectos adversos , Cardiopatías/diagnóstico por imagen , Humanos , Exposición Profesional/efectos adversos , Salud Laboral , Traumatismos Ocupacionales/etiología , Traumatismos Ocupacionales/prevención & control , Exposición a la Radiación/efectos adversos , Traumatismos por Radiación/etiología , Traumatismos por Radiación/prevención & control , Radiografía Intervencional/efectos adversos , Radiólogos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Ultrasonografía Intervencional/efectos adversosRESUMEN
OBJECTIVES: There are minimal data regarding clinical outcomes and echocardiographic findings after transcatheter mitral valve-in-valve replacement (TMVR) compared with redo surgical mitral valve replacement (SMVR). BACKGROUND: TMVR therapy has emerged as therapy for a degenerated bioprosthetic valve failure. METHODS: The authors retrospectively identified patients with degenerated mitral bioprostheses who underwent redo SMVR or TMVR at 3 U.S. institutions. The authors compared clinical and echocardiographic outcomes of patients who had TMVR with those of patients who underwent redo SMVR. RESULTS: Sixty-two patients underwent TMVR and 59 patients underwent SMVR during the study period. Mean age and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) scores were significantly higher in patients with TMVR than in those with SMVR (age 74.9 ± 9.4 years vs. 63.7 ± 14.9 years; p < 0.001; STS PROM 12.7 ± 8.0% vs. 8.7 ± 10.1%; p < 0.0001). Total procedure time, intensive care unit hours, and post-procedure length of stay were all significantly shorter in the TMVR group. There was no difference in mortality at 1 year between the 2 groups (TMVR 11.3% vs. SMVR 11.9%; p = 0.92). Mean mitral valve pressure gradient and the grade of mitral regurgitation (MR) were similar between the TMVR group and the SMVR group (mitral valve pressure gradient 7.1 ± 2.5 mm Hg vs. 6.5 ± 2.5 mm Hg; p = 0.42; MR [≥moderate] 3.8% vs. 5.6%; p = 1.00) at 30 days. At 1 year, the mitral valve pressure gradient was higher in the TMVR group (TMVR 7.2 ± 2.7 vs. SMVR 5.5 ± 1.8; p = 0.01), although there was no difference in the grade of MR. CONCLUSIONS: Despite the higher STS PROM in TMVR patients, there was no difference in 1-year mortality between the TMVR and SMVR groups. Echocardiographic findings after TMVR were similar to SMVR at 30 days. There was a statistically significant difference in mitral gradient at 1 year, though this is likely not clinically important. TMVR may be an alternative to SMVR in patients with previous mitral bioprosthetic valves.
Asunto(s)
Bioprótesis , Cateterismo Cardíaco/instrumentación , Remoción de Dispositivos , Ecocardiografía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Válvula Mitral/cirugía , Falla de Prótesis , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/mortalidad , Remoción de Dispositivos/efectos adversos , Remoción de Dispositivos/mortalidad , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/fisiopatología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Valor Predictivo de las Pruebas , Recuperación de la Función , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Estados UnidosAsunto(s)
Valvuloplastia con Balón , Bioprótesis , Cateterismo Cardíaco/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Anciano , Ecocardiografía Doppler en Color , Ecocardiografía Tridimensional , Ecocardiografía Transesofágica , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/fisiopatología , Diseño de Prótesis , Recuperación de la Función , Resultado del TratamientoAsunto(s)
Cateterismo Cardíaco/instrumentación , Remoción de Dispositivos , Migración de Cuerpo Extraño/terapia , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral/instrumentación , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Anciano de 80 o más Años , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/métodos , Remoción de Dispositivos/métodos , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/etiología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Anuloplastia de la Válvula Mitral/efectos adversos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Diseño de Prótesis , Resultado del TratamientoRESUMEN
BACKGROUND: Device loss and entrapment are infrequent but potentially grave complications of percutaneous coronary interventions (PCI). There are limited contemporary data on the frequency, treatment, and consequences of these complications. METHODS: We reviewed 2338 consecutive PCI cases performed between 1/2005 and 5/2010 at our institution to identify cases of device loss or entrapment. The angiograms and outcomes of these patients were reviewed. RESULTS: During the study period, device loss occurred in 9 cases (0.38%; 95% confidence interval [CI], 0.18%-0.73%) and entrapment in 4 cases (0.17%; 95% CI, 0.05%-0.44%). The lost devices were stents (n = 5; 0.21%), a coronary balloon shaft (n = 1; 0.04%), a femoral arterial sheath (n = 1; 0.04%), an arterial catheter (n = 1; 0.04%), and an Ostial Pro catheter (Ostial Solutions) distal tip (n = 1; 0.04%). Entrapped devices included a coronary guidewire (n = 2; 0.08%), a Tornus catheter (Abbott Vascular; n = 1; 0.04%) and a Filterwire (Boston Scientific; n = 1; 0.04%). All patients with device loss were successfully managed percutaneously (1 patient experienced periprocedural myocardial infarction). Retrieval of the lost devices was attempted in 7 of 9 cases (78%) and was successful in 6 cases (86%). Retrieval was successful with the initial attempt in 2 patients but required >1 attempt in 4 patients. In contrast, 3 of 4 patients (75%) with device entrapment required emergency surgical removal and coronary artery bypass grafting. CONCLUSIONS: Device loss or entrapment is an infrequent complication of contemporary PCI. Device loss can be successfully managed percutaneously, whereas device entrapment often requires emergency cardiac surgery.
Asunto(s)
Angioplastia Coronaria con Balón/efectos adversos , Remoción de Dispositivos/métodos , Anciano , Angioplastia Coronaria con Balón/instrumentación , Angiografía Coronaria , Falla de Equipo , Femenino , Migración de Cuerpo Extraño/etiología , Migración de Cuerpo Extraño/terapia , Humanos , Persona de Mediana Edad , StentsRESUMEN
BACKGROUND: The Venture catheter (St Jude, Minneapolis, MN) has a deflectable tip for facilitating wire steering and a stiff body. Both properties can be useful in percutaneous coronary interventions (PCI) of coronary chronic total occlusions (CTOs). METHODS: We reviewed 26 consecutive patients in whom the Venture catheter was utilized during coronary CTO PCI at our institution between May 2008 and September 2009. RESULTS: Mean age was 63 ± 9 years and 96% of the patients were men. The CTO target lesion was located in the right coronary artery (35%), left anterior descending artery (27%), circumflex (27%) or a saphenous vein graft (4%). A prior attempt for CTO PCI had been done in 19%. The primary CTO PCI approach was antegrade in 92% and retrograde in 8%, but a retrograde approach was used in an additional 27% of the patients after antegrade approach failed. The Venture catheter was used to overcome vessel tortuosity (73%), for CTOs with side branch at the occlusion site (15%), to facilitate collateral branch wiring during retrograde PCI (8%), and to provide extra support (4%). The overall CTO PCI success rate was 77% and was 92% in patients with upfront Venture catheter use and in 64% of patients in whom the Venture was used after PCI attempts using other equipment failed. Procedural failure was due to inability to cross the lesion in all cases. CONCLUSIONS: The Venture catheter can facilitate CTO PCI, especially in patients with marked coronary tortuosity or when additional support is required.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Catéteres , Oclusión Coronaria/terapia , Anciano , Angioplastia Coronaria con Balón/efectos adversos , Enfermedad Crónica , Angiografía Coronaria , Oclusión Coronaria/diagnóstico por imagen , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Texas , Resultado del TratamientoRESUMEN
OBJECTIVES: We sought to compare the clinical presentation and angiographic patterns of saphenous vein graft (SVG) failure after stenting with a paclitaxel-eluting stent (PES) versus a similar bare-metal stent (BMS). BACKGROUND: The mode of SVG failure after stenting has been poorly characterized. METHODS: The SOS (Stenting Of Saphenous Vein Grafts) trial enrolled 80 patients with 112 lesions in 88 SVGs who were randomized to a BMS or PES. Angiographic follow-up at 12 months was available in 83% of the patients. RESULTS: Binary angiographic restenosis occurred in 51% (24 of 47) of BMS-treated lesions versus 9% (4 of 43) of PES-treated lesions (p < 0.0001). Graft occlusion occurred in 9 of the 21 SVGs (43%) that failed in the BMS group and in 2 of 4 SVGs (50%) that failed in the PES group. SVG failure after stenting presented as an acute coronary syndrome in 10 of the 24 patients (42%) (7 of those 10 patients presented with non-ST-segment elevation acute myocardial infarction), stable angina in 9 (37%) patients, and without symptoms in 5 (21%) patients. Of the 19 patients (with 20 grafts) who developed symptomatic graft failure, repeat SVG revascularization was successfully performed in all 13 (100%) subtotally obstructed SVGs but was attempted (and successful) in only 1 of 7 (14%) occluded SVGs. Revascularization of a native coronary artery was performed in an additional 4 of 7 (57%) symptomatic patients with an occluded SVG. CONCLUSIONS: SVG failure after stenting often presents as acute myocardial infarction and with SVG occlusion. Compared with BMS, PES reduce SVG failure.