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BACKGROUND: Chronic pressure overload secondary to severe aortic stenosis causes impairment of left ventricular myocardial deformation and associated with adverse outcome. The present study aimed to assess the response of myocardial mechanics after transcatheter aortic valve implantation (TAVI). METHODS: Assessment of myocardial mechanics by quantification of LV longitudinal, circumferential strain and rotational deformation (apical, basal rotation and twist) by 2-D Speckle-tracking echocardiography at baseline and at midterm follow-up post-TAVI. The patients were divided into 2 groups based on baseline left ventricular ejection fraction. 46 patients had preserved LV EF ≥50% preserved ejection fraction (PEF) and 34 patients had reduced left ventricular ejection (REF) < 50%. RESULTS: 80 patients with severe AS and high surgical risk were evaluated. At a mean follow-up of 8 ± 3 months after TAVI, left ventricular longitudinal strain (LS) significantly improved in reduced ejection fraction (REF) group from -9.88 ± 3.93% to 11.89 ± 3.15% (P = 0.001). In preserved ejection fraction (PEF) group, longitudinal strain improved from -13.8 ± 3.1% to -15.2 ± 3.3% (P < 0.001). Longitudinal strain rate (LSR) improved significantly in REFgroup, -0.48 ± 0.20sec-1 to -0.62 ± 0.16 sec-1 (P < 0.001) and in PEF group,-0.73 ± 0.19 sec-1 to-0.77 ± 0.16 sec -1 (P < 0.005). In PEF group, LV twist angle was supra-physiological at baseline and decreased after TAVI towards normal values (P = 0.006). In REF group LV twist angle was reduced at baseline with significant increase towards normal value after transcatheter aortic valve implantation (TAVI),P = 0.005. That was attributed to severe LV dysfunction associated with reduction of left ventricular twist at baseline which improved in response to TAVI alongside with improvement of left ventricular systolic function. In reduced ejection fraction (REF) group circumferential strain and strain rate improved significantly after TAVI. CONCLUSIONS: Myocardial mechanics of the left ventricle including strain, strain rate and twist are deformed in severe aortic stenosis. TAVI restores myocardial mechanics towards physiological values in patients with preserved and reduced ejection fraction.
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BACKGROUND: Haemolytic anaemia is a complication of paravalvular leak (PVL). The correlation between the size of the leak and the severity of haemolysis is unclear. Small leaks can cause severe haemolysis, whereas significant leaks may cause no haemolysis. CASE SUMMARY: We report the case of a 40-year-old male who underwent mechanical mitral and aortic valve replacement 20 years ago. In the last 3 years, the procedure was repeated three times due to infective endocarditis. He presented with severe shortness of breath. A transoesophageal echocardiogram with three-dimensional surgical view showed that both discs of the mechanical mitral valve opened sufficiently but a severe PVL had occurred at the 9-12 o'clock position. The location of the mitral valve was abnormal, the sewing ring was inserted high at the mid-interatrial septum. The mechanical aortic valve functioned well. Closure of the transcutaneous PVL was accomplished with two percutaneously implanted devices, leaving a small leak in between. After closure, he developed haemolytic anaemia (haemoglobin: 6 g/dL, lactate dehydrogenase: 1896 units/L, reticulocyte count: 4.6%). He then received 16 units of packed red blood cells. He developed acute kidney injury and was started on haemodialysis. We then installed two additional devices to completely close the mild residual leak and another device to resolve the bidirectional transseptal defect. After 2 days, his renal function returned to normal and anaemia improved (haemoglobin: 9.1 g/dL). DISCUSSION: Mild residual paravalvular leak can cause severe haemolytic anaemia that is correctable via percutaneous closure of the leak.
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Coronary artery fistula (CAF) is a congenital connection between a coronary artery and cardiac chambers, or a vessel bypassing a capillary system. The clinical presentation of congenital CAF varies, depending on its size and the draining chamber. A 40-year-old female presented with right-sided heart failure and was diagnosed by transthoracic echocardiography and computed tomography with 3D printing to have substantial coronary to right atrium fistula. Left main artery was cannulated to the outlet of the fistula at the base of the superior vena cava to the right atrium. The wire snared and created the arterio-venous loop. A 7F delivery sheath through the arterio-venous loop landed in proximal left circumflex part of the fistula, Amplatzer duct occluder I size 12/10 selected with the distal (aortic) skirt positioned distal to the most distal visible coronary branch. We waited for 10 min monitoring the ST segments for any changes. Finally, the device was released with complete closure of the fistula sparing all coronary branches. Follow-up transthoracic echocardiography after six months showed no flow to fistula sacs; the patient's symptoms improved dramatically. In conclusion, transcatheter closure of an isolated enormous multiloculated CAF is feasible and relatively safe. Surgery should be reserved for CAF with failed percutaneous closure.
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Reported cases of uni-leaflet mitral valve (MV) were related to the absence or dysplasia of the posterior mitral leaflet with ample anterior mitral leaflet. We present here a new entity of uni-leaflet MV where the MV appears as a membrane-like structure with a single slit-like orifice at its lateral part with no commissures. CASE REPORT: Continuous Doppler flow revealed a mean pressure gradient of 19 mmHg across the mitral valve indicating severe mitral stenosis. In 3D images from the left atrial view, the MV appeared like a membrane with a single orifice in its lateral part toward the left atrial appendage, the area of this orifice by 3D was 0.52 cm2, there were no commissures or even any residual lines at the site where commissures should be. The diagnosis of congenital severe mitral stenosis due to acommissural MV was confirmed. During surgery, the surgical appearance of the MV confirmed our diagnosis by 3D. CONCLUSION: Isolated congenital severe mitral stenosis presenting in adulthood is rare, uni-leaflet MV as a cause is only reported in a few cases. MV replacement is usually indicated due to the abnormal anatomy of MV leaflets and the subvalvular apparatus.
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BACKGROUND: Percutaneous implantation of aortic valve for severe aortic stenosis (AS) in the presence of pedunculated mobile left ventricular outflow tract (LVOT) mass not reported before. In this case report, we address the feasibility of this procedure. CASE SUMMARY: An 80-year-old patient who presented with presyncope, transthoracic echocardiogram (TTE), and transoesophageal echocardiography (TOE) revealed severe calcific AS and LVOT mass measuring 2.1*1.5 cm. The patient was turned down for surgery. It was decided that transcatheter aortic valve implantation (TAVI) be performed because the valve compresses the mass against the proximal part of the interventricular septum. The mass peduncle was 1.4 cm, and it was 4 mm away from the annulus. This meant the valve was needed to be deployed 18 mm below the annulus to cover the mass completely. Gentle manipulation and direct valve deployment without preballoon dilation to decrease the possibility of fragment embolization were necessary. Self-expandable core valve deployed as low as possible, after initial deployment, the distance of LVOT covered by the valve measured by TOE 1.66 cm, the whole mass was covered, then the valve was fully deployed. The patient was extubated in the catheterization room; there was no clinical evidence of embolization. The patient was discharged home after 2 days. A follow-up TTE after 6 months showed a well-functioning valve and the LVOT mass then disappeared. DISCUSSION: Pedunculated LVOT mass should be resected surgically. In high-risk surgical patients, direct TAVI to compress the mass is feasible in experienced canters. The safety issues need more research and more cases to judge. Transoesophageal echocardiography during the procedure is mandatory to guide the valve position.
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This case report describes a novel bailout technique (TAIBA technique) used in a MitraClip procedure that was complicated by a tear of the posterior mitral valve leaflet and caused torrential mitral regurgitation (MR). This is the first case report in which Amplatzer vascular plugs were used to treat severe MR after a tear in the posterior leaflet occurred during a MitraClip procedure. (Level of Difficulty: Advanced.).
RESUMEN
BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been recognized as a valid alternative to surgery for severe aortic valve stenosis (AS) in high-risk surgical patients. OBJECTIVE: Determine first-year clinical outcomes for TAVI at Madinah Cardiac Center (MMC) in Saudi Arabia. DESIGN: Retrospective, analytical cross-sectional. SETTING: Tertiary cardiac care center. PATIENTS AND METHODS: All patients who underwent TAVI for severe AS between February 2013 and December 2016 were included. Clinical, imaging, and laboratory information at baseline and at one year follow-up were analyzed. MAIN OUTCOME MEASURES: Clinical and echocardiography out.comes at discharge, at 1-month, and at end of follow-up; one-year mortality, complications and clinical response to TAVI procedure. SAMPLE SIZE AND CHARACTERISTICS: N=80, mean (SD) age 79.5 (10.6) years, with severe AS and high-surgical risk. RESULTS: Fifty-five (69.2%) patients received Core valves, and 25 (30.8%) received Edward valves. Peri-procedure mortality was 3.8% and 1-year post-operative mortality was 13.8%. Ten patients (12.5%) had life-threatening or major bleeding. Nineteen (23.8%) patients had vascular complications, which were mostly minor. Fourteen patients (17.5%) developed acute kidney injury and 86% of these patients recovered. Five patients (6.25%) had pericardial effusion. Two patients (2.5%) developed endocarditis and another 2 patients (2.5%) had cerebrovascular accidents. Five patients (6.25%) received pacemakers. Mean aortic valve gradient significantly reduced from a mean (SD) 47.6 (19) mm Hg to 10.7 (6.0) mm Hg (P less than .001). New York Heart Association functional class was significantly reduced (P less than .001). CONCLUSION: The TAVI experience at MCC is encouraging and comparable to international outcomes in terms of success, morbidity, and mortality rate. LIMITATIONS: Retrospective, relatively small sample size. Rate of minor bleeding was overestimated. CONFLICT OF INTEREST: None.