RESUMEN
Cardiogenic shock from acute on chronic heart failure is a lethal condition that frequently requires temporary mechanical circulatory support devices (tMCS) as a bridge to stabilization, durable support, or heart transplantation. However, there are limited data on methods to optimize use of tMCS in this population. We identified patients who received tMCS devices for cardiogenic shock from acute on chronic heart failure at a single center from August 2016 to July 2020. All the patients had invasive hemodynamic data before and immediately after tMCS placement. We classified patients according to whether they showed stabilization or decompensation with tMCS. We then evaluated hemodynamics pre-tMCS, post-tMCS, and the change in hemodynamics with tMCS (∆-tMCS) and assessed their relationship with clinical outcomes. Among 111 patients who received tMCS, 71 stabilized, and 40 decompensated. Post-tMCS hemodynamics were more likely than were pre-tMCS or ∆-tMCS to predict stabilization. Post-tMCS cardiac index >2.1 (area under the curve: 92.2) and cardiac power index >0.3 (area under the curve: 89.6) were the best predictors of stabilization. Patients who decompensated had increased in-hospital all-cause mortality (hazard ratio 3.06 [1.29 to 7.24], p = 0.011), cardiovascular mortality, and increased hospital and intensive care unit length of stay and were less likely to receive left ventricular assist device or heart transplant (hazard ratio 0.56 [0.36 to 0.88], p = 0.01). In conclusion, among patients with cardiogenic shock from acute on chronic heart failure who received tMCS, post-tMCS cardiac index and cardiac power index were highly predictive of stabilization. Those who decompensated had increased mortality, hospital length of stay, and intensive care unit length of stay and were less likely to receive heart replacement therapy.
Asunto(s)
Insuficiencia Cardíaca , Trasplante de Corazón , Corazón Auxiliar , Humanos , Choque Cardiogénico/etiología , Choque Cardiogénico/terapia , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/terapia , Mortalidad Hospitalaria , Hemodinámica , Resultado del TratamientoRESUMEN
As the average maternal age advances with increasing concurrent cardiovascular disease risk factors, more women are entering pregnancy with or at risk for various cardiovascular conditions. Although rare, pregnant patients may require various cardiac interventions in the catheterization laboratory. An understanding of indications for intervention in pregnant patients with conditions such as myocardial infarction, severe valvular disease, and cardiogenic shock is critical to optimizing both fetal and maternal outcomes. This document highlights the most common cardiovascular conditions that may be encountered during pregnancy that may require intervention and highlights indications for intervention and periprocedural considerations to facilitate favorable maternal and fetal outcomes.
RESUMEN
[Figure: see text].
Asunto(s)
Aterectomía Coronaria , Intervención Coronaria Percutánea , Humanos , Láseres de Excímeros/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Sistema de RegistrosRESUMEN
BACKGROUND: Balloon aortic valvuloplasty (BAV) is used in high-risk patients with severe aortic stenosis (AS) when the benefit of transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is unclear. Our objective was to identify clinical or echocardiographic features that identify patients likely to benefit from BAV. METHODS: We studied 141 consecutive patients who underwent BAV from July, 2011 to October, 2017. Clinical characteristics, routine echocardiographic parameters, and speckle tracking imaging of global longitudinal strain (GLS) were assessed before and after BAV. The primary outcome was all-cause mortality as ascertained by the National Death Index. RESULTS: There were 141 patients, median age, 80 years (interquartile range [IQR], 74-87 years) with severe AS (median aortic valve area, 0.66 cm²; IQR, 0.53-0.79 cm²) and median mean gradient of 36 mm Hg (IQR, 27-48 mm Hg) who underwent BAV. The 1-year mortality rate was 52%. Characteristics associated with survival were New York Heart Association class I symptoms, lower brain natriuretic peptide level, higher left ventricular ejection fraction (LVEF) >53%, and higher GLS (>13.2%; absolute values were used for GLS). Landmark analysis at 60 days showed the 47 patients who underwent TAVR/SAVR after BAV had significantly better 1-year survival than those who did not (P<.001). CONCLUSION: A high 1-year mortality rate was observed in severe AS patients selected for BAV. LVEF and left ventricular (LV)-GLS offer similar prognostic value for 1-year mortality; however, LV-GLS may have potentially increased clinical utility, as it provides a clear threshold for predicting poor outcomes compared with LVEF. As patients who undergo TAVR/SAVR have markedly improved mortality, careful consideration should be given to advance definitive valve therapy in carefully selected BAV patients.
Asunto(s)
Estenosis de la Válvula Aórtica , Valvuloplastia con Balón , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/cirugía , Ecocardiografía , Humanos , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Volumen Sistólico , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
We report a pediatric patient with nonatherosclerotic chronic total occlusion (CTO) of the left main coronary artery (LMCA) leading to complete LMCA atresia which was successfully recanalized via retrograde techniques through a previous internal mammary bypass graft. After the CTO was treated, the artery was found to be anomalous off the right cusp with an intramural coarse and slit-like orifice. The patient's ischemic symptoms resolved after Percutaneous Coronary Intervention (PCI), and she has continued to do well.
Asunto(s)
Puente de Arteria Coronaria , Oclusión Coronaria/cirugía , Anomalías de los Vasos Coronarios/cirugía , Intervención Coronaria Percutánea , Seno Aórtico/anomalías , Niño , Circulación Colateral , Circulación Coronaria , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/fisiopatología , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Anomalías de los Vasos Coronarios/fisiopatología , Femenino , Humanos , Intervención Coronaria Percutánea/instrumentación , Seno Aórtico/diagnóstico por imagen , Seno Aórtico/fisiopatología , Stents , Resultado del TratamientoRESUMEN
BACKGROUND: Transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve replacement expose operators to radiation. These procedures differ primarily in whether they are performed via a transfemoral (TF) or an alternative access (AA) approach. This study compared operator radiation exposure during transcatheter valve implantation when performed via a TF vs an AA approach, when performed in a catheterization lab vs a hybrid operating room (OR), and investigated the potential benefit of disposable shielding. METHODS: Dosimeters were worn during TAVR-TF (n = 50) and TAVR-AA (n = 31) procedures by operators. All TAVR-AA procedures were performed in a hybrid OR and TF procedures were performed in either catheterization labs (n = 16) or a hybrid OR (n = 34). Disposable radiation shielding pads (RADPAD; Worldwide Innovations and Technologies, Inc, Kansas City) or a placebo were added in a randomized, blinded fashion. RESULTS: Team radiation exposure was higher after TAVR-AA vs TAVR-TF (median 15.1 mRad [interquartile range: IQR 8.6, 32.4] vs 5.5 mRad [IQR 2.4, 9.8], P < .001). TAVR-TF procedures required the same amount of fluoroscopy time regardless of where they were performed (20.3 ± 7.4 min in hybrid OR vs 19.0 ± 6.4 min in catheterization lab, P = .55). However, radiation exposure for TAVR-TF remained higher when performed in a hybrid OR (median 9.0 mRad [IQR 4.5, 11.9] vs 2.2 mRad [IQR 1.3, 2.8], P < .001). Radiation exposure was greatest for TAVR-AA (median 15.1 mRad [IQR 8.6, 32.4]). The use of RADPAD did not decrease radiation exposure (median 9.0 mRad [IQR 4.5, 14.7] vs 9.4 mRad [IQR 2.8, 19.5], P = .82). CONCLUSIONS: Procedures performed in the hybrid OR were associated with higher operator radiation exposure. In comparison with the TF approach, AA cases had the highest levels of operator radiation. This is particularly important in cases of transcatheter mitral valve replacement that can only be done via an AA approach. The use of disposable radiation shielding in this series did not attenuate operator radiation exposure. Radiation shielding within hybrid ORs should be scrutinized in an effort to remain on par with that found within catheterization labs.
Asunto(s)
Exposición Profesional/prevención & control , Dosis de Radiación , Exposición a la Radiación/prevención & control , Protección Radiológica , Cirugía Torácica , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Arteria Femoral , Humanos , Método Simple CiegoAsunto(s)
Lesión Renal Aguda/economía , Lesión Renal Aguda/prevención & control , Medios de Contraste/efectos adversos , Medios de Contraste/economía , Medicina Basada en la Evidencia/economía , Costos de Hospital , Atención Dirigida al Paciente/economía , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/economía , Lesión Renal Aguda/inducido químicamente , Lesión Renal Aguda/epidemiología , Anciano , Medios de Contraste/administración & dosificación , Ahorro de Costo , Análisis Costo-Beneficio , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Missouri/epidemiología , Evaluación de Programas y Proyectos de Salud , Factores Protectores , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
OBJECTIVE: The observed-to-expected 30-day mortality ratio (O:E ratio) is a standard metric by which transcatheter aortic valve replacement (TAVR) trials have been evaluated. Early TAVR trials consistently demonstrated O:E ratio less than 0.6 after TAVR when based on the Society for Thoracic Surgery Predicted Risk of Mortality (STS-PROM) for surgical aortic valve replacement. Recent published results from the Transcatheter Valve Therapy (TVT) Registry have demonstrated O:E ratios of 1.0. We evaluated our own O:E ratios for TAVR to investigate this discordance. METHODS: Data were collected prospectively for TAVR patients from 2008 through 2015 (N = 546) and were reviewed retrospectively. The observed mortality and STS-PROM were calculated to formulate O:E ratios and were compared over a variety of subgroups. RESULTS: Overall, the O:E ratio for 30-day mortality was 0.4 and significantly less than 1 (P < .001; 95% confidence interval, 0.25-0.63). The O:E ratio relationship remained less than 0.5 for patients with low (STS-PROM < 4), moderate (STS-PROM = 4-8) and high risk (STS-PROM > 8). The O:E ratio was significantly higher for transapical patients (O:E ratio = 0.8) when compared with transfemoral patients (O:E ratio = 0.2). Lastly, O:E ratios for both commercial (O:E ratio = 0.5) and research (O:E ratio = 0.3) patients were similar (P = .337), and both were significantly less than 1 (P = .007 and P < .001, respectively). CONCLUSIONS: The STS-PROM consistently overestimated 30-day mortality after TAVR. Achieving an O:E ratio less than 0.6 may be a realistic goal for all TAVR programs. While an accurate and specific risk calculator for 30-day mortality after TAVR remains to be established, our data suggest that current TVT results are not acceptable for commercial TAVR and that programs with an O:E ratio greater than 0.6, based on the STS-PROM, should reevaluate internal processes to improve their results.
RESUMEN
Right ventricular (RV) failure is difficult to predict and is a major determinant of poor outcomes after left ventricular assist device (LVAD) implantation. We evaluated the associations of the following variables with severe RV failure in LVAD patients: tricuspid annular plane systolic excursion (TAPSE), pulmonary artery pulsatility index (PAPi), simplified RV contraction pressure index (sRVCPI), and HeartMate Risk Score (HMRS). We performed a retrospective case-control study on 216 patients who underwent continuous-flow LVAD implantation between 2008 and 2014. The primary analysis assessed the ability of HMRS, PAPi, sRVCPI, and TAPSE to predict severe RV failure. A secondary analysis evaluated the incremental benefit of combining predictive variables. Seventy-four patients developed severe RV failure (24%). Compared with the control group, the severe RV failure group had lower TAPSE (1.30 vs. 1.55; p < 0.001), lower PAPi (1.77 vs. 2.47; p = 0.001), lower sRVCPI (42.71 vs. 57.82; p < 0.001), and higher HMRS (2.12 vs. 1.65; p < 0.001). All four variables had similar receiver operating characteristic curves with modest area under the receiver operating characteristic curve (0.63-0.67, all p values < 0.001). In the evaluation of combined predictive variables, the combination of TAPSE with HMRS was found to be best for predicting severe RV failure. In summary, patients at risk for severe RV failure after LVAD implantation were successfully identified using TAPSE, PAPi, sRCPI, and HMRS. The combination of TAPSE and HMRS-incidentally, the least invasive and most readily available variables-proved to be superior to RV-centric metrics for predicting severe RV failure. The predictive and clinical use of these two variables should be tested prospectively.
Asunto(s)
Pruebas de Función Cardíaca/métodos , Corazón Auxiliar/efectos adversos , Disfunción Ventricular Derecha/diagnóstico , Disfunción Ventricular Derecha/etiología , Adulto , Anciano , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: Approximately 50% of patients with severe symptomatic mitral regurgitation are deemed too high risk for surgery. The MitraClip procedure is a viable option for this population. Our goal was to assess outcomes and survival of patients who underwent the MitraClip procedure at an institution where mitral valve surgery is routinely performed. METHODS: A retrospective study of patients undergoing the MitraClip procedure was performed. Baseline characteristics, perioperative outcomes, and follow-up echocardiographic and clinical outcomes were examined. Primary end point was survival. Secondary end points included technical failure (residual 3/4+ mitral regurgitation), reoperation, New York Heart Association symptoms, 30-day mortality, and other clinical outcomes. Predictors of mortality were determined using multivariable regression analysis. RESULTS: Fifty consecutive patients underwent the MitraClip procedure during the 4-year period. The average age was 83, the Society of Thoracic Surgeons predicted risk of mortality mean was 9.4%, 88% (44/50) had New York Heart Association III/IV symptoms, 86% (43/50) had 4+ mitral regurgitation, and 72% (36/50) had degenerative mitral disease etiology. Echocardiographic data (median [interquartile range] follow-up = 43 [26-392]) showed that 86% (43/50) of patients had 2+ or less mitral regurgitation. Sixty percent (24/40) had New York Heart Association I/II symptoms at last follow-up. Predictors of mortality were higher Society of Thoracic Surgeons predicted risk of mortality (P = 0.042, hazard ratio = 1.098) and previous cardiac surgery (P = 0.013, hazard ratio = 3.848). Survival at 1 and 2 years was 75% and 63%, respectively. CONCLUSIONS: Many patients with mitral valve regurgitation who are high risk for open surgery can be treated with the MitraClip procedure. In our study, most patients (86%) had a technically successful operation and postoperative outcomes including survival were acceptable.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/mortalidad , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Ecocardiografía , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Insuficiencia de la Válvula Mitral/mortalidad , Complicaciones Posoperatorias , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Air embolism is a rare but potentially catastrophic complication of interventional procedures. The occurrence of acute right ventricular dysfunction during intraoperative auto-transfusion of blood, presumably related to pulmonary embolism of agitated air microbubbles and microthrombi, is less commonly recognized. We report a case of auto-transfusion complicated by acute right ventricular failure and pulseless electrical activity arrest. Auto-transfusion of recovered blood is a practical solution to reduce need for post-procedure allogenic transfusions. Although such interventions are frequently performed without complications, they do have inherent risks that should be readily acknowledged. This case clearly describes a severe complication and sequelae of auto-transfusion.
RESUMEN
OBJECTIVE: To investigate repeat revascularisation outcomes in patients with rheumatoid arthritis(RA) after percutaneous coronary intervention (PCI). METHODS: We performed a single-centre, retrospective matched cohort study of patients with RA matched to non-RA patients post PCI. Primary endpoints were time to target lesion revascularisation (TLR) and target vessel revascularisation (TVR) analysed by Cox proportional hazard shared frailty models. RESULTS: A total of 228 lesions (143 patients) were identified in the RA cohort and matched to 677 control lesions (541 patients). TLR occurred in 33% (n=75) of RA lesions versus 25% (n=166) of control lesions (adjusted HR 1.3; 95% CI 0.97 to 1.8). TVR occurred in 39% (n=89) of RA lesions versus 31% (n=213) of control lesions (adjusted HR 1.15; 95% CI 0.82 to 1.6). There was a significant hazard for TLR (adjusted HR 1.48; 95% CI 1.03 to 2.13) and TVR (adjusted HR 1.55; 95% CI 1.12 to 2.14) when excluding lesions with revascularisation events or follow-up less than 1â year. When stratified by treatment with methotrexate or tumour necrosis factor (TNF) α inhibitors or both at discharge, lesions from patients with RA treated with these agents had similar TVR and TLR as control lesions, whereas lesions from patients with RA not treated with these agents had significantly more TLR and TVR (TLR adjusted HR 1.48; 95% CI 1.08 to 2.03; TVR adjusted HR 1.38; 95% CI 1.04 to 1.84). CONCLUSIONS: RA predisposes to repeat revascularisation, specifically in patients followed after the 1-year landmark. In the absence of RA treatments including methotrexate and/or TNFα inhibitors, RA is associated with a 50% increased relative risk of repeat revascularisation following PCI. These findings emphasise the adverse effects of chronic inflammation on the durability of PCI and provide further support for aggressive anti-inflammatory treatment in patients with RA.
Asunto(s)
Artritis Reumatoide/complicaciones , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea/efectos adversos , Anciano , Antirreumáticos/uso terapéutico , Artritis Reumatoide/diagnóstico , Artritis Reumatoide/tratamiento farmacológico , Productos Biológicos/uso terapéutico , Distribución de Chi-Cuadrado , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/diagnóstico , Bases de Datos Factuales , Femenino , Humanos , Inmunosupresores/uso terapéutico , Estimación de Kaplan-Meier , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Missouri , Análisis Multivariante , Intervención Coronaria Percutánea/instrumentación , Modelos de Riesgos Proporcionales , Retratamiento , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
OPINION STATEMENT: Coronary anomalies originating from the opposite sinus of Valsalva (ACAOS) are a rare anomaly associated with sudden cardiac death. Dynamic, invasive evaluation using coronary angiography, intravascular ultrasound, and fractional flow reserve can more clearly identify important pathophysiologic variants and guide treatment. This dynamic evaluation can assist the clinician in the appropriate surgical and percutaneous treatment options and aid in patient counseling. Long-term outcomes data regarding treatment and prognosis is still lacking.
RESUMEN
OBJECTIVE: The aim of this work was to characterize the clinical response and identify predictors of clinical stabilization after intra-aortic balloon counterpulsation (IABP) support in patients with chronic systolic heart failure in cardiogenic shock before implantation of a left ventricular assist device (LVAD). BACKGROUND: Limited data exist regarding the clinical response to IABP in patients with chronic heart failure in cardiogenic shock. METHODS: We identified 54 patients supported with IABP before LVAD implantation. Criteria for clinical decompensation after IABP insertion and before LVAD included the need for more advanced temporary support, initiation of mechanical ventilation or dialysis, increase in vasopressors/inotropes, refractory ventricular arrhythmias, or worsening acidosis. The absence of these indicated stabilization. RESULTS: Clinical decompensation after IABP occurred in 23 patients (43%). Both patients who decompensated and those who stabilized had similar hemodynamic improvements after IABP support, but patients who decompensated required more vasopressors/inotropes. Clinical decompensation after IABP was associated with worse outcomes after LVAD implantation, including a 3-fold longer intensive care unit stay and 5-fold longer time on mechanical ventilation (P < .01 for both). Although baseline characteristics were similar between groups, right and left ventricular cardiac power indexes (cardiac power index = cardiac index × mean arterial pressure/451) identified patients who were likely to stabilize (area under the receiver operating characteristic curve = 0.82). CONCLUSIONS: Among patients with chronic systolic heart failure who develop cardiogenic shock, more than one-half of patients stabilized with IABP support as a bridge to LVAD. Baseline measures of right and left ventricular cardiac power, reflecting work performed for a given flow and pressure, may allow clinicians to identify patients with sufficient contractile reserve who will be likely to stabilize with an IABP versus those who may need more aggressive ventricular support.
Asunto(s)
Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/cirugía , Mortalidad Hospitalaria/tendencias , Contrapulsador Intraaórtico/métodos , Choque Cardiogénico/mortalidad , Choque Cardiogénico/cirugía , Anciano , Causas de Muerte , Enfermedad Crónica , Estudios de Cohortes , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico por imagen , Corazón Auxiliar , Hemodinámica/fisiología , Humanos , Contrapulsador Intraaórtico/efectos adversos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Cuidados Preoperatorios/métodos , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Choque Cardiogénico/diagnóstico , UltrasonografíaRESUMEN
OBJECTIVE: In heart failure populations without aortic stenosis (AS), the prognostic utility of multiple biomarkers in addition to clinical factors has been demonstrated. We aimed to determine whether multiple biomarkers of cardiovascular stress are associated with mortality in patients with AS undergoing aortic valve replacement (AVR) independent of clinical factors. METHODS: From a prospective registry of patients with AS, 345 participants who were referred for and treated with AVR (transcatheter (n=183) or surgical (n=162)) were included. Eight biomarkers were measured on blood samples obtained prior to AVR: growth differentiation factor 15 (GDF15), soluble ST2 (sST2), amino-terminal pro-B-type natriuretic peptide (NTproBNP), galectin-3, high-sensitivity cardiac troponin T, myeloperoxidase, high-sensitivity C reactive protein and monocyte chemotactic protein-1. Biomarkers were evaluated based on median value (high vs low) in a Cox proportional hazards model for all-cause mortality and a parsimonious group of biomarkers selected. Mean follow-up was 1.9±1.2â years; 91 patients died. RESULTS: Three biomarkers (GDF15, sST2 and NTproBNP) were retained in the model. One-year mortality was 5%, 12%, 18% and 33% for patients with 0 (n=79), 1 (n=96), 2 (n=87) and 3 (n=83) biomarkers elevated, respectively (p<0.001). After adjustment for the Society of Thoracic Surgeons (STS) risk score, a greater number of elevated biomarkers was associated with increased mortality (referent: 0 elevated): 1 elevated (HR 1.47, 95% CI 0.60 to 3.63, p=0.40), 2 elevated (HR 2.89, 95% CI 1.24 to 6.74, p=0.014) and 3 elevated (HR 4.59, 95% CI 1.97 to 10.71, p<0.001). Among patients at intermediate or high surgical risk (STS score ≥4), 1-year and 2-year mortality rates were 34% and 43% for patients with three biomarkers elevated versus 4% and 4% for patients with 0 biomarkers elevated. When added to the STS score, the number of biomarkers elevated provided a category-free net reclassification improvement of 64% at 1â year (p<0.001). The association between a greater number of elevated biomarkers and increased mortality after valve replacement was similar in the transcatheter and surgical AVR populations. CONCLUSIONS: These findings demonstrate the potential utility of multiple biomarkers to aid in risk stratification of patients with AS. Further studies are needed to evaluate their utility in clinical decision-making in specific AS populations.
Asunto(s)
Estenosis de la Válvula Aórtica/terapia , Cateterismo Cardíaco , Factor 15 de Diferenciación de Crecimiento/sangre , Implantación de Prótesis de Válvulas Cardíacas , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Receptores de Superficie Celular/sangre , Estrés Fisiológico , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/sangre , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/cirugía , Biomarcadores/sangre , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/mortalidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Proteína 1 Similar al Receptor de Interleucina-1 , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: Coronary subclavian steal syndrome (CSSS) is the reversal of blood flow in an internal mammary artery bypass graft that results in coronary ischemia. CSSS is an uncommon but treatable cause of coronary ischemia. In this review, we highlight the historical background and epidemiology of CSSS, common clinical presentations, diagnosis of CSSS and management strategies for relieving ischemia. We also present a case report to illustrate the complexity of CSSS and percutaneous management using current technology. RECENT FINDINGS: Most commonly, CSSS results from atherosclerotic stenosis of the subclavian artery and occurs in 2.5-4.5% of patients referred for coronary artery bypass grafting (CABG). All patients referred for CABG should have bilateral noninvasive brachial blood pressures checked to screen for the underlying subclavian stenosis. A review of 98 case reports with 128 patients demonstrated a diverse clinical presentation of CSSS, including acute myocardial infarction, unstable angina and acute systolic heart failure. Resolution of CSSS symptoms has been reported with both surgical and percutaneous revascularization. Long-term patency with either revascularization strategy is excellent. Percutaneous revascularization is largely considered the first-line therapy for CSSS and can be safely performed prior to CABG to prevent CSSS. SUMMARY: CSSS should be suspected in patients presenting with angina, heart failure or myocardial infarction after CABG. Successful amelioration of CSSS symptoms can be safely and effectively performed via percutaneous revascularization.
Asunto(s)
Síndrome de Robo Coronario-Subclavio/diagnóstico , Arteria Subclavia/diagnóstico por imagen , Anciano , Angiografía , Síndrome de Robo Coronario-Subclavio/cirugía , Diagnóstico Diferencial , Humanos , Masculino , Arteria Subclavia/cirugía , Tomografía Computarizada por Rayos X , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
Transcatheter aortic valve replacement (TAVR) has been shown to significantly impact mortality and quality of life in patients with severe aortic stenosis (AS) who are deemed high risk for surgical aortic valve replacement (SAVR). Essential to these outcomes is proper patient selection. The multidisciplinary TAVR heart team was created to provide comprehensive patient evaluation and aid in proper selection. This review with outline the history and components of the heart team, and delineate the team's role in risk and frailty assessment, evaluation of common co-morbidities that impact outcomes, and the complex multi-modality imaging necessary for procedural planning and patient selection. The heart team is critical in determining patient eligibility and benefit and the optimal operative approach for TAVR. The future of structural heart disease will certainly require a team approach, and the TAVR heart team will serve as the successful model.
Asunto(s)
Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/terapia , Cateterismo Cardíaco , Técnicas de Apoyo para la Decisión , Implantación de Prótesis de Válvulas Cardíacas/métodos , Imagen Multimodal , Grupo de Atención al Paciente , Selección de Paciente , Cateterismo Cardíaco/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Imagen Multimodal/métodos , Valor Predictivo de las Pruebas , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Despite improvements in the care of patients who have received cardiac transplants, coronary allograft vasculopathy (CAV) remains the most prevalent cause of late allograft failure and cardiac mortality. Few proven therapies are available for this important disease. The presence of coronary collaterals imparts a favorable prognosis in patients with native ischemic heart disease; however, the impact of collaterals in CAV is unknown. METHODS AND RESULTS: To determine whether the development of coronary collaterals is associated with improved outcomes in patients with CAV, we performed a retrospective analysis of patients followed in the heart transplant program at Barnes Jewish Hospital from 1994 to 2008. The primary end points included all cause mortality and the composite of all cause mortality, retransplantation, and inotrope dependence. We screened 485 patients and identified 59 (12%) subjects with moderate-to-severe CAV. Angiographically visible coronary collaterals were present in 34 (57%) subjects. Kaplan-Meier and Cox multivariable analyses revealed that patients with collaterals had reduced incidence of all cause mortality (hazard ratio, 0.20; P<0.001) and the composite end point (hazard ratio, 0.17; P<0.001). In addition, patients with collaterals had less severe heart failure symptoms as measured by New York Heart Association class. Immunostaining of biopsy specimens revealed that among patients with CAV, the presence of coronary collaterals correlated with increased microvascular density, reduced fibrosis, and decreased left ventricular end-diastolic pressure. CONCLUSIONS: Together, these data demonstrate that the presence of coronary collaterals predicts a favorable prognosis in patients with CAV and suggests that interventions aimed at promoting collateral and microvascular growth may serve as effective therapies for this disease.