RESUMO
Mycotic pseudoaneurysms (PA) are an infrequent complication of infective endocarditis (IE). However, due to advanced imaging modality and early therapy, this complication has been seen less frequently in the past few years. The reported incidence is 5%-15% of the patients, with the most common site being intracranial vessels (up to 65%), followed by abdominal and then peripheral vessels. We describe a young patient with a bicuspid aortic valve complicated by IE, who developed a giant mycotic PA. This was treated with a cover stent of the aneurysmal segment, which was complicated by distal stent migration and eventually managed with bypass surgery.
RESUMO
BACKGROUND: Although segmental or circumferential ablation is effective in eliminating pulmonary vein (PV)-mediated atrial fibrillation (AF), this procedure may be complicated by the occurrence of PV stenosis. METHODS AND RESULTS: To establish the clinical presentation, diagnostic manifestations, and interventional management of PV stenosis, 23 patients with stenosis of 34 veins complicating ablation of AF were evaluated. Each patient became symptomatic 103+/-100 days after undergoing ablation. In 8 veins, the ablation producing the PV stenosis was a repeated procedure for continued AF. Nineteen patients presented with dyspnea on exertion, 7 with dyspnea at rest, 9 with cough, and 6 with chest pain. On multirow spiral computed tomography examination, the narrowest lumen of the affected PVs measured 3+/-2 mm compared with 13+/-3 mm at baseline (P< or =0.001). The relative perfusion of affected lung segments on isotope scans was reduced to 4+/-3% of total perfusion compared with 22+/-10% in unaffected segments. At percutaneous intervention, these veins showed 80+/-13% stenosis, with a mean gradient of 12+/-5 mm Hg. This was significantly reduced to a residual stenosis of 9+/-8% (P< or =0.001) and a residual gradient of 3+/-4 mm Hg (P< or =0.001). Twenty veins were treated with balloon dilatation alone, whereas 14 veins were stented with standard 10-mm-diameter bare-metal stents. Although the symptomatic response was nearly immediate and impressive, 14 patients developed in-stent or in-segment restenosis, requiring repeated interventions in 13. CONCLUSIONS: Percutaneous intervention produces rapid and dramatic symptom relief in patients with highly symptomatic PV stenosis after radiofrequency ablation for AF. Nevertheless, alternative treatment methods will be required to decrease recurrent in-stent or in-segment restenosis.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter , Veias Pulmonares/cirurgia , Pneumopatia Veno-Oclusiva/diagnóstico , Pneumopatia Veno-Oclusiva/terapia , Adulto , Fibrilação Atrial/complicações , Constrição Patológica/diagnóstico , Constrição Patológica/etiologia , Constrição Patológica/terapia , Ecocardiografia Transesofagiana , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Veias Pulmonares/diagnóstico por imagem , Pneumopatia Veno-Oclusiva/etiologia , Tomografia Computadorizada por Raios XAssuntos
Angioplastia Coronária com Balão , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Pacientes Ambulatoriais , Sobreviventes , Adulto , Idoso , Idoso de 80 Anos ou mais , Antiarrítmicos/uso terapêutico , Cardiotônicos/uso terapêutico , Desfibriladores Implantáveis , Feminino , Seguimentos , Humanos , Balão Intra-Aórtico , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Masculino , Pessoa de Meia-Idade , Minnesota , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/terapia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Fibrilação Ventricular/mortalidade , Fibrilação Ventricular/terapiaRESUMO
OBJECTIVES: The goal of this study was to examine the effect of enhanced external counterpulsation (EECP) on endothelial function. BACKGROUND: Enhanced external counterpulsation improves symptoms and exercise tolerance in patients with symptomatic coronary artery disease (CAD). However, the exact mechanisms by which this technique exerts its clinical benefit are unclear. METHODS: Reactive hyperemia-peripheral arterial tonometry (RH-PAT), a noninvasive method to assess peripheral endothelial function by measuring reactive hyperemic response in the finger, was performed in 23 patients with refractory angina undergoing a 35-h course of EECP. In each patient RH-PAT measurements were performed before and after the first, at midcourse, and the last EECP session. In addition, RH-PAT response was assessed one month after completion of EECP therapy; RH-PAT index, a measure of reactive hyperemia, was calculated as the ratio of the digital pulse volume during reactive hyperemia divided by that at rest. RESULTS: Enhanced external counterpulsation led to symptomatic improvement (>/=1 Canadian Cardiovascular Society class) in 17 (74%) patients; EECP was associated with a significant immediate increase in average RH-PAT index after each treatment (p < 0.05). In addition, average RH-PAT index at one-month follow-up was significantly higher than that before EECP therapy (p < 0.05). When patients were divided by their clinical response, RH-PAT index at one-month follow-up increased only in those patients who experienced clinical benefit. CONCLUSIONS: Enhanced external counterpulsation enhances peripheral endothelial function with beneficial effects persisting at one-month follow-up in patients with a positive clinical response. This suggests that improvement in endothelial function may contribute to the clinical benefit of EECP in patients with symptomatic CAD.
Assuntos
Doença das Coronárias/fisiopatologia , Contrapulsação , Endotélio Vascular/fisiopatologia , Idoso , Volume Sanguíneo , Doença das Coronárias/terapia , Feminino , Dedos/irrigação sanguínea , Humanos , Hiperemia , Masculino , Pletismografia , Estudos ProspectivosRESUMO
Outcome studies of percutaneous coronary intervention (PCI) with conventional balloon angioplasty have established increased in-hospital and 1-year mortality in patients with left ventricular (LV) dysfunction compared with others. It is unclear whether recent PCI practice innovations, including stents and adjunctive pharmacotherapy, have made PCI safer and more effective in patients with LV dysfunction. We evaluated the influence of LV ejection fraction (EF) indexes on in-hospital and 1-year outcomes in 1,458 patients within the National Heart, Lung, and Blood Institute-sponsored Dynamic Registry. Patients (n = 300) with acute myocardial infarction were excluded. The remaining 1,158 patients were subdivided into 3 categories: group 1, EF
Assuntos
Angioplastia Coronária com Balão/mortalidade , Sistema de Registros , Disfunção Ventricular Esquerda/mortalidade , Idoso , Intervalos de Confiança , Angiografia Coronária , Doença das Coronárias/mortalidade , Doença das Coronárias/terapia , Determinação de Ponto Final , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Masculino , Análise de Regressão , Volume Sistólico/fisiologia , Análise de Sobrevida , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
Adjuvant medical therapy plays a central role in the ongoing care of patients with coronary artery disease after percutaneous revascularization. The cardiac and vascular protective effects of angiotensin converting enzyme (ACE) inhibitors make these agents an attractive choice in this setting, especially in light of the HOPE study results. Mounting evidence suggests that ACE inhibitors exert their favorable effects at the cellular level by antagonizing angiotensin II and enhancing nitric oxide bioavailability and, in the process, restoring normal endothelial function.