RESUMO
PURPOSE OF REVIEW: Tricuspid transcatheter edge-to-edge repair (T-TEER) has emerged as a well tolerated and effective therapeutic option for many patients with symptomatic severe tricuspid regurgitation at prohibitive surgical risk. However, there remain several important limitations to clip-based technology in the context of other rapidly emerging percutaneous treatment options for tricuspid regurgitation. RECENT FINDINGS: Tricuspid lesions pose unique challenges to treatment with the current toolbox of transcatheter clip-based technologies. This review will explore key issues related to patient factors, anatomical factors, and imaging factors that may render lesions to be unsuitable for treatment with T-TEER. SUMMARY: Selection for T-TEER must include a detailed clinical evaluation in the context of a 'heart team' approach involving multiple subspecialists, with screening for patient/lesion characteristics that make T-TEER suboptimal with current clip-based technologies. Future directions for research include patient-specific 3D modeling techniques, leaflet grasping techniques, clip deployment strategies, and personalized device sizing to increase the spectrum of lesions that may be treated with T-TEER within the context of other emerging transcatheter treatment options.
Assuntos
Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Tricúspide , Humanos , Insuficiência da Valva Tricúspide/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Resultado do Tratamento , Cateterismo Cardíaco/métodos , PrevisõesRESUMO
INTRODUCTION: Hypertrophic cardiomyopathy (HCM) is often associated with ischaemia despite lack of focal epicardial coronary stenosis. Our aim was to assess invasive coronary microvascular circulation and correlate findings with echocardiography. METHODS: We prospectively enrolled patients with HCM and controls who were referred for diagnostic coronary angiography. A pressure-temperature sensor coronary guidewire was used with intracoronary injections of room-temperature saline to measure mean coronary transit time during rest and hyperaemia induced with intravenous adenosine. The index of microvascular resistance (IMR) was calculated. Left ventricular mass was calculated during echocardiographic studies. RESULTS: Patients with HCM (n=12) and controls (n=7), had similar demographics. Left ventricular ejection fraction was higher in HCM (76.7%±11.0% vs 55.0%±15.9%, p=0.003). IMR was non-significantly higher in HCM (21.7±10.2 vs 15.3±4.8, p=0.16). Only patients with HCM had abnormal IMR (>25). Coronary flow reserve was non-significantly higher in HCM (2.7±1.6 vs 2.1±1.2, p=0.34). IMR correlated with left ventricular mass in hypertrophic cardiomyopathy subjects (Pearson r=0.68, p=0.02). CONCLUSIONS: Microvascular dysfunction as assessed by IMR may be abnormal in HCM and is correlated with left ventricular mass.
Assuntos
Cardiomiopatia Hipertrófica , Função Ventricular Esquerda , Cardiomiopatia Hipertrófica/diagnóstico , Circulação Coronária , Ecocardiografia , Humanos , Volume SistólicoAssuntos
Remoção de Dispositivo , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Tricúspide , Humanos , Remoção de Dispositivo/métodos , Próteses Valvulares Cardíacas/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Marca-Passo Artificial/efeitos adversos , Valva Tricúspide/cirurgia , Insuficiência da Valva Tricúspide/cirurgia , Insuficiência da Valva Tricúspide/etiologiaRESUMO
PURPOSE OF REVIEW: Review recent advances in the diagnosis and management of right ventricular (RV) failure. RECENT FINDINGS: Temporary and durable device-based management of RV failure has emerging applications. SUMMARY: Research advances and clinical management in RV failure have been limited by a lack of consensus on a universal definition. Echocardiographic and cardiac MRI-based predictors of RV failure are imperfect. Combinations of hemodynamic and imaging variables may have better predictive value. Loading conditions and ventriculo-arterial coupling play important roles in RV function. The current treatment approach to RV failure includes a combination of inotropy and vasodilatation but lacks conclusive evidence. Emerging biochemical and molecular targets hold promise but have yet to be proven in human studies.
Assuntos
Insuficiência Cardíaca , Disfunção Ventricular Direita , Ecocardiografia , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/terapia , Hemodinâmica , Humanos , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/terapia , Função Ventricular DireitaRESUMO
BACKGROUND: Radial artery occlusion (RAO) is the most common complication following transradial approach (TRA) for cardiac catheterisation. Our aim was to assess if decreasing radial hemostatic device (RHD) time reduces the risk of RAO among individuals receiving small sheath sizes with no adjunctive heparin. METHODS: We randomised 450 individuals undergoing diagnostic cardiac catheterization via TRA to 3 durations of RHD time: 10, 20, or 30 minutes. After these time periods, the RHD was gradually released over 20 minutes. The primary efficacy end point was forearm hematoma grade ≥ 2 (5-10 cm) and the primary safety end point was RAO (as determined by Doppler ultrasound) 1 hour after RHD removal (before discharge). RESULTS: The mean age was 66 years and 64% were male. Five-French sheaths were used in all patients. Hematoma grade ≥ 2 occurred in only 1 patient, who was in the 20-minute group (P = 0.39). RAO occurred in 6.7% of patients in the 10-minute group, 10.7% in the 20-minute group and 6% in the 30-minute group (P = 0.26). CONCLUSIONS: Among patients receiving small-caliber sheaths without adjunctive heparin, the incidence of forearm hematoma and RAO are low. Shorter durations of RHD time did not further reduce the risk of these complications.
Assuntos
Arteriopatias Oclusivas , Cateterismo Cardíaco/efeitos adversos , Cateterismo Periférico , Hemostasia Cirúrgica , Hemorragia Pós-Operatória/prevenção & controle , Artéria Radial , Idoso , Arteriopatias Oclusivas/etiologia , Arteriopatias Oclusivas/prevenção & controle , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/métodos , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/métodos , Duração da Terapia , Feminino , Hemostasia Cirúrgica/efeitos adversos , Hemostasia Cirúrgica/instrumentação , Hemostasia Cirúrgica/métodos , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Artéria Radial/patologia , Artéria Radial/cirurgia , Risco Ajustado/métodosRESUMO
Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis (AS) in patients with elevated surgical risk. Concomitant coronary artery disease affects 55-70% of patients with severe AS. Percutaneous coronary intervention in patients with TAVI can be challenging. We report a case of acute coronary obstruction immediately following transapical TAVI deployment requiring emergent rotational atherectomy.
Assuntos
Estenose da Valva Aórtica/cirurgia , Intervenção Coronária Percutânea/efeitos adversos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Aterectomia Coronária/métodos , Angiografia Coronária , Humanos , Masculino , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Contemporary transcatheter and minimally invasive approaches allow for improved cosmesis and eliminate sternotomy; however, access to a 'Heart Team' approach to minimally invasive atrial septal defect (ASD) repair remains limited in Canada. METHODS: Retrospective chart review of all minimally invasive atrial septal defect repairs performed between 2009 and 2017 at a quaternary cardiac care centre were included. We compared residual shunt, functional status, periprocedural complications, and hospital lengths-of-stay between patients undergoing transcatheter and minimally invasive endoscopic ASD repair. RESULTS: Between 2009 and 2017, 61 consecutive patients underwent ASD repair at a single centre: 28 patients underwent transcatheter closure (64.3% female; median age 57, interquartile range 43-70.5) and 33 patients underwent minimally invasive endoscopic repair (72.7% female; median age 37, interquartile range 24-50). Patient demographics were similar between the two groups with the exception of transcatheter patients having smaller defect size (1.65 cm versus 2.35 cm, p = 0.002). Procedural success was 93% (26/28) and 100% (33/33) for transcatheter and minimally invasive groups (p = 0.21), respectively. Periprocedural complications were similarly low between the two groups with the exception of longer hospital length-of-stay in the surgical patients (5 days vs 1 day, p < 0.0001). Over a follow-up period (transcatheter: 0.5-56.5 months, surgical: 0.25-89 months), there was no difference in residual shunt (14.3% versus 6.1%, p = 0.4) or NYHA I Functional Class (88.5% versus 96.9%, p = 0.21). CONCLUSION: Transcatheter and minimally invasive approaches to ASD repair are safe and feasible in selected patients using a 'Heart Team' approach and represent attractive alternatives to median sternotomy.
Assuntos
Cateterismo Cardíaco , Comunicação Interatrial/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Equipe de Assistência ao Paciente , Adulto , Idoso , Cateterismo Cardíaco/efeitos adversos , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Abstract Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis (AS) in patients with elevated surgical risk. Concomitant coronary artery disease affects 55-70% of patients with severe AS. Percutaneous coronary intervention in patients with TAVI can be challenging. We report a case of acute coronary obstruction immediately following transapical TAVI deployment requiring emergent rotational atherectomy.
Resumo O implante valvar aórtico transcateter (TAVI) é um tratamento estabelecido para estenose aórtica grave (EA) em pacientes com risco cirúrgico elevado. Doença arterial coronariana concomitante afeta 55-70% dos pacientes com EA grave. A intervenção coronária percutânea em pacientes com TAVI pode ser um desafio. Relatamos um caso de obstrução coronariana aguda imediatamente após o implante de TAVI transapical, exigindo aterectomia rotacional emergencial.
Assuntos
Humanos , Masculino , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/cirurgia , Intervenção Coronária Percutânea/efeitos adversos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Angiografia Coronária , Aterectomia Coronária/métodosAssuntos
Coagulação Sanguínea , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Forame Oval Patente/terapia , Dispositivo para Oclusão Septal , Trombofilia/complicações , Trombose/etiologia , Adulto , Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Humanos , Desenho de Prótese , Trombofilia/diagnóstico , Trombofilia/tratamento farmacológico , Trombose/sangue , Trombose/diagnóstico por imagem , Trombose/tratamento farmacológico , Resultado do TratamentoRESUMO
PURPOSE: To evaluate the efficacy of prophylactic ketorolac 0.5% versus nepafenac 0.1% versus placebo on macular volume 1 month after uneventful phacoemulsification and evaluate the health-related quality-of-life (HRQOL) of topical nonsteroidal antiinflammatory drugs (NSAIDs) in the context of cataract surgery. SETTING: Hotel Dieu Hospital, Kingston, Ontario, Canada. DESIGN: Prospective placebo-controlled parallel-assignment double-masked randomized clinical trial. METHODS: In this study, patients 18 years or older scheduled for routine phacoemulsification were randomized to a placebo, ketorolac 0.5%, or nepafenac 0.1% and dosed 4 times a day starting 1 day before surgery and continuing for 4 weeks. Spectral-domain macular cube ocular coherence tomography scans measuring central subfield thickness, macular cube volume, and average macular cube thickness were performed at baseline and 1 month postoperatively. The HRQOL metrics were determined with the Comparison of Ophthalmic Medications for Tolerability (COMTOL) questionnaire. RESULTS: Each study group comprised 54 patients. One month postoperatively, although a trend toward significance occurred for nepafenac and ketorolac, analysis of the means of differences showed no statistically significant differences between the 3 study groups (P=.2901). The COMTOL analysis found no difference in tolerability, compliance, side-effect frequency and bother, and effects on HRQOL between ketorolac and nepafenac compared with the placebo. CONCLUSIONS: One month after uneventful phacoemulsification, there was no difference in macular volume between the placebo, ketorolac, and nepafenac. Ketorolac and nepafenac were well tolerated with minimal side-effect profiles. Thus, for patients without risk factors having routine surgery, prophylactic topical NSAIDs are not recommended.
Assuntos
Anti-Inflamatórios não Esteroides/administração & dosagem , Benzenoacetamidas/administração & dosagem , Cetorolaco/administração & dosagem , Edema Macular/prevenção & controle , Facoemulsificação , Fenilacetatos/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios não Esteroides/efeitos adversos , Benzenoacetamidas/efeitos adversos , Método Duplo-Cego , Feminino , Nível de Saúde , Humanos , Cetorolaco/efeitos adversos , Edema Macular/diagnóstico , Masculino , Pessoa de Meia-Idade , Soluções Oftálmicas/administração & dosagem , Soluções Oftálmicas/efeitos adversos , Fenilacetatos/efeitos adversos , Estudos Prospectivos , Qualidade de Vida , Inquéritos e Questionários , Tomografia de Coerência Óptica , Resultado do TratamentoRESUMO
BACKGROUND: Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) presents challenges in a large geographic area for achieving treatment time targets and creates demands on the PCI centre resources. OBJECTIVE: We compare the in-hospital mortality rate of patients presenting with STEMI and referred for PCI from 11 transfer hospitals with those presenting to the cardiac centre in a regional STEMI program with a selective repatriation strategy. METHODS: Between June 1, 2003, and June 30, 2007, clinical and procedural data of all STEMI patients who were referred to the catheterization laboratory were prospectively collected. Patients who sustained prolonged cardiac arrest were excluded. RESULTS: A total of 1154 patients from regional hospitals and 325 patients initially presenting to the PCI centre were referred for acute intervention. There was no significant in-hospital mortality difference between the 2 groups (3.7% vs 4.0%, respectively; P = 0.87). Multiple logistic regression analysis showed that advanced age, female gender, multivessel coronary disease, history of hypertension, low ejection fraction, increased left ventricular end-diastolic pressure, and thrombolytic pretreatment, but not transfer status, were independent predictors for mortality. Among the 1154 transfer patients, 937 patients (81.2%) returned immediately post procedure and had a lower mortality rate than the remaining 217 patients (18.2%) who required admission to the PCI centre following cardiac catheterization (1.9% vs 11.5%, P < 0.001). CONCLUSION: A regional system of STEMI care based on rapid patient transfer to a PCI centre and repatriation was feasible and safe.