RESUMEN
Transcatheter valve-in-valve (VIV) implantation has been recently proposed as an alternative to surgical reoperative aortic valve replacement in patients with a failing aortic bioprosthesis. Experience with transcatheter VIV implantation at other valve positions is very limited. Herein is reported the case of an 18-year-old man with Ebstein's anomaly and severe tricuspid valve (TV) regurgitation status after bioprosthetic valve replacement, who developed new dyspnea on exertion three years after the initial valve replacement. Transesophageal echocardiography showed a severely dilated right atrium and new TV stenosis with an immobile leaflet. The patient underwent successful VIV implantation of a 29-mm SAPIEN XT bioprosthetic valve, with resolution of symptoms and no residual TV regurgitation or stenosis at the two-year follow up. Video 1: Degenerative bioprosthetic tricuspid valve. TEE showing the degenerative bioprosthetic tricuspid valve, and color Doppler during systole showing severe tricuspid regurgitation. Video 2: Degenerative bioprosthetic tricuspid valve. Three-dimensional TEE showing stenosis with an immobile leaflet creating a coaptation defect, viewed from the right atrium. Video 3: Transcatheter VIV replacement with a 29-mm Edwards SAPIEN XT deployed within the tricuspid valve prosthesis. Final result after valve implantation, demonstrating a patent valve orifice, and appropriate apposition of transcatheter valve within a pre-existing surgical Carpentier-Edwards bioprosthetic valve, viewed from the right ventricle. Video 4: Transcatheter VIV replacement with a 29-mm Edwards SAPIEN XT deployed within the tricuspid valve prosthesis. Final result after valve implantation, demonstrating a patent valve orifice, and appropriate apposition of transcatheter valve within a pre-existing surgical Carpentier-Edwards bioprosthetic valve, viewed from the right atrium.
Asunto(s)
Bioprótesis , Anomalía de Ebstein , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Adolescente , Cateterismo Cardíaco , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Diseño de Prótesis , Falla de Prótesis , Resultado del TratamientoAsunto(s)
Válvula Aórtica/microbiología , Enfermedad de la Arteria Coronaria/microbiología , Embolia/microbiología , Endocarditis Bacteriana/complicaciones , Infecciones Estafilocócicas/complicaciones , Staphylococcus aureus , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Embolia/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Continuous-flow left ventricular assist devices have revolutionized the management of advanced heart failure. Device complications continue to limit survival, but enhanced management strategies have shown promise. This study compared outcomes for HeartMate II recipients before and after implementation of a multidisciplinary continuous support heart team (HTMCS) strategy. METHODS: Between January 2012 and December 2016, 124 consecutive patients underwent primary HeartMate II implantation at our institution. In January 2015, we instituted a HTMCS approach consisting of (1) daily simultaneous cardiology/cardiac surgery/critical care/pharmacy/coordinator rounds, (2) pharmacist-directed anticoagulation, (3) speed optimization echocardiogram before discharge, (4) comprehensive device thrombosis screening and early intervention, (5) blood pressure clinic with pulsatility-adjusted goals, (6) early follow-up after discharge and individual long-term coordinator/cardiologist assignment, and (7) systematic basic/advanced/expert training and credentialing of ancillary in-hospital providers. All patients completed 1-year of follow-up. RESULTS: Demographic characteristics for pre-HTMCS (n = 71) and HTMCS (n = 53) groups, including age (55.8 ± 12.1 versus 52.5 ± 14.1 years, p = not significant), percentage of men (77.5% versus 71.7%, p = not significant), and Interagency Registry for Mechanically Assisted Circulatory Support class 3 (84.5% versus 83.0%, p = not significant), were comparable. One-year survival was 74.6% versus 100% for the pre-HTMCS and HTMCS groups, respectively (p = 0.0002). One-year survival free of serious adverse events (reoperation to replace device or disabling stroke) was 70.4% versus 84.9% for the pre-HTMCS and HTMCS groups, respectively (p = 0.059). Event per patient-year rates for disabling stroke (0.15 versus 0, p = 0.019), gastrointestinal bleeding (0.87 versus 0.51, p = 0.11), and driveline infection (0.24 versus 0.10, p = 0.18) were lower for the HTMCS group, whereas pump thrombosis requiring device exchange was higher (0.09 versus 0.18, p = 0.14). CONCLUSIONS: Implementing a comprehensive multidisciplinary approach substantially improved outcomes for recipients of continuous-flow left ventricular assist devices.
Asunto(s)
Insuficiencia Cardíaca/cirugía , Corazón Auxiliar , Sistema de Registros , Adolescente , Adulto , Anciano , Ecocardiografía , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Trasplante de Corazón , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Adulto JovenAsunto(s)
Stents Liberadores de Fármacos/efectos adversos , Eosinofilia , Síndrome de Kounis , Níquel , Intervención Coronaria Percutánea , Prednisona/administración & dosificación , Anciano de 80 o más Años , Diagnóstico Diferencial , Eosinofilia/diagnóstico , Eosinofilia/etiología , Humanos , Inmunosupresores/administración & dosificación , Síndrome de Kounis/diagnóstico , Síndrome de Kounis/tratamiento farmacológico , Síndrome de Kounis/etiología , Síndrome de Kounis/fisiopatología , Masculino , Metales Pesados/efectos adversos , Metales Pesados/análisis , Níquel/efectos adversos , Níquel/análisis , Infarto del Miocardio sin Elevación del ST/cirugía , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/métodos , Pruebas Cutáneas/métodosRESUMEN
BACKGROUND: Secundum atrial septal defects (ASDs) are treated by surgical closure (SC) or transcatheter device closure (TCC). Due to a scarcity of data directly comparing these approaches, it remains unclear which is superior. This meta-analysis compares the clinical outcomes of the two treatment options. METHODS: A literature search was performed in MEDLINE, Embase, PubMed, Google Search, and Cochrane databases for studies directly comparing SC and TCC of ASDs. Outcomes studied were major and minor acute complications, all-cause mortality, residual shunt, reinterventions, and length of stay (LOS). Relative risk (RR), difference in mean (DM) and 95% confidence intervals (CI) were calculated using the Mantel-Haenszel method with a fixed effect model. In cases of heterogeneity (defined as I2>25%), random effect models were used. Sensitivity and meta-regression analyses were performed for each outcome. RESULTS: Of the 1742 manuscripts screened, 26 observational studies fulfilled the inclusion criteria (total n=14,559 patients). TCC was superior to SC for the following outcomes: all-cause mortality (RR, 0.66; 95% CI 0.64-0.99), total complications (RR, 0.48; 95% CI 0.35-0.65), major complications (RR, 0.57; 95% CI 0.40-0.81), minor complications (RR, 0.35; 95% CI 0.23-0.53), and LOS (DM, -2.92; 95% CI -3.25 to (-2.58)). Residual shunts were more common with TCC (RR, 3.35; 95% CI 1.72-6.51). No difference was observed regarding the need of reintervention (RR, 1.45; 95% CI 0.60-3.51). Meta-regression analysis showed that older age increases the risk of death and complications in patients undergoing TCC. CONCLUSIONS: Though both approaches are effective, TCC is associated with lower mortality, complications, and LOS while SC has a lower rate of residual shunting.