RESUMEN
We present the case of a 28-year-old woman with a history of tricuspid valve endocarditis leading to chronic thromboembolic pulmonary hypertension (CTEPH) with multiple pulmonary artery chronic total occlusions (CTOs) due to septic emboli. Following a multidisciplinary care discussion, the patient was brought forward for balloon pulmonary angioplasty (BPA) with successful revascularization of all chronically occluded territories. This case highlights advances in pulmonary artery CTO interventions and demonstrates the feasibility of BPA for CTEPH patients with a history of septic emboli.
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Angioplastia de Balón , Hipertensión Pulmonar , Embolia Pulmonar , Femenino , Humanos , Adulto , Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/terapia , Embolia Pulmonar/complicaciones , Embolia Pulmonar/diagnóstico por imagen , Resultado del Tratamiento , Enfermedad Crónica , Arteria PulmonarRESUMEN
BACKGROUND: The Harmony TPV25 transcatheter pulmonary valve (Medtronic Inc.) is constructed with a self-expanding stent frame comprising six zigged nitinol wires sewn together and covered with knitted polyester fabric, with flared inflow and outflow ends and a porcine pericardial valve sutured to the central portion of the device. It was approved for treatment of pulmonary regurgitation after prior right ventricular outflow tract repair in 2021. Early outcomes of this procedure have been excellent, but little is known about valve durability or ultimate mechanisms of dysfunction. METHODS: We collected data on patients who underwent reintervention for TPV25 dysfunction and described findings related to distortion of the stent frame and tissue accumulation. RESULTS: We describe six patients who underwent valve-in-valve implant for TPV25 obstruction (peak catheterization gradient peak 28-73 mmHg) 10-28 months after implant. In all cases, there was tissue accumulation within the inflow and valve-housing segments of the device and deformation of the self-expanding valve frame characterized by variable circumferential narrowing at the junction between the valve housing and the inflow and outflow portions of the device, with additional geometric changes in all segments. All six patients underwent valve-in-valve implant that results in a final peak gradient ≤10 mmHg and no regurgitation. DISCUSSION: The occurrence of short-term Harmony TPV25 dysfunction in multiple patients with a similar appearance of frame distortion and tissue accumulation within the inflow and valve housing portions of the device suggests that this may be an important failure mechanism for this valve. Potential causes of the observed findings are discussed. It is possible to treat this mechanism of TPV25 dysfunction with valve-in-valve implant using balloon expandable transcatheter valves.
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Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Pulmonar , Válvula Pulmonar , Obstrucción del Flujo de Salida Ventricular Derecho , Obstrucción del Flujo Ventricular Externo , Humanos , Porcinos , Animales , Prótesis Valvulares Cardíacas/efectos adversos , Obstrucción del Flujo Ventricular Externo/diagnóstico por imagen , Obstrucción del Flujo Ventricular Externo/etiología , Obstrucción del Flujo Ventricular Externo/cirugía , Resultado del Tratamiento , Cateterismo Cardíaco , Insuficiencia de la Válvula Pulmonar/diagnóstico por imagen , Insuficiencia de la Válvula Pulmonar/etiología , Insuficiencia de la Válvula Pulmonar/cirugía , Stents/efectos adversos , Diseño de PrótesisRESUMEN
Access to the arterial circulation and full anticoagulation carries a risk of serious bleeding during and after percutaneous coronary intervention. Important sources of bleeding include the arterial access site and coronary artery perforation. Prompt and effective management of hemorrhagic complications is an essential interventional skill. Protamine sulfate is well-known as a heparin reversal agent. Despite this, there is heterogeneity in the use of protamine during interventional procedures. While protamine is generally well-tolerated, it is associated with a risk of hypersensitivity reaction, including anaphylaxis, among others. The purpose of this review is to summarize the existing evidence about and experience with the use of protamine sulfate in the setting of percutaneous coronary and structural interventional procedures.
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Hemorragia , Protaminas , Humanos , Protaminas/efectos adversos , Resultado del Tratamiento , Hemorragia/inducido químicamente , Hemorragia/prevención & control , Coagulación Sanguínea , Cateterismo Cardíaco/efectos adversosRESUMEN
Significant hemolysis is a recognized complication of transcatheter high-velocity shunt occlusion using some Amplatzer devices. We describe a case of severe hemolysis following occlusion of an iatrogenic Gerbode defect with an Amplatzer muscular ventricular septal defect occluder successfully managed by transcatheter device removal and reocclusion with a Gore Cardioform Atrial Septal Defect Occluder.
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Defectos del Tabique Interatrial , Defectos del Tabique Interventricular , Dispositivo Oclusor Septal , Cateterismo Cardíaco/efectos adversos , Defectos del Tabique Interatrial/complicaciones , Defectos del Tabique Interatrial/diagnóstico por imagen , Defectos del Tabique Interatrial/terapia , Hemólisis , Humanos , Dispositivo Oclusor Septal/efectos adversos , Resultado del TratamientoRESUMEN
Kawasaki disease (KD) is an acute vasculitis that can cause coronary artery inflammation and aneurysm formation leading to early obstructive disease. We describe the use of PK Papyrus covered stents (Biotronic, Inc.) in three pediatric patients to exclude coronary artery aneurysms (CAA) from the circulation and relieve aneurysm associated stenoses. Follow-up angiography at 11-17 months postprocedure demonstrated persistent exclusion of CAA and varying degrees of in-stent restenosis (ISR). Two patients required percutaneous coronary intervention with drug eluting stent (DES) implantation to relieve in-stent stenosis. Our findings suggest that CAA exclusion with the PK Papyrus stent is possible and may be a valuable tool in simultaneously treating stenotic and thrombogenic CAA in pediatric KD patients. ISR of these non-DES remains an issue and may require additional interventions within the short-term to maintain vessel patency.
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Aneurisma Coronario , Reestenosis Coronaria , Stents Liberadores de Fármacos , Síndrome Mucocutáneo Linfonodular , Intervención Coronaria Percutánea , Humanos , Niño , Síndrome Mucocutáneo Linfonodular/complicaciones , Síndrome Mucocutáneo Linfonodular/diagnóstico , Stents Liberadores de Fármacos/efectos adversos , Vasos Coronarios , Resultado del Tratamiento , Aneurisma Coronario/diagnóstico por imagen , Aneurisma Coronario/etiología , Aneurisma Coronario/terapia , Stents , Intervención Coronaria Percutánea/efectos adversos , Reestenosis Coronaria/etiología , Angiografía CoronariaRESUMEN
BACKGROUND: Angiopoietin-1 and 2 (Ang1, Ang2) are important mediators of angiogenesis. Angiopoietin levels are perturbed in cardiovascular disease, but it is unclear whether angiopoietin signaling is causative, an adaptive response, or merely epiphenomenon of disease activity. METHODS AND RESULTS: In a cohort free of cardiovascular disease at baseline (Multi-Ethnic Study of Atherosclerosis [MESA]), relationships between angiopoietins, cardiac morphology, and subsequent incidence of heart failure or cardiovascular death were evaluated. In cohorts with pulmonary arterial hypertension or left heart disease, associations between angiopoietins, invasive hemodynamics, and adverse clinical outcomes were evaluated. In MESA, Ang2 was associated with a higher incidence of heart failure or cardiovascular death (hazard ratio 1.21 per standard deviation, P < .001). Ang2 was associated with increased right atrial pressure (pulmonary arterial hypertension cohort) and increased wedge pressure and right atrial pressure (left heart disease cohort). Elevated Ang2 was associated with mortality in the pulmonary arterial hypertension cohort. CONCLUSIONS: Ang2 was associated with incident heart failure or death among adults without cardiovascular disease at baseline and with disease severity in individuals with existing heart failure. Our finding that Ang2 is increased before disease onset and that elevations reflect disease severity, suggests Ang2 may contribute to heart failure pathogenesis.
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Angiopoyetina 2/metabolismo , Enfermedades Cardiovasculares , Insuficiencia Cardíaca , Adulto , Angiopoyetina 1/metabolismo , Angiopoyetinas , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Humanos , Incidencia , Índice de Severidad de la EnfermedadRESUMEN
PURPOSE OF REVIEW: Review the recently updated guidelines for the management of patients with adult congenital heart disease (ACHD) with a focus on the changes between these guidelines and the prior guidelines. RECENT FINDINGS: The 2018 guidelines for the management of patients with ACHD focused on utilizing the available data and limiting the number recommendations based only on expert opinion. These guidelines implement a new anatomic and physiological classification scheme to guide management of patients, which takes into account both the underlying anatomy as well as residual cardiac disease and symptoms. Given a lack of robust outcomes data for many types of CHD, the new guidelines provide fewer total recommendations than the prior version, emphasizing the data that is available and drawing attention to the need for additional data. The 2018 guidelines provide the field with a comprehensive update in the management of ACHD patients with an emphasis on the available data.
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Cardiología/normas , Cardiopatías Congénitas/terapia , Insuficiencia Cardíaca/terapia , Guías de Práctica Clínica como Asunto , Adulto , Cardiólogos , Manejo de la Enfermedad , Cardiopatías Congénitas/complicaciones , Insuficiencia Cardíaca/etiología , HumanosRESUMEN
PURPOSE OF REVIEW: Ebstein's anomaly (EA) is a rare, but complex form of congenital heart disease consisting of a right ventricular myopathy and morphologic tricuspid valve disease leading to a high incidence of right ventricular dysfunction and arrhythmias. This review offers an updated overview of the current understanding and management of patients with EA with a focus on the adult population. RECENT FINDINGS: Increased understanding of anatomic accessory atrioventricular pathways in EA has resulted in an improvement in ablation techniques and long-term freedom of atrial arrhythmia recurrence. Despite an improvement in understanding and recognition of EA, significant disease heterogeneity and complex treatment options continue to challenge providers, with the best outcomes achieved at expert congenital heart disease centers.
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Anomalía de Ebstein , Cardiopatías Congénitas , Insuficiencia de la Válvula Tricúspide , Adulto , Arritmias Cardíacas/etiología , Anomalía de Ebstein/diagnóstico por imagen , Anomalía de Ebstein/cirugía , Humanos , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugíaRESUMEN
BACKGROUND: The incidence of heart failure is increasing within the Fontan population. The use of serological markers, including B-type natriuretic peptide, has been limited in this patient population. METHODS: This was a single-centre retrospective study of Fontan patients in acute decompensated heart failure. Fontan patients underwent a 1:2 match with non-Fontan patients for each heart failure hospitalisation for comparative analysis. A univariate logistic regression model was used to assess associations between laboratory and echocardiographic markers and a prolonged length of stay of 7 days or greater. RESULTS: B-type natriuretic peptide levels were significantly lower in Fontan patients admitted for heart failure than that in non-Fontan patients [390.9 (±378.7) pg/ml versus 1245.6 (±1160.7) pg/ml, respectively, p < 0.0001] and were higher in Fontan patients with systemic ventricular systolic or diastolic dysfunction than that in Fontan patients with normal systemic ventricular function [833.6 (±1547.2) pg/ml versus 138.6 (±134.0) pg/ml, p = 0.017]. The change from the last known outpatient value was smaller in Fontan patients in comparison with non-Fontan patients [65.7 (±185.7) pg/ml versus 1638.0 (±1444.7) pg/ml, respectively, p < 0.0001]. Low haemoglobin and high blood urea nitrogen levels were associated with a prolonged length of stay. CONCLUSION: B-type natriuretic peptide levels do not accurately reflect decompensated heart failure in Fontan patients when compared to non-Fontan heart failure patients and should, therefore, be used with caution in this patient population.
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Insuficiencia Cardíaca , Adulto , Biomarcadores , Ventrículos Cardíacos , Humanos , Péptido Natriurético Encefálico , Estudios RetrospectivosRESUMEN
BACKGROUND: The present study designed to evaluate feasibility of transesophageal echocardiographic (TEE) imaging of the pulmonary valve (PV) at the transaortic upper esophageal (TAUE) window. We hypothesized that patients with larger aorta would be more likely to have visualization of the PV from this TAUE window. METHODS: 2D TEE images of the PV were prospectively acquired by one operator at the TAUE window looking through the aortic arch. Patients were divided into four groups based on image quality of PV (group 1, not visualized; group 2, barely visualized; group 3, sufficient visualization; group 4, excellent visualization). Clinical, echocardiographic, and radiologic parameters were collected. RESULTS: A total of 212 consecutive patients (54 ± 14 years, 63.7% male) were enrolled. Group distribution was as follows: group 1, n = 60 (28.3%); group 2 n = 39 (18.4%); group 3, n = 27 (12.7%); group 4, n = 86 (40.6%). There were no differences between groups' baseline clinical characteristics. There was a weak although statistically negative correlation between PV image quality and aortic arch dimension (r = -0.17 P = 0.01). There was a stronger positive correlation between PV thickness (r = 0.38 P < 0.001) and PV image quality. Retrospective subgroup analysis of 76 patients with recent chest CT showed similar, but not significant trends as by TEE. CONCLUSION: The use of 2D TEE TAUE results in diagnostic image quality of the PV in the majority of patients and outstanding image quality in a subset of patients. PV image quality is negatively affected by increasing aorta diameter and positively affected by PV thickness.
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Ecocardiografía Transesofágica/métodos , Válvula Pulmonar/diagnóstico por imagen , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
We present a case of successful bicaval Melody valve implantation to treat severe mitral regurgitation in a 44-year-old man with d-transposition of the great arteries, repaired via a Mustard operation. The patient sustained injury to the anterior mitral valve leaflet during laser extraction of a ventricular pacing lead resulting in acute, severe, symptomatic mitral regurgitation. The presence of systemic venous baffles of similar caliber to right ventricular outflow tract conduits allowed for implantation of Melody valves within each baffle. The patient remains asymptomatic with excellent Melody valve function 14 months post procedure.
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Operación de Switch Arterial , Remoción de Dispositivos/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Transposición de los Grandes Vasos/cirugía , Adulto , Operación de Switch Arterial/efectos adversos , Valvuloplastia con Balón , Ecocardiografía Doppler en Color , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/fisiopatología , Marcapaso Artificial/efectos adversos , Flebografía , Diseño de Prótesis , Radiografía Intervencional , Recuperación de la Función , Índice de Severidad de la Enfermedad , Transposición de los Grandes Vasos/fisiopatología , Resultado del TratamientoRESUMEN
Kawasaki disease is a self-limiting vasculitis presenting in childhood that can lead to aneurysms of the coronary arteries. Patients who develop giant coronary aneurysms have a high incidence of coronary stenoses and occlusions resulting in myocardial ischemia. The mainstay of treatment for these lesions is surgical bypass due to complex coronary anatomy and a high rate of chronic total occlusions precluding traditional percutaneous coronary intervention techniques. We report the first successful percutaneous revascularization of two chronically occluded giant coronary aneurysms using the Hybrid Interventional Strategy for approaching chronic total occlusions. Both antegrade and retrograde dissection-reentry techniques were employed to fully revascularize two major epicardial arteries. Despite procedural success, longer-term vessel patency was not maintained following stent deployment highlighting the difficulty in maintaining durable results with percutaneous coronary intervention in this patient population.
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Intervención Coronaria Percutánea , Enfermedad Crónica , Aneurisma Coronario , Angiografía Coronaria , Vasos Coronarios , Humanos , Síndrome Mucocutáneo Linfonodular , Isquemia Miocárdica , Resultado del TratamientoRESUMEN
Chronic thromboembolic pulmonary hypertension is a rare form of pulmonary hypertension in patients who have evidence of chronic thromboembolic occlusion of the pulmonary vasculature. Historically, surgical pulmonary thromboendarterectomy has been the treatment of choice. However, with up to 40% of patients deemed inoperable, balloon pulmonary angioplasty has emerged as an additional treatment strategy. Balloon pulmonary angioplasty is a complementary strategy alongside surgical pulmonary thromboendarterectomy and offers the opportunity for pulmonary revascularization in patients who have more distal disease, higher comorbidities, or residual obstruction following operative intervention. This review examines the history of balloon pulmonary angioplasty, highlights its effectiveness, discusses important complications and risk reduction strategies, and emphasizes the importance of centers forming a multidisciplinary team of providers to manage the complexity of patients with chronic thromboembolic pulmonary hypertension.
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Angioplastia de Balón , Hipertensión Pulmonar , Arteria Pulmonar , Embolia Pulmonar , Humanos , Embolia Pulmonar/fisiopatología , Embolia Pulmonar/terapia , Embolia Pulmonar/cirugía , Embolia Pulmonar/complicaciones , Enfermedad Crónica , Resultado del Tratamiento , Hipertensión Pulmonar/fisiopatología , Hipertensión Pulmonar/terapia , Hipertensión Pulmonar/diagnóstico , Arteria Pulmonar/fisiopatología , Arteria Pulmonar/cirugía , Factores de Riesgo , Presión Arterial , Endarterectomía/efectos adversosRESUMEN
Chronic thromboembolic pulmonary hypertension (CTEPH) is a sequela of a pulmonary embolus that occurs in approximately 1%-3% of patients. Pulmonary thromboendoarterectomy (PTE) can be a curative procedure, but balloon pulmonary angioplasty (BPA) has emerged as an option for poor surgical candidates. We used the National Inpatient Sample to query patients who underwent PTE or BPA between 2012 and 2019 with CTEPH. The primary outcome was a composite of in-hospital mortality, myocardial infarction, stroke, tracheostomy, and prolonged mechanical ventilation. Outcomes were compared between low- and high-volume centers, defined as 5 and 10 procedures per year for BPA and PTE, respectively. During our study period, 870 BPA and 2395 PTE were performed. There was a 328% relative increase in the number of PTE performed during the study period. Adverse events for BPA were rare. There was an increase in the primary composite outcome for low-volume centers compared to high-volume centers for PTE (24.4% vs. 12.1%, p = 0.003). Patients with hospitalizations for PTE in low-volume centers were more likely to have prolonged mechanical ventilation (20.0%% vs. 7.2%, p < 0.001) and tracheostomy (7.8% vs. 2.6%, p = 0.017). In summary, PTE rates have been rising over the past 10 years, while BPA rates have remained stable. While adverse outcomes are rare for BPA, patients with hospitalizations at low-volume centers for PTE were more likely to have adverse outcomes. For patients undergoing treatment of CTEPH with BPA or PTE, referral to high-volume centers with multidisciplinary teams should be encouraged for optimal outcomes.
RESUMEN
BACKGROUND: Transverse aortic arch obstruction is a challenging lesion for which stent implantation provides a potentially important alternate therapy. The objectives were to evaluate the technical, procedural, and medium-to-long-term clinical outcomes of percutaneous stent implantation of transverse aortic arch obstruction. METHODS: This is a retrospective, multicenter study of transverse aortic arch stent implantation. Univariable and multivariable analyses were performed. RESULTS: Index catheterization included 187 stent implants in 146 patients. The median age is 14.3 years (interquartile range, 9.3-19), weight is 53 kg (30-69), and follow-up is 53 months (12-120). The most common stent design was open cell (n=90, 48%). Stents overlapped 142 arch vessels (37 carotid arteries) in 118 (81%) cases. Technical and procedural success rates were 100% and 88%, respectively. Lower weight (P=0.018), body surface area (P=0.013), and minimum-to-descending aortic diameter ratio (P<0.001) were associated with higher baseline aortic gradient. The residual gradient was inversely associated with implant and final dilation diameters (P<0.001). The combined incidence of aortic injury and stent-related complications was 14%. There were no reports of abnormal brain scans or stroke. Blood pressure cuff gradient, echocardiographic arch velocity, and hypertension rates improved within 1-year follow-up with increased antihypertensive medication use. Reintervention was reported in 60 (41%) patients at a median of 84 (22-148) months to first reintervention. On multivariable logistic regression, residual aortic gradient >10 mmâ Hg was associated with increased odds of reintervention at all time points when controlling for each final dilation diameter, weight, and minimum-to-descending aortic diameter ratio. CONCLUSIONS: Transverse aortic arch stent implantation has high rates of technical, procedural, and medium-to-long-term clinical success. Aortic gradient >10 mmâ Hg is associated with increased odds of reintervention at 1-year and most recent follow-ups. Open cell stent design was frequently used for its advantages in conformability, perfusion of arch vessels, low fracture rate, and the ability to perform effective angioplasty of side cells.
Asunto(s)
Angioplastia de Balón , Aorta Torácica , Diseño de Prótesis , Stents , Humanos , Estudios Retrospectivos , Masculino , Femenino , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aorta Torácica/fisiopatología , Resultado del Tratamiento , Factores de Tiempo , Factores de Riesgo , Adolescente , Adulto Joven , Angioplastia de Balón/instrumentación , Angioplastia de Balón/efectos adversos , Niño , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/terapia , Enfermedades de la Aorta/fisiopatología , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/terapia , Constricción Patológica , Estados Unidos , AortografíaRESUMEN
Myocardial bridging is a common anatomical variant in which a major epicardial coronary artery takes an intramyocardial course, leading to dynamic systolic compression. Because coronary perfusion occurs primarily during diastole, most patients with this anatomical variant have no associated perfusion abnormalities or symptoms. Despite this, there is a subset of patients with myocardial bridging who experience ischaemic symptoms. Determining which anatomical variants are benign and which are clinically relevant remains a challenge. Further complicating the picture, functional factors such as diastolic dysfunction and coronary vasospasm may exacerbate myocardial bridging-related ischaemia. In patients with ischaemic symptoms in the absence of alternative explanations, a detailed assessment of myocardial bridging with invasive physiology should be performed to define the significance of the lesion and guide tailored medical therapy. Patients with refractory symptoms despite maximally tolerated medical therapy should be considered for surgical coronary unroofing.
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Puente Miocárdico , Humanos , Puente Miocárdico/diagnóstico , Puente Miocárdico/diagnóstico por imagen , Corazón , Angiografía CoronariaRESUMEN
The removal of intramyocardial masses has long been thought of as a surgical procedure and is generally reserved for patients with obstructive symptoms when the mass is thought to be benign. Thus, many patients who are incidentally diagnosed with intracardiac masses are either subjected to protracted follow-up with serial imaging awaiting tumor growth before surgical excision is ultimately offered. We report a novel procedure in which a 54-year-old man with an atrial myxoma underwent successful percutaneous resection using electrosurgery followed by removal with a novel endovascular retrieval system. This approach provides an alternative to either surgical excision or watchful waiting in patients with small- to medium-sized intracardiac tumors. (Level of Difficulty: Advanced.).
RESUMEN
INTRODUCTION: Balloon pulmonary angioplasty (BPA) is a less invasive treatment alternative for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are unable to move forward with pulmonary thromboendarterectomy. This report describes a single-center experience with a nascent BPA program in the United States (US). METHODS: All patients who underwent BPA between August 2018-2021 were included in this retrospective, single-center observational cohort. Pre- and post-procedure clinical information was collected, along with procedural characteristics. RESULTS: Thirty patients began their BPA series during the study period. The majority of patients had segmental disease (n = 25, 83.3%). A total of 135 BPA procedures were performed on 417 segments. On average, patients completed 4.5 sessions and the majority of patients (n = 23, 76.7%) underwent more than 2. There were 24 episodes of hemoptysis and 20 procedural events that required treatment, typically with either heparin reversal or balloon tamponade. Of 26 participants with completed series, mean PA pressure (-6 mmHg, 95% CI -9 to -4 mmHg, p = 0.0001), PVR (-1.9 Wood units, 95% CI -2.9 to -1.0, p = 0.0002), and pulmonary compliance (-1.0 mL/mmHg, 95% CI -1.5 to -0.5, p = 0.0002) improved. Improvement was also seen in NYHA functional classification and walk distance (p = 0.01). Two deaths occurred, with one death peri-procedurally. CONCLUSION: This paper describes an early experience with BPA at a single US center. Improvement in non-invasive and invasive metrics were seen without adding a significant morbidity to an already high-risk patient population.
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Angioplastia de Balón , Hipertensión Pulmonar , Embolia Pulmonar , Humanos , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/cirugía , Embolia Pulmonar/complicaciones , Embolia Pulmonar/cirugía , Estudios Retrospectivos , Enfermedad Crónica , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/métodos , Arteria Pulmonar/cirugía , Resultado del TratamientoRESUMEN
INTRODUCTION: Pulmonary arterial hypertension (PAH) remains a serious and life-threatening illness. Thyroid dysfunction is relatively understudied in individuals with PAH but is known to affect cardiac function and vascular tone in other diseases. The aim of this observational study was to evaluate the association between thyroid-stimulating hormone (TSH), mortal and non-mortal outcomes in individuals with PAH. METHODS: The Seattle Right Ventricle Translational Science (Servetus) Study is an observational cohort that enrolled participants with PAH between 2014 and 2016 and then followed them for 3 years. TSH was measured irrespective of a clinical suspicion of thyroid disease for all participants in the cohort. Linear regression was used to estimate the relationships between TSH and right ventricular basal diameter, tricuspid annular plane systolic excursion and 6-minute walk distance. Logistic regression was used to estimate the relationship with New York Heart Association Functional Class, and Cox proportional hazards were used to estimate the relationship with mortality. Staged models included unadjusted models and models accounting for age, sex at birth and aetiology of pulmonary hypertension with or without further adjustment for N-terminal-pro hormone brain natriuretic peptide. RESULTS: Among 112 participants with PAH, TSH was strongly associated with mortality irrespective of adjustment. There was no clear consistent association between TSH and other markers of severity in a cohort with PAH. DISCUSSION: This report reinforces the important observation that TSH is associated with survival in patients with PAH, and future study of thyroid dysfunction as a potential remediable contributor to mortality in PAH is warranted.
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Hipertensión Pulmonar , Hipertensión Arterial Pulmonar , Hipertensión Pulmonar Primaria Familiar/complicaciones , Ventrículos Cardíacos , Humanos , Hipertensión Pulmonar/etiología , Recién Nacido , TirotropinaRESUMEN
OBJECTIVE: To evaluate the frequency of and risk factors for stroke as a presenting feature in adult patients with secundum atrial septal defect (ASD); rates of post-closure atrial fibrillation (AF) and stroke were also assessed. METHODS: We retrospectively reviewed adult patients who presented with an ASD between 2002 and 2018, excluding those with known atrial arrhythmias. Risk factors for stroke were identified using multivariable logistic regression. Post-closure stroke was evaluated using survival analysis stratified by the presence of post-procedure AF. RESULTS: Of 346 patients with ASD (median age 44 years), 34 (10%) presented with a history of stroke. Independent risk factors included elevated body mass index over 25 (OR: 18.2; 95% CI: 4.0 to 82.2; p<0.001), smoking (OR: 9.5; 95% CI: 3.8 to 23.9; p<0.001) and a prominent Eustachian valve (OR: 9.2; 95% CI: 3.4 to 25.2; p<0.001). A scoring system based on these three parameters provided robust stroke risk stratification. During a median follow-up of 12 months after closure, 12 patients (4%) experienced AF and 4 patients (1%) had a new stroke. AF was highly associated with development of stroke post-closure (p<0.001). CONCLUSIONS: In this study population, the incidence of stroke prior to ASD closure among patients without atrial arrhythmias was 10%. Risk factors included obesity, smoking and prominent Eustachian valve anatomy. Lifestyle changes should be recommended for at-risk patients, and it may be reasonable to consider ASD closure in the absence of haemodynamic indications in patients at increased risk of stroke.