Management of an Iatrogenic Pulmonary Artery Rupture via Balloon Tamponade.

Pulmonary artery rupture is a rare complication of right heart catheterization characterized by a rapid clinical deterioration and high mortality rate. We present the case of an 89-year-old woman with severe symptomatic aortic stenosis who underwent cardiac catheterization prior to aortic valve replacement. The patient had acute cardiopulmonary deterioration due to pulmonary artery rupture at the time of right heart catheterization, that was successfully sealed by balloon tamponade.

Right Ventricular Dysfunction and Short-Term Outcomes Following Left-Sided Valvular Surgery: An Echocardiographic Study.

Background The prognostic value of echocardiographic evaluation of right ventricular (RV) function in patients undergoing left-sided valvular surgery has not been well described. The objective of this study is to determine the role of broad echocardiographic assessment of RV function in predicting short-term outcomes after valvular surgery. Methods and Results Preoperative echocardiographic data, perioperative adverse outcomes, and 30-day mortality were analyzed in patients who underwent left-sided valvular surgery from 2006 to 2014. Echocardiographic parameters used to evaluate RV function include RV fractional area change, tricuspid annular plane systolic excursion, systolic movement of the RV lateral wall using tissue Doppler imaging (S'), RV myocardial performance index, and RV dP/dt. Subjects with at least 3 abnormal parameters out of the 5 aforementioned indices were defined as having significant RV dysfunction. The study included 269 patients with valvular surgery (average age: 67±15, 60.6% male, 148 aortic, and 121 mitral). RV dysfunction was found in 53 (19.7%) patients; 30-day mortality occurred in 20 patients (7.5%). Compared with normal RV function, patients with RV dysfunction had higher 30-day mortality (22.6% versus 3.8%; P=0.01) and were at risk for developing multisystem failure/shock (13.2% versus 3.2%; P=0.01). Multivariate analyses showed that preexisting RV dysfunction was the strongest predictor of increased 30-day mortality (odds ratio: 3.5; 95% CI, 1.1-11.1; P<0.05). Conclusions Preoperative RV dysfunction identified by comprehensive echocardiographic assessment is a strong predictor of adverse outcomes following left-sided valvular surgery.

Left atrial appendage perforation with Watchman device implantation: Strategies for surgical repair.

Percutaneous occlusion of the left atrial appendage is increasingly being used as an alternative for stroke prevention in patients with non-valvular atrial fibrillation at high risk of complications from long term anticoagulation. We describe a case of left atrial appendage perforation during Watchman device implantation requiring emergency repair of the left atrium using sternotomy and cardiopulmonary bypass. Technical considerations for surgical decision making are discussed; in hemodynamically unstable patients as well as those at high risk for embolization.

Endothelin 1 Is Associated with Heart Failure Hospitalization and Long-Term Mortality in Patients with Heart Failure with Preserved Ejection Fraction and Pulmonary Hypertension.

BACKGROUND: The prevalence of pulmonary hypertension (PH) in heart failure with preserved ejection fraction (HFpEF) is increasing. We aim to study the role of big endothelin 1 (Big ET1), endothelin 1 (ET1), and neprilysin (NE) in HFpEF with PH. METHOD: This was a single center prospective cohort study including 90 HFpEF patients; 30 with no PH, 30 with postcapillary PH, and 30 with combined post- and precapillary PH. After enrollment, pulmonary venous and pulmonary arterial samples of Big ET1, ET1, and NE were collected during right heart catheterization. Subjects were then followed long term for adverse outcomes which included echocardiographic evidence of right ventricular dysfunction, heart failure hospitalization, and all-cause mortality. RESULTS: Patients with HFpEF-PH were found to have increased ET1 in pulmonary veins (endothelin from the wedge; ET1W) compared to controls (2.3 ± 1.4 and 1.6 ± 0.9 pg/mL, respectively). ET1W levels were associated with both PH (OR 2.7, 95% CI 1.5-4.7, p = 0.01) and pulmonary vascular resistance (OR 1.6, 95% CI 1.04-2.3, p = 0.03). No evidence of right ventricular dysfunction was observed after 1 year of follow-up. ET1W (OR 1.8, 95% CI 1.2-2.6, p = 0.01) and ET1 gradient (ET1G; OR 1.4, 95% CI 1.04-2, p = 0.03) were predictive of 1-year hospitalization. ET1G ≥0.2 pg/mL was associated with long-term mortality (log-rank 4.8, p = 0.03). CONCLUSION: In HFpEF patients, ET1W and ET1G are predictive of 1-year heart failure hospitalization, while elevated ET1G levels were found to be associated with long-term mortality in HFpEF. This study highlights the role of ET1 in developing PH in HFpEF patients and also explores the potential of ET1 as a prognostic biomarker.

Myocardial ischemia in a patient with peripheral vascular disease, an arteriovenous fistula, and patent coronary artery bypass grafts.

Patients with coronary artery disease often have concurrent peripheral vascular disease. The presence of concurrent vascular pathologies can pose unique challenges among patients who have undergone coronary artery bypass grafting utilizing the left internal mammary artery. We describe a patient with peripheral vascular disease and prior history of coronary artery bypass grafting, who presented with recurrent anginal symptoms and an abnormal stress test despite the absence of significant residual unrevascularized coronary artery disease. Additional evaluation led to the identification of an ipsilateral severe subclavian stenosis with a concomitant ipsilateral upper extremity arteriovenous fistula. Patient's symptoms resolved with the treatment of the underlying vascular lesions.

Effect of weight loss after weight loss surgery on plasma N-terminal pro-B-type natriuretic peptide levels.

Natriuretic peptides have multiple beneficial cardiovascular effects. Previous cross-sectional studies have indicated that obese subjects have lower natriuretic peptide concentrations than those of normal weight. It is not known whether this relative natriuretic peptide deficiency is reversible with weight loss. We studied 132 obese subjects undergoing weight loss surgery with serial measurement of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations at preoperative, early (1 to 2 months), and late postoperative (6 months) points. In addition, 20 subjects also underwent echocardiography at baseline and 6 months after surgery. Significant weight loss was observed after surgery (median body mass index 45.1, 41.0, and 32.9 kg/m(2) for the 3 corresponding points, analysis of variance p <0.001). The median NT-proBNP levels increased substantially (31.6, 66.9, and 84.9 pg/ml; p <0.001). The average intrasubject increase in NT-proBNP at the 2 postoperative points was 3.4 and 5.0 times the preoperative level (p <0.001 for both points vs preoperatively). In the multivariate regression models adjusted for clinical characteristics and insulin resistance, the strongest predictor of the change in NT-proBNP level 6 months after weight loss surgery was the change in weight (p = 0.03). Echocardiography showed a mean intrasubject reduction in left ventricular mass index of 18% (p <0.001) and mild improvements in diastolic function, with no change in ejection fraction. In conclusion, we have demonstrated that weight loss is associated with early and sustained increases in NT-proBNP concentrations, despite evidence of preserved systolic and improved diastolic function. These findings suggest a direct, reversible relation between obesity and reduced natriuretic peptide levels.

Pharmacological therapy for myocardial reperfusion injury.

In the ischemic myocardium, reperfusion is necessary for the salvage of cells and cardiac function. However, reperfusion itself causes 'reperfusion injury', leading to the damage of myocardial cells. This is reduced by several interventions, as measured by the limitation of infarct size or reduction of arrhythmias. Pharmacological agents that protect against injury include Na(+)/H(+) exchanger inhibitors, antioxidants, calcium antagonists, renin-angiotensin system antagonists and adenosine. N-acetylcysteine, diltiazem, verapamil, enalaprilat and adenosine have all showed promising results in patients with acute myocardial infarction when given before reperfusion. Cariporide was beneficial when added to cardioplegia. However, their use in daily practice awaits results from large clinical trials.

Sequential use of thrombolytic agents for thrombosed mitral valve prosthesis during pregnancy.

Thrombolytic therapy has gained popularity as an alternative to surgery in the treatment of prosthetic heart valve thrombosis. We report on the sequential use of streptokinase followed by recombinant tissue type plasminogen activator (rt-PA) for the treatment of a thrombosed prosthetic mitral valve in a pregnant woman at 26 weeks of gestation. Although thrombolysis was unsuccessful, the patient carried till 34 weeks of gestation and delivered by cesarean section a live newborn with an uneventful postpartum course. Based on our case and on what has been previously described in the literature, thrombolytic therapy should be considered as an option in the management of hemodynamically unstable pregnant patients with prosthetic valve thrombosis. When a single agent proves insufficient, combination therapy should be considered as it might provide hemodynamic stability and improvement in cardiac function that would allow patients at a high surgical risk to carry their pregnancy to viability.