Cannulation of the Femoral Arterial Bypass Cannula Allows Completion of TAVR in Unstable Patients.

When hemodynamic instability occurs during transcatheter aortic valve replacement, peripheral cardiopulmonary bypass is required. The pigtail catheter, initially placed through the femoral artery to direct placement of the valve, is exchanged over a wire for an arterial bypass cannula. Other than time-consuming arterial cut-down procedures in hypotensive patients, there are few techniques described to allow the operator to continue bypass and complete transcatheter aortic valve replacement. This report describes a method to reintroduce the pigtail catheter by puncturing the arterial bypass cannula. This technique allows the operator to support the patient, continue bypass, and successfully place the valve without aborting the procedure.

Angiographic investigation of the pathophysiology of perioperative myocardial infarction.

BACKGROUND: The study of the pathophysiologic mechanism of perioperative myocardial infarctions is limited to two small autopsy studies suggesting a major role for plaque rupture and thrombosis. However, the perioperative period is characterized by increased cardiac metabolic demand that may lead to infarction in patients with otherwise stable obstructive coronary artery disease. The purpose of this study is to investigate the pathophysiology of perioperative myocardial infarctions. METHODS: Hospital records and coronary angiograms from patients from 1998 to 2006 who underwent noncardiac surgery complicated by a perioperative myocardial infarction (MI) were reviewed. The culprit lesion was identified based on ECG, left ventriculography, and coronary angiography. Degree of stenosis, TIMI flow, ACC thrombus grade, calcification score, and lesion morphology were evaluated. Based on these criteria, MIs were categorized as thrombotic, demand, or nonobstructive. RESULTS: Sixty-six patients (average age, 71 years and 44% male), 77% of whom underwent an intermediate risk surgery with a 2% perioperative mortality, were identified. The distribution of demand, thrombotic, and nonobstructive MI was 55%, 26%, and 19%, respectively. There was neither statistical difference in the occurrence of prolonged hypotension or tachycardia between groups nor was there any difference in the use of antiplatelets, ß-blockers, or statins. CONCLUSION: This study identified demand ischemia as the predominant etiology of perioperative MIs in this cohort. An improved understanding of the pathophysiologic mechanism of perioperative MIs may facilitate the evaluation and management of preoperative patients.

Diagnosis, management, and future developments of fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) is a nonatherosclerotic noninflammatory vascular disease that primarily affects women from age 20 to 60, but may also occur in infants and children, men, and the elderly. It most commonly affects the renal and carotid arteries but has been observed in almost every artery in the body. FMD has been considered rare and thus is often underdiagnosed and poorly understood by many health care providers. There are, however, data to suggest that FMD is much more common than previously thought, perhaps affecting as many as 4% of adult women. When it affects the renal arteries, the most common presentation is hypertension. When it affects the carotid or vertebral arteries, the patient may present with transient ischemic attack or stroke, or dissection. An increasing number of patients are asymptomatic and are only discovered incidentally when imaging is performed for some other reason or by the detection of an asymptomatic bruit. FMD should be considered in the differential diagnosis of a young person with a cervical bruit; a "swishing" sound in the ear(s); transient ischemic attack, stroke, or dissection of an artery; or in individuals aged ≤ 35 years with onset hypertension. Treatment consists of antiplatelet therapy for asymptomatic individuals and percutaneous balloon angioplasty for patients with indications for intervention. Patients with aneurysms should be treated with a covered stent or open surgical repair. Little new information has been published about FMD in the last 40 years. The recently instituted International Registry for Fibromuscular Dysplasia will remedy that situation and provide observational data on a large numbers of patients with FMD.

Peripheral artery disease: current insight into the disease and its diagnosis and management.

Peripheral artery disease (PAD), which comprises atherosclerosis of the abdominal aorta, iliac, and lower-extremity arteries, is underdiagnosed, undertreated, and poorly understood by the medical community. Patients with PAD may experience a multitude of problems, such as claudication, ischemic rest pain, ischemic ulcerations, repeated hospitalizations, revascularizations, and limb loss. This may lead to a poor quality of life and a high rate of depression. From the standpoint of the limb, the prognosis of patients with PAD is favorable in that the claudication remains stable in 70% to 80% of patients over a 10-year period. However, the rate of myocardial infarction, stroke, and cardiovascular death in patients with both symptomatic and asymptomatic PAD is markedly increased. The ankle brachial index is an excellent screening test for the presence of PAD. Imaging studies (duplex ultrasonography, computed tomographic angiography, magnetic resonance angiography, catheter-based angiography) may provide additional anatomic information if revascularization is planned. The goals of therapy are to improve symptoms and thus quality of life and to decrease the cardiovascular event rate (myocardial infarction, stroke, cardiovascular death). The former is accomplished by establishing a supervised exercise program and administering cilostazol or performing a revascularization procedure if medical therapy is ineffective. A comprehensive program of cardiovascular risk modification (discontinuation of tobacco use and control of lipids, blood pressure, and diabetes) will help to prevent the latter.

Recurrent orthostatic global amnesia in a patient with postoperative hyperfibrinogenemia.

Transient global amnesia (TGA) is characterized by sudden, temporary dysfunction of antegrade and recent retrograde memory without other neurologic deficits. Although there is sometimes a precipitating event, the origin of TGA remains controversial. We encountered a patient who developed recurrent TGA when upright, in whom the symptom promptly and regularly resolved when supine. Symptoms began about a week after cardiac surgery concurrent with marked hyperfibrinogenemia and acceleration of the erythrocyte sedimentation rate, and abated without recurrence when these laboratory abnormalities were ameliorated by anticoagulant and corticosteroid therapy. Diagnostic studies, including temporal artery biopsy and cerebral angiography, disclosed no anatomic vascular pathology. This is the first report of TGA associated with postoperative inflammation in which amnesia was provoked by orthostatic positioning. In conclusion, these observations implicate ischemia caused by hemodynamic vascular insufficiency as a possible cause of TGA.