Delayed coronary ischemia after transfemoral aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) offers a less invasive treatment alternative to surgical aortic valve replacement for high-risk patients. Although the procedure can be performed at low risk, life-threatening complications may arise in single cases during or even months after the procedure. Here, the details are presented of two patients who underwent TAVI by a transfemoral approach with Medtronic CoreValve prostheses and suffered myocardial ischemia months later. The patients' anatomy with small aortic root, narrow sinus of Valsalva and small distance between the annulus base and coronary arteries and/or the relative oversizing of the CoreValve prosthesis with a high positioning may have contributed to this late complication. Hence, caution is mandatory in this type of patient, with exact pre-procedural planning and close follow up required.

Two-dimensional strain and strain rate imaging of the right ventricle in adult patients before and after percutaneous closure of atrial septal defects.

AIMS: Echocardiographic speckle tracking or two-dimensional (2D) strain analysis is a new tool to assess myocardial function. This prospective controlled study evaluates systolic right ventricular (RV) function by 2D strain in adult patients with atrial septal defect (ASD) before and 3 months after percutaneous closure. METHODS AND RESULTS: Assessment of global longitudinal strain (GLS), global longitudinal strain rate (GLSR), and regional peak systolic strain (PSS) of right ventricle was performed in 33 ASD patients. The data were compared with those from 34 age-matched adults with patent foramen ovale. Before percutaneous closure, mean GLS was significantly increased in comparison to control group, and significantly reduced after closure. Analysis of regional PSS showed significant decrease in the lateral apical, lateral mid, and septal apical segments. GLSR was not influenced by ASD closure. CONCLUSION: Two-dimensional strain appears to be helpful also for the assessment of RV function and its response to correction of volume overload.

Transfemoral aortic valve-in-valve implantation with the CoreValve Evolut for small degenerated stented bioprosthesis.

Transcatheter aortic valve-in-valve implantation represents one interesting therapeutic option for high-risk surgical patients with degenerated bioprostheses. The procedure is less invasive and can be performed without thoracotomy and general anesthesia, if the femoral approach is used. Until recently, failing small bioprostheses could only be treated percutaneously by underexpanding the CoreValve (Medtronic, Inc) or Edwards Sapien valve (Edwards Lifesciences). Underexpansion of these valves might compromise the hemodynamic performance and potentially limit its durability. Herein, we report our initial experience with the 23 mm CoreValve Evolut in 4 patients with degenerated 21 mm Mitroflow valves. The CoreValve prosthesis was successfully implanted in all 4 patients, with no major complications and no mortality at 3-month follow-up exam. However, 2 of the 4 patients developed mildly elevated transvalvular gradients. Therefore, despite our promising results, caution is necessary when considering patients with small degenerated bioprostheses for a valve-in-valve procedure.

63-year survival after Blalock-Taussig shunt operation in a patient with single ventricle, tricuspid atresia, and pulmonary stenosis.

A 63-year-old female with complex congenital heart disease underwent a classical Blalock-Taussig (B-T) shunt operation at the age of 3 years in 1948. The cardiac morphology was not amenable to further definite surgical repair in that period of time. With this palliative operation, the patient survived to the age of 63 years and now presented with exercise intolerance and significant desaturation. Cardiac catheterization with angiography revealed a severe stenosis of the B-T shunt at the pulmonary end. Balloon dilation and stent implantation could be performed successfully. Follow-up after 5 months showed a patent B-T shunt and an increase of oxygen saturation from 65% to 80% and mild improvement of pulmonary blood flow and exercise tolerance.

Interventional closure of atrial septal defects in adult patients with Ebstein's anomaly.

Ebstein's anomaly is frequently associated with interatrial communications. In patients with severe tricuspid regurgitation standard treatment is the surgical repair or replacement of the tricuspid valve and patch closure of the atrial septal defect. We sought to evaluate the feasibility and short-term outcome of interventional device closure of interatrial communications in Ebstein patients with mild to moderate tricuspid regurgitation and various degrees of clinical symptoms. In this case series of 9 patients the device closure could be performed safely and 8 of 9 patients improved in their exercise capacity or clinical condition. However, the patients need to be selected carefully and appropriately for this palliative method. In those with predominant left-to-right shunting, ASD-closure reduces the volume load of the right ventricle and can be performed according to routine procedures. In those patients with cyanosis and right-to-left shunting however, test occlusion of the interatrial communication with adequate balloon size followed by careful examination of the hemodynamics at rest and under catecholamine stimulation is compulsatory to evaluate the feasibility of device closure. The tricuspid regurgitation should not exceed moderate level, the right atrial and ventricular pressure should be within normal range for an adequate time during test occlusion and the systemic blood pressure and cardiac output maintained safely.