Sudden heart failure due to a ruptured posterior Valsalva sinus aneurysm into the right atrium: feasibility of catheter closure using the Amplatzer duct occluder.

Valsalva sinus aneurysms are usually congenital and relatively rare and tend to be more frequent in adults. Rupture of these aneurysms can result in sudden death or in an abrupt and rapid progressive heart failure. Surgical repair is the traditional treatment of choice. We report the case of a 48-year-old female with a ruptured posterior non-coronary Valsalva sinus aneurysm, resulting in an anomalous aorto-right atrial fistula. Successful percutaneous catheter closure of the massive left-to-right shunt by using the Amplatzer duct occluder is presented.

The treatment of carotid artery bifurcation stenoses with systematic stenting: experience of first 100 consecutive cardiological procedures.

Carotid endarterectomy still represents the gold standard treatment of carotid artery bifurcation stenosis but percutaneous angioplasty with stenting is rapidly growing as a non-invasive alternative. In this paper we report the results of systematic application of carotid stenting performed in a cardiological setting, particularly as regards clinical management of patients and technical approach. One-hundred (100) procedures of carotid artery stenting (CAS) on 94 consecutive patients, both symptomatic and asymptomatic, with a carotid stenosis > 70%, were performed over a period of 30 months. The technical approach was directly derived from coronary angioplasty with use of large lumen guiding catheters, 0.014 in. intravascular guidewires and distal protection devices usually employed in coronary interventions. In 3 cases, a post-carotid endarterectomy restenosis and in 97 cases, a de-novo lesion, were treated respectively; in 71 cases, the degree of stenosis was 71-89% and in 29 cases, 90-99%. Cerebral protection was obtained with a distal to the lesion endovascular filter in 63 cases. Immediate technical success, i.e. residual stenosis of the treated vessel < 30% and no significant pathologic acceleration of blood flow (< 1.5 m/sec) at the Doppler ultrasound evaluation, was achieved in all procedures (100%). Ninety-six (96) procedures were totally uncomplicated; in-hospital cerebral complications were 1 TIA, 2 minor and 1 major strokes; at 30-day follow-up one additional major stroke occurred. Despite a particularly high incidence of comorbidities, neither unfavorable cardiological complications nor neurologic deaths were reported. Systematic CAS is a feasible treatment of the carotid artery bifurcation stenosis with high procedural success and low perioperative and short term complications. Its performance in a cardiological setting can combine satisfying procedural results and potentially successful handling of cardiovascular complications.

[Stress-induced transient left ventricular apical ballooning]. / Un caso di sindrome "tako-tsubo-like" da stress.

Transient left ventricular apical ballooning is a quite rare clinical event mostly described in the Japanese population. It is also known as tako-tsubo-like syndrome due to the peculiar shape on endsystolic left ventriculogram which is like a tako-tsubo, an ancient device used for trapping octopuses in the Japanese sea. The clinical features of this cardiomyopathy, which mimicked an acute coronary syndrome in an Italian 78-year-old man, are described. Acute left ventricular dysfunction with the typical left ventriculogram and normal epicardial coronary arteries followed an acute emotional and physical stress: the patient felt off his boat, while lifted well up above the water of a great Italian lake during routinary servicing, with consequent chest and head traumas. The combination of emotional and physical stress with the dive in the lake cold water could have caused a brisk and marked increase in catecholamines with possible direct myocardial injury. The occurrence of a rare case of a Japanese cardiomyopathy, also mentioned by a device used in sea-fishing, in an Italian patient following an accidental dive in a lake, appears at least peculiar.

Cut-and-transfer technique for ischemic mitral regurgitation and severe tethering of mitral leaflets.

BACKGROUND: Chronic ischemic mitral regurgitation (MR) denotes abnormal function of normal leaflets resulting from left ventricular enlargement. We present the midterm results of a tailored mitral repair technique using a combination of the following subvalvular procedures: (1) detachment and reimplantation of secondary chordae on the free edge of the anterior leaflet ("cut-and-transfer" technique), (2) relocation of the posterior papillary muscle (PPM) closer to the mitral annulus, and (3) infarct plication on the lateral wall of the left ventricle. METHODS: From 2008 to 2011, 49 patients with moderate to severe ischemic MR underwent coronary surgery plus mitral valve repair using the cut-and-transfer and PPM relocation techniques. All the patients received a "true-sized" semirigid complete annuloplasty ring. In 20 patients, a plication of the lateral wall of the left ventricle was performed to reduce the tethering of the mitral leaflets. The mean number of coronary grafts per patient was 3.4 ± 0.4. RESULTS: Hospital mortality was 2%. No patient died during 1-year follow-up and New York Heart Association (NYHA) class improved from 3.4 ± 0.5 to 1.4 ± 0.6 (p < 0.0001). The 1-year echocardiogram showed the following changes from baseline: mitral regurgitation grade (0-4) 2.9 ± 0.4 versus 0.2 ± 0.4 (p < 0.0001), left ventricular end-systolic volume index (mL/m(2)) 52.7 ± 13.1 versus 48.2 ± 10.1 (p = 0.07), left ventricular end-systolic index (mL/m(2)) 92.9 ± 16.5 versus 83.4 ± 15.9 (p <0.005), and ejection fraction (%) 37.8 ± 6.3 versus 44.2 ± 8.1 (p < 0.0001). CONCLUSIONS: Both clinical and echocardiographic results show that reducing the tethering of the mitral leaflets with tailored interventions on subvalvular apparatus without undersizing the mitral annulus can safely and effectively correct chronic ischemic MR.

An unusual case of acute fatal pulmonary congestion: oesophageal stenting.

Extrinsic left atrial compression with consequent hemodynamic compromise has been described secondary to aortic aneurysm, huge gastroesophageal distension and neoplastic diseases involving mediastinum. Prompt correction of the primary pathology usually leads to reversal of hemodynamic alterations. We report the case of a lady, who, in order to treat a stenosis of the lower third of the oesophagus, underwent stenting with subsequent hemodynamic deterioration due to compression of the posterior left atrial wall disclosed by echocardiography. The sudden recovery of the oesophageal lumen at the expense of the left atrial volume with the impossibility of prompt removal of the stent led to a progressive and fatal deterioration of the hemodynamic picture. Stenting of the lower part of the oesophagus should be performed only when reciprocal anatomic relationship between heart and oesophagus itself is clearly elucidated and possibly well maintained.