Dyspnea following thoracostomy closure after right pneumonectomy: An uncommon echocardiographic diagnosis and therapeutic approach.

Dyspnea and hypoxemia are common postoperative problems after pneumonectomy. One of the rarer causes of respiratory distress after right pneumonectomy is the development of a significant right-to-left shunt across a patent foramen ovale (PFO), which can evolve at a variable interval of time after the operation. We report here our experience with a patient who underwent right pneumonectomy, followed by several complications, and who presented severe dyspnea 7 months later, after the closure of a right thoracostomy. This report outlines the management of this challenging clinical condition; transesophageal echocardiography (TOE) provided a clear diagnosis and guided an effective percutaneous treatment.

Transcatheter tricuspid valve implantation by femoral approach in trivalvular heart disease.

A man with severe rheumatic trivalvular disease was treated with surgical implantation of mechanical aortic and mitral prostheses at the age of 30 years and tricuspid bioprosthesis at the age of 50 years. At 61 years of age, he developed severe symptomatic tricuspid regurgitation due to bioprosthesis degeneration and was judged at very high risk for a third surgical approach. The investigators describe the successful transfemoral positioning of a 29-mm Edwards SAPIEN XT percutaneous valve inside the degenerated tricuspid prosthesis, with excellent acute results and no major complications. In conclusion, percutaneous valve-in-valve treatment of degenerated bioprostheses is feasible by the transfemoral route and may be of assistance in very selected patients at high surgical risk.

Transfemoral Edwards-Novaflex valve implantation in a patient with aorto-iliac endoprosthesis and severely tortuous bilateral external iliac arteries-"Railing track".

Transcatheter aortic valve implantation (TAVI) has nowadays been introduced as an alternative for surgical aortic valve replacement as a treatment for high risk aortic stenosis patients. This procedure is not free of complications: the SOURCE registry, indeed, showed that vascular complications are more frequent with the transfemoral approach. We present the case of an 82-year-old man with known history of severe aortic stenosis at high-risk for surgery. Pre-TAVI screening shows bilateral severely tortuous iliac arteries and aorto-bi-iliac endoprosthesis. Transapical TAVI as a first choice was rejected due to severe lung disease. The patient was then treated by Transfemoral TAVI using a dedicated interventional technique that is described in this case-report.

Safety of percutaneous left heart catheterization directly performed by cardiology fellows: a cohort analysis.

BACKGROUND: No previous study has analyzed the possible responsibility of fellows-in-training in terms of the risk of complications during cardiac catheterization. Thus, we sought to identify possible risk factors for access site complications following cardiac catheterization procedures, with particular attention to the role of cardiology fellows. METHODS: A total of 1,288 left heart catheterization procedures (both diagnostic and interventional), performed over a 1-year period at a university hospital, were retrospectively evaluated to determine the incidence of local complications (pseudoaneurysm, arterio-venous fistula, major hematoma or bleeding, vascular dissection). Several clinical (age, gender, previous coronary artery bypass surgery, indication to the exam) and procedural (procedure performed by the fellow, access site, type of procedure, urgent setting, use of glycoprotein IIb/IIIa inhibitors, simultaneous right heart catheterization, use of closure devices) covariables were considered. Major adverse cardiovascular and cerebrovascular events (MACCE: death, myocardial infarction, cerebrovascular event) were also assessed. RESULTS: The overall access site complication rate was 2.6%. On multivariate regression analysis, the only two predictors of local complications were female gender (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.6-6.5) and femoral approach (OR 3.9, 95% CI 1.2-12.1). The rate of MACCE was 1.2%, mainly after percutaneous coronary interventions, with only 1 death overall (0.07%). Procedures performed by cardiology fellows were not associated with an increased incidence of either complication. CONCLUSIONS: Cardiology fellows can safely perform cardiac catheterization procedures without an increase in the rate of local and major cardiovascular complications. Of course, the presence and watchful supervision of an attending physician is still essential to ensure both patient safety and optimal training.

Safety and efficacy of the percutaneous radial artery approach for coronary angiography and angioplasty in the elderly.

BACKGROUND: The transradial approach to coronary interventions has been accepted as a safe and effective alternative to the femoral approach due to fewer access site complications and improved patient comfort. In the present study we aimed to investigate the safety and efficacy of transradial procedure in the elderly. METHODS: We analyzed 850 patients who underwent transradial coronary angiography and/or angioplasty. All patients were divided into two groups, according to age. The first group consisted of patients < 70 years (600; 70.5%) and the second group consisted of patients greater than or equal to 70 years (250; 29.5%). RESULTS: Baseline characteristics did not differ between the two groups, except for diabetes mellitus which affected more patients greater than or equal to 70 years of age. Procedure duration, X-ray time and number of catheters used were similar in the two groups. No deaths or acute myocardial infarctions occurred. There were some vascular complications in both groups, with no statistically significant difference between groups. In Group 2 (the older group) 2 TIAs and 1 stroke occurred, whereas in Group 1, there was 1 TIA (p = 0.08). CONCLUSIONS: From our experience, we conclude that the transradial catheterization is a safe and effective technique in the elderly, with a reduced risk of local vascular complications and a noteworthy increase in patient comfort, especially in view of the age-related diseases that frequently affect older patients.