Long-term clinical impact of permanent cardiac pacing after transcatheter aortic valve implantation with the CoreValve prosthesis: a single center experience.

Aims: To determine the impact of permanent cardiac pacing after transcatheter aortic valve implantation (TAVI) with the CoreValveTM prosthesis in terms of all-cause mortality and morbidity [rehospitalizations for heart failure (HF) or stroke] at the long-term follow-up. Methods and results: The prospective analysis comprised 259 patients (138 women, 53.3%, age 78 ± 6 years) treated by a CoreValveTM prosthesis from April 2008 to December 2015. Forty-two patients were excluded for analysis: 9 with pre-existing permanent pacemaker (PPM) implantation, 19 who required a PPM during the follow-up and 14 patients because of hospital mortality during or after the CoreValveTM prosthesis implantation procedure. The remaining 217 patients were divided in two groups: Group-1 included those patients who required a PPM immediately after TAVI, and Group-2 included those patients who did not require permanent cardiac pacing at the long-term follow-up. Patients received follow-up at 1-month, 6-months, 12-months, and yearly thereafter. A total of 39 patients required a PPM immediately after TAVI (15.0%), but 178 patients (68.7%) did not. The mean follow-up was 37 ± 27 months (range 3-99 months) in both groups. There was no difference between the two groups in terms of all-cause mortality (52.6% vs. 56.8%, P = 0.125; HR 1.22 [0.87-1.77, 95% CI]), or stroke (13.3% vs. 15.1% P = 0.842; HR 1.12 [0.37-3.32, 95% CI]). However, patients who underwent PPM implantation developed an increase in readmissions for HF (21.1% vs. 31.9%, P = 0.015; HR 1.82 [1.23-3.92, 95% CI]). Conclusion: Patients requiring a PPM after TAVI did not have an increase in mortality, or an increase in the likelihood of developing a stroke at a long-term follow-up. However, this subgroup of patients showed an increase in rehospitalization due to HF at medium- and long-term follow-up.

Randomized comparison of elective stent implantation and coronary balloon angioplasty guided by online quantitative angiography and intracoronary Doppler. DESTINI Study Group (Doppler Endpoint STenting INternational Investigation).

BACKGROUND: The purpose of this study was to compare long-term outcomes of coronary stenting in all lesions (elective stenting) or only in lesions with inadequate morphological and functional results after balloon angioplasty (guided PTCA). METHODS AND RESULTS: Treatment of multivessel disease, with any lesion length and vessel size, was allowed provided that all lesions were suitable for stent implantation. Patients were randomized to elective stent implantation (n=370) or guided PTCA (n=365). An optimal PTCA result (residual diameter stenosis 2.0, absence of threatening dissections) was achieved in 166 lesions (43%). The remaining 218 lesions underwent stent implantation (provisional stenting). Final residual diameter stenosis was lower in the elective and provisional stent groups (9.3% and 10.2%) than in the optimal PTCA group (24.8%, P:<0. 00001). On an intention-to-treat analysis, the probability of >/=1 major adverse cardiac event at 12 months was 17.8% in the elective stenting group and 18.9% in the guided PTCA group (20.1% for optimal PTCA and 18.0% for the provisional stenting subgroup, P:=NS). The incidence of repeat target lesion revascularization at 1 year was 14. 9% in the elective stent group and 15.6% in the guided PTCA group (17.6% for optimal PTCA and 14.1% for the provisional stenting subgroup, P:=NS). CONCLUSIONS: When balloon angioplasty is guided by online quantitative angiography and Doppler-derived coronary flow reserve, with provisional stenting reserved for suboptimal results, early and late clinical outcomes are comparable to those achieved by elective stenting of all patients.

Intracoronary ultrasound assessment of directional coronary atherectomy: immediate and follow-up findings.

OBJECTIVES: This study was conducted to assess the relations among intracoronary ultrasound, angiographic and histologic data obtained from patients with coronary artery disease successfully treated by directional coronary atherectomy. In addition, it was designed to elucidate whether some aspects of intravascular ultrasound or pathologic findings could predict a propensity to restenosis. BACKGROUND: Intracoronary ultrasound is a useful technique in guiding and assessing atherectomy. However, there is little information about the characterization of the different types of coronary plaques and the changes observed in them after resection. Furthermore, the follow-up ultrasound appearance of previously treated lesions remains undepicted. METHODS: Fifty-two patients (54 +/- 10 years old) were studied. All were successfully treated by atherectomy with the aid of intracoronary ultrasound guidance. Qualitative and quantitative ultrasound and angiographic variables were derived before and after resection. Quantitative histologic morphometric information was also obtained from the specimens. In 22 patients, a follow-up echoangiographic reevaluation was performed 6 +/- 4 months later. RESULTS: Echogenic plaques had a higher collagen and calcium content, whereas echolucent plaques had an increased level of fibrin, nuclei and lipids. Ultrasound plaque reduction after atherectomy was greater in echolucent (76 +/- 21%) than in echogenic plaques (60 +/- 18%; p < 0.05). That reduction correlated with the weight of the resected material (r = 0.62; p < 0.01). At follow-up study, 13 of 22 patients had angiographic and ultrasound evidence of restenosis. Most recurrent lesions had a stenotic three-layer appearance. The incidence of restenosis of primary lesions treated with atherectomy was higher in echolucent (100%) than in echogenic (33%) plaques. Similarly, a higher proportion of nuclear content in the resected material was observed in patients who developed restenosis (2.1 +/- 0.7%) than in patients who had late success after atherectomy (1.2 +/- 0.6%). CONCLUSIONS: Our findings suggest that echolucent plaques are easier to resect than are echogenic plaques but frequently develop restenosis. In contrast, the resection of echogenic plaques, although often incomplete, is associated with better long-term results.

Immediate and follow-up results of transluminal balloon dilation for discrete subaortic stenosis.

This study presents the findings in 33 patients with discrete subaortic stenosis who were treated by percutaneous balloon dilation and were followed up for 2 months to 6.2 years (mean 34 +/- 21 months). The mean age was 13 +/- 11 years; 10 (30%) were female and 23 (70%) male. Associated malformations were observed in nine patients (27%). All patients underwent noninvasive studies and cardiac catheterization. The mean value to membrane distance was 4.5 +/- 2 mm/m2. After balloon dilation, the pressure gradient from the left ventricle to the aorta decreased from 68 +/- 30 to 20 +/- 13 mm Hg (p less than 0.00001); there were no significant changes in the degree of aortic regurgitation. A fluttering and widely mobile remaining membrane was clearly visualized after dilation. Better immediate results were obtained in patients with a smaller baseline gradient, a larger aortic anulus and a longer valve to membrane distance. Serial follow-up echographic studies were available in 30 patients, and 18 hemodynamic reevaluations were performed in 13 patients. However, seven patients who demonstrated restenosis underwent redilation at a mean of 29 +/- 17 months after the first dilation. Redilation in six of the seven patients obtained benefits similar to those observed at the first dilation. Only one patient with unsuccessful redilation required surgery. The mean value of the last explored residual gradient (on hemodynamic or Doppler study) in the remaining 32 patients was 21 +/- 10 mm Hg. No significant changes were observed in the angiographic evolution of aortic regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Physiopathology of transient ventricular occlusion during balloon valvuloplasty for pulmonic or aortic stenosis.

Hemodynamic observations were made at different cardiac levels during transient balloon occlusion at the time of aortic or pulmonary valvuloplasty in 37 patients (mean age 8 +/- 9 years); 22 had pulmonary stenosis and 15 had aortic stenosis (6 valvular and 9 discrete subvalvular types). Eighty-two tentative dilatations were performed in patients with pulmonary stenosis and 61 in patients with aortic stenosis. The hemodynamics of the right and left heart were monitored during inflation-deflation time. From selected tracings mean beat-to-beat pressures curves were constructed during occlusion-recovery time. The cycle length (RR interval) did not change significantly during occlusion, except for patients with pulmonary occlusion and patent foramen ovale, where a significant increase in cycle length (p less than 0.01) was observed during recovery time. The mean maximal increase in ventricular pressure reached 95% of basal values for the right ventricle and 58% for the left ventricle. The hypertension was retrogradely transmitted to all cardiac chambers. Angiographic observations during occlusion suggest that the atrioventricular valves and the foramen ovale, when patent, become escape orifices during occlusion, for adapting and relieving intracavitary pressures. The ventricle seems to adapt to sudden occlusion by generating hypertensive and hypokinetic contractions, with atrioventricular regurgitation.

Percutaneous transluminal balloon dilatation for discrete subaortic stenosis.

Seven patients, mean age 8 +/- 3.6 years, with clinical and hemodynamic diagnoses of discrete subaortic stenosis were treated by percutaneous transluminal balloon dilatation (PTBD) of the membrane during cardiac catheterization. One patient had an associated aortic coarctation that was first dilated. After PTBD left ventricular (LV) systolic pressure decreased significantly, from 181 +/- 25 to 139 +/- 11 mm Hg (p less than 0.005); peak gradient diminished from 65 +/- 18 to 12 +/- 9 mm Hg (p less than 0.001). Mild aortic regurgitation was present in 6 patients during basal conditions. After PTBD, the same degree of regurgitation was observed in all but 1 patient, in whom it disappeared. There were no major complications. Clinical observations after PTBD were consistent with hemodynamic findings. Precordial thrill always disappeared and the peak murmur became earlier in systole. In 2 patients the discrete subaortic stenosis was clearly visualized at 2-dimensional echocardiography as a fixed subvalvular structure throughout the cardiac cycle. After dilatation this was only identifiable at its implantation base; during contraction there was no fixed structure at the LV outflow tract. Four patients were hemodynamically reevaluated 6.7 +/- 1.7 months later and were found to have LV pressure relief and a degree of aortic regurgitation similar to those observed immediately after PTBD.

Immediate and follow-up findings after stent treatment for severe coarctation of aorta.

Experimental studies have shown that stents implanted at the aorta become incorporated within the aortic wall and can be further expanded in growing animals. Few clinical studies have shown that the stent repair of severe coarctation of aorta provides excellent initial results, and little is known on the follow-up of these patients. We assessed the immediate and follow-up results obtained in a series of 48 patients (mean age 14+/-12 years) with severe coarctation of the aorta who were treated by Palmaz stent implantation; 30 of them (63%) underwent angiographic follow-up studies at a mean of 25+/-11 months after treatment. Quantitative serial analysis of the aortogram (baseline, after treatment, and at follow-up) was performed. Significant relief (mean residual gradient 3+/-4 mm Hg) was always obtained after stent implantation. The isthmus, when hypoplastic (60%), was always expanded with the stent. One associated aneurysm became occluded after the implant. Complications included aortic disruption, stent migration, and decreased or absent femoral pulses. At angiographic follow-up, the stent remained always in place, without recoil. In 22 patients (73%), there were no detectable neointimal proliferation at late angiogram; however, 8 patients (27%) had some degree of intimal thickening (1 to 5 mm), causing mild restenosis in 3 patients treated at early age, and nonsignificant lumen reduction in 5. The serial aortogram analysis revealed a minor but significant increase in nonstented aortic diameters that seemed related to the normal growth of children. No need for stent reexpansion was observed at 2-year follow-up (mean). Two patients (7%) developed late small aneurysm formation at the stented wall; both were occluded by the insertion of coils through the stent orifices. We conclude that stent treatment for severe coarctation of aorta provides excellent immediate and long-term results in young adults and children. However, at early age, restenosis by intimal growth may develop.

Factors determining late success after mitral balloon valvulotomy.

Mitral balloon valvulotomy (MBV) has proved to be an effective method in the treatment of patients with mitral stenosis. Although several factors determining an optimal immediate result have been described, there is little information regarding long-term follow-up, as well as factors influencing late success after MBV. This study analyzes 350 patients (mean age 46 +/- 12 years) treated by MBV who were clinically followed up between 6 months and 6 years. At least 1 echo-Doppler follow-up study was obtained in 298 patients 28 +/- 14 months after MBV; hemodynamic reevaluations were performed in 66 patients after 23 +/- months. Late success was considered if the patient was in functional class I to II and free of major events (death, restenosis and valve surgery). Restenosis was defined as a 50% loss of initial gain with regard to valve area by echocardiography, which was confirmed hemodynamically. After a mean follow-up of 38 +/- 15 months, 296 patients (84%) remained in functional class I to II, without surgery or the need for an increase in medical treatment. The 5-year Kaplan-Meier survival rate was 94 +/- 1%, whereas restenosis, valve surgery and major event-free probability were 90 +/- 3%, 91 +/- 2% and 85 +/- 2%, respectively. Multivariate study (Cox regression model) identified the presence of sinus rhythm (p < 0.001) and the absence of calcium at fluoroscopy (p < 0.003) as the only independent factors of late success.(ABSTRACT TRUNCATED AT 250 WORDS)

Abrupt homeostatic responses to transient intracardiac occlusion during balloon valvuloplasty.

The present study analyzes the hemodynamics of intracardiac occlusive periods during balloon mitral or aortic valvuloplasty and compares them with immediate plasma levels of atrial natriuretic factor (ANF), vasopressin and renin activity. Forty-nine patients were studied; 33 of them had mitral stenosis and 16 had aortic stenosis. The mean age was 52 +/- 17 years. During dilations pressures were monitored from the ascending aorta and left atrium. Plasma levels of ANF, vasopressin and renin were serially determined at baseline, after diagnostic procedures, within 15 to 30 seconds after the first 2 occlusive dilations, and 1 and 7 hours later. There were no significant changes in plasma renin throughout the study stages. ANF and vasopressin significantly increased after the dilations. These hormonal changes were related to the significant hemodynamic changes observed during intracardiac occlusion. The left atrial pressure correlated directly and significantly (r = 0.54, p less than 0.001) with plasma ANF levels throughout the conditions. On the other hand, the plasma vasopressin also correlated (r = 0.76, p less than 0.001) with systemic pressure in an exponential fashion. These findings show that abrupt releases of ANF and vasopressin occur immediately after intracardiac occlusive periods as a response to the acute and transient hemodynamic changes observed.

Obliteration of femoral pseudoaneurysm complicating coronary intervention by direct puncture and permanent or removable coil insertion.

We report on percutaneous obliteration of femoral pseudoaneurysm complicating percutaneous coronary interventions in 6 patients. Our findings suggest that permanent or transient direct coil insertion may be an useful alternative in the treatment of pseudoaneurysm in patients who do not respond to mechanical compression.

Factors influencing progression of mitral regurgitation after transarterial balloon valvuloplasty for mitral stenosis.

This study analyzes the clinical, echocardiographic and hemodynamic factors affecting progression of mitral regurgitation (MR) after transarterial balloon valvuloplasty in 200 consecutive patients with rheumatic mitral stenosis. After valvuloplasty, the mitral valve area increased in all patients, from 1.03 +/- 0.36 to 2.06 +/- 0.71 cm2 (p less than 0.0001). With regard to the basal stage, the mitral valve was competent in 139 patients and there was mild MR in 61 (grade I in 53, and grade II in 8). Three patients had progression of MR induced by a technical deficiency and they were excluded from analysis. Patients were classified into 2 groups on the basis of the degree of MR before and after valvuloplasty: group A--no progression of MR (n = 167; 85%) when the degree of MR did not change, disappeared after valvuloplasty, or increased from grade 0 to I; group B--progression of MR (n = 30; 15%) when the degree of MR increased to greater than or equal to grade II. Progression of MR was observed more frequently in older patients with presence of chronic atrial fibrillation, larger left atrial size and left ventricular volumes, baseline MR, more severe stenosis and a lower ejection fraction. Multivariate analysis selected age, left ventricular volumes and ejection fraction as independent predictors of progression of MR. All these factors suggest that progression of MR after balloon valvuloplasty could be related to a more advanced degree of disease.

Simple and complex stent strategies for bifurcated coronary arterial stenosis involving the side branch origin.

Coronary lesions located in major bifurcations constitute a challenge for the use of stents. Although the occlusion of a side branch covered by a stent is infrequent, the maintenance of a patent, stenosis-free bifurcation may result in a complex procedure. Between September 1994 and April 1998, 70 patients were treated by stent implantation for coronary bifurcation stenosis. The side branch always had a diameter >2 mm. The pairs of treated arteries were: left anterior descending (LAD)/diagonal artery in 32 patients, circumflex/obtuse marginal in 26, right coronary/posterior descending artery in 5, and LAD/circumflex in 7. We applied 2 different techniques of stent implantation: (1) deployment of 1 stent in the parent vessel covering the takeoff of the side branch and subsequent angioplasty of the side branch across the metallic structure (group A, n = 47 patients), and (2) implantation of 1 stent at the ostium of the side branch and complete reconstruction of the entire bifurcation with additional implantation of 1 or 2 stents at the parent vessel (group B, n = 23 patients). There were no significant differences between groups at baseline variables. Procedural success was similar in both groups: 42 (89%) in group A versus 21 (91%) in group B. However, major cardiac events at 18 months follow-up were higher in group B (event-free probability 44% vs 75%, p <0.05). Selected patients with coronary stenosis at major bifurcations can be treated with an acceptable rate of primary and late success. Complex techniques providing radical stent reconstruction of the bifurcation seems to provide no advantages over the simpler stent jail followed by ostial side branch balloon dilation.

In-laboratory removal of femoral sheath following protamine administration in patients having intracoronary stent implantation.

Two hundred twenty-eight patients with successful coronary stent implantation were randomized either to protamine administration and femoral sheath removal (group I, n = 117) or no heparin neutralization and delayed sheath removal (group II, n = 111). The hospital stay after treatment was shorter in patients receiving protamine; therefore, protamine use for neutralizing circulating heparin may be safely administered immediately after stent implantation.

Aberrant right subclavian artery associated with common carotid trunk. A rare cause of vascular ring.

We have reviewed four cases of incomplete vascular rings caused by the presence of a common carotid trunk from which arose both carotid arteries associated with an aberrant right subclavian artery. The patients were aged between 3 and 9 months. All patients presented with recurrent respiratory tract infections. Three patients showed signs of malnutrition and failure to thrive caused by episodes of bronchial aspiration from extrinsic compression of the oesophagus. One patient presented with dyspnoea induced by feeding and another had stridor. A common carotid trunk associated with an aberrant subclavian artery was confirmed in all cases. No other associated anomaly was observed in any patient. Ligature and section of the anomalous right subclavian artery was performed in all patients. The low incidence of this type of vascular ring, its physiopathological mechanism and surgical management are discussed.

Percutaneous balloon-expandable stents for sealing of acute aortic dissection.

Acute aortic dissection is a highly lethal disease. When dissection involves only the descending aorta and there are no ischemic complications, medical management may be the treatment of choice. However, a high risk of expansion or rupture of the dissection remains. When renal or limb ischemic complications do appear, surgery has been the only option, despite high mortality and morbidity. Percutaneous placement of stents for sealing an acute aortic dissection might be an alternative to surgical treatment. We treated 2 patients with acute type B aortic dissection by stent-fixation of the proximal and distal descending aorta. In both patients, there was evidence of persistent flap fixation at midterm follow-up.

[Acute pericarditis as initial clinical manifestation of hypereosinophilia syndrome]. / Pericarditis aguda como manifestación clínica inicial del síndrome hipereosinófilo.

The case of a patient in whom acute pericarditis was the initial manifestation of an idiopathic hypereosinophilia is reported. Endomyocardial abnormalities were not found by echocardiography. Response to prednisone therapy was good; symptoms, pericardial effusion and eosinophilia early disappeared after therapy. Some clinical aspects of this uncommon disease are discussed.

[Listeria monocytogenes endocarditis in a patient with mitral prosthesis, left auricular thrombus and adenocarcinoma of the colon]. / Endocarditis por Listeria monocytogenes en un paciente con prótesis mitral, trombo auricular izquierdo y adenocarcinoma de colon.

A case of Listeria monocytogenes endocarditis in a patient with mitral prosthetic valve, left atrial thrombus and colonic adenocarcinoma is reported. Vegetations were not demonstrated by transesophageal echocardiography and the clinical course was benign and without complications. Cure was achieved with antibiotic therapy, and surgery was not required. These features suggest that atrial thrombus could be the source of infection.

[Bradyarrhythmias secondary to the use of ophthalmic timolol. A report of 3 cases]. / Bradiarritmias secundarias al uso de timolol oftálmico. Descripción de 3 casos.

Three cases of symptomatic bradycardia due to topical ocular timolol administration are reported. Two patients had syncope related to atrioventricular block, and the other one complained of dizziness due to sinus bradycardia. Heart disease was not present in any case, although a right bundle branch block was observed in one patients. A normal sinus rhythm resumed in all patients after discontinuation of timolol.

[Digitalis poisoning from medicinal herbs. Two different mechanisms of production]. / Intoxicación digitálica por hierbas medicinales. Dos mecanismos diferentes de producción.

Two cases of digitalis toxicity due to uncontrolled ingestion of medicinal herbs are presented. The first of them was caused by oleander (Nerium oleander); digoxinemia levels were very high in this patient (4.44 ng/l), who presented many brady- and tachyarrhythmias. These arrhythmias disappeared when digoxinemia returned to normal values. The second patient had atrial fibrillation with slow ventricular rate, severe hypokalemia (2.1 mEq/l) and normal digoxinemia levels. He was taking medicinal herbs for a cold, with sorbitol between its components. Sorbitol may be similar to mannitol and glycerol (osmotic diuretic drugs) when taken at high doses. Uncontrolled ingestion of medicinal herbs is not safe, and severe poisoning can occur.

[Valvulopathies (XIV). The role of percutaneous valvuloplasty in congenital valvular diseases]. / Valvulopatías (XIV). Papel de la valvuloplastia percutánea en enfermedades valvulares congénitas.

The present article describes the cooperative experience Córdoba-Las Palmas since 1983 in 123 patients with congenital right or left ventricular outflow obstructions who were treated by percutaneous balloon dilatation. Seventy of them had pulmonary stenosis (63 valvular and seven supravalvular types); two had pulmonary atresia, 25 valvular aortic stenosis and 27 discrete subaortic stenosis. In patients with valvular pulmonic stenosis the gradient and the right ventricular pressure decreased significantly. No significant changes were observed in the degree of pulmonary regurgitation. One neonate died. No other major complications occurred. After a mean follow up of 3 +/- 2 years, we did not observe significant changes in the degree of pressure relief. The mean residual gradient is 26 +/- 19 mmHg. In our 21 patients out of the neonatal period with valvular aortic stenosis the gradient and the left ventricular pressure dropped significantly. Progression of aortic regurgitation in more than I grade was observed in 4 patients (19%), although only one (5%) progressed to grade III. There were no major complications in this group. After a mean follow up period of 24 +/- 17 months they persist with the obtained pressure relief and same degree of valvular competence. All 4 neonates with critical aortic stenosis had unsuccessful dilations and they died, wether after ulterior surgery or without it. In 27 patients with discrete subaortic stenosis the gradient and the left ventricular pressure decreased markedly, without significant changes in valve competence. There were no related major complications. After dilation, a broken and mobile membrane was frequently seen. At follow up (24 +/- 18 months), 6 patients (22%) had restenosis; five of them were successfully redilated. The remaining 21 patients persist with a reduced residual gradient (24 +/- 7 mmHg) and without significant changes in valve competence.