Intra-cardiac echocardiography guided trans-septal puncture in patients with dilated left atrium undergoing percutaneous transvenous mitral commissurotomy.

Percutaneous transvenous mitral commissurotomy (PTMC) is an effective treatment for mitral stenosis, but trans-septal puncture carries a certain risk of complications. There have been few reports on phase-array intra-cardiac echocardiography (ICE) guidance in trans-septal puncture for PTMC, especially in patients with dilated left atrium or distorted anatomy. Herein, we report our preliminary experience with ICE-guided trans-septal puncture in patients with dilated left atrium (>or=5.5 cm) who underwent PTMC. From June 2005 to March 2006, there were nine consecutive patients with symptomatic mitral stenosis and left atrium size larger than 5.5 cm who underwent trans-septal puncture for PTMC with the ICE guidance in this institution by a same operator. The procedural and catheterization results were analyzed. Using ICE guidance, the success rate for trans-septal puncture was 100% for all patients with dilated left atrium (>or=5.5 cm). The trans-septal procedures were free of major and minor complications and the patients were not exposed to contrast medium. Mitral valve area increased significantly from 1.0+/-0.2 cm(2) to 1.9+/-0.2 cm(2). Our preliminary result showed that ICE safely and effectively guided trans-septal puncture for PTMC in patients with dilated left atrium (>or=5.5 cm), thus eliminating contrast medium usage and avoiding unnecessary longer X-ray exposure.

Immediate and late outcomes of patients undergoing transseptal left-sided heart catheterization for symptomatic valvular and arrhythmic diseases.

BACKGROUND: The transseptal technique has been widely used for diagnostic and therapeutic left-sided heart catheterization. However, its differential immediate and late outcomes among patients with various valvular and arrhythmic diseases are not yet determined. METHODS: Beginning from 1993, all patients undergoing transseptal procedures were screened and categorized into diagnosis, arrhythmia, and valvuloplasty groups according to the purposes of the catheterization. Incidences of transseptum-related acute major events (cardiac perforation, embolic stroke, and bradyarrhythmia during the procedure) and late complications (residual atrial septal defect [ASD], embolic stroke, bradyarrhythmia, and death up to 18 months) were analyzed and compared between groups. RESULTS: From January 1993 to May 2003, a total of 176 patients underwent 184 transseptal procedures for diagnosis of valvular heart diseases (n = 8), catheter ablation of arrhythmogenic foci (n = 29), and mitral valvuloplasty (n = 147). The immediate outcome was similar among the 3 groups, with an overall acute complication incidence of 3.8%. At follow-up, the incidences of bradyarrhythmia, embolic stroke, and death were not different among the 3 groups. Patients undergoing valvuloplasty had a significantly higher prevalence of residual ASD, especially for those with more severe mitral stenosis and less valvuloplasty success. However, presence of ASD did not impose disadvantage over the 1.5-year prognosis. CONCLUSION: Transseptal left-sided heart catheterization can be safely applied to patients with different categories of cardiac diseases with comparably good immediate and late outcomes. Although patients undergoing percutaneous valvuloplasty have a higher chance of permanent ASD creation, their prognosis is not influenced.

Conversion of rheumatic atrial fibrillation by amiodarone after percutaneous balloon mitral commissurotomy.

Amiodarone, used in conjunction with percutaneous balloon mitral commissurotomy, can safely convert rheumatic atrial fibrillation in 38% of patients compared with 0% in those without it. However, whether this treatment exerts long-term benefits on prognosis awaits further investigation.

Percutaneous coronary revascularization improves the prognosis of patients with cardiogenic shock in acute coronary syndrome: a chronological study.

BACKGROUND: Cardiogenic shock complicating acute coronary syndrome (ACS) implies grim prognosis with conventional management. Previous studies of coronary intervention yielded controversial results and were rarely analyzed chronologically. This study was to determine the impact of percutaneous coronary revascularization on outcome by studying two time periods 5 years apart in which the revascularization was more frequent and techniques more refined in the later period. METHODS AND MATERIALS: All patients admitted to the intensive or coronary care unit for ACS in two 1.5-year study periods (Period I: Jan 1994-Jun 1995, Period II: Oct 1999-Apr 2000) were retrospectively screened. Patients who met strict criteria of cardiogenic shock within 24 h of ACS were enrolled. The demographics, management and in-hospital/3-month outcomes were analyzed. RESULTS: Thirty-seven patients (33M/4F, aged 65+/-8 years) were enrolled in Period I and 32 patients (25M/7F, aged 68+/-13 years) in Period II. The incidence of cardiogenic shock was 11.8 and 9.3%, respectively. The demographics were similar except patients in Period II were older. Significantly more coronary angiography and interventions were done in the later period. The in-hospital (68 vs. 44%, P=0.047) and 3-month mortalities (70 vs. 44%, P=0.03) were significantly reduced in Period II. The in-hospital survivors in two study periods differed only in use of coronary angiography (94 vs. 50%, P=0.005) and interventions (83 vs. 33%, P=0.005) but not others. CONCLUSIONS: Percutaneous coronary revascularization does improve the clinical outcome of cardiogenic shock when analyzed chronologically. This treatment is warranted in every such patient in the interventional era.

Atrial demand pacemakers in sick sinus syndrome: an efficient and reliable approach in selected patients.

BACKGROUND: Atrial demand pacemakers offer the advantages of lower cost and less cumbersome implantation in selected sick sinus syndrome patients with acceptable atrioventricular (AV) conduction. However, concerns about their long-term performance and AV conduction degeneration still worry certain implantation physicians. There were still limited long-term follow-up data of atrial demand pacemakers, especially in oriental people. Thus, we reviewed our long-term follow-up results. METHODS: From January 1996 to December 1998, all symptomatic sick sinus syndrome patients with atrial demand pacemaker (AAI, AAIR) treatment were retrospectively studied. They were all regularly followed up at our pacemaker clinic. The patients' clinical presentations, coronary angiography, electrophysiology results and their initial implantation parameters were collected. All outpatient follow-up histories, electrocardiogram (EKG) rhythm strips, and chronic threshold test data were also retrieved. RESULTS: There were 51 patients enrolled in this study, with a mean age of 68 +/- 7 years. The average follow-up duration was 44 +/- 17 months. The baseline His bundle-ventricular (HV) interval was 40 +/- 6 ms and AV 1:1 conduction cycle lengths were up to 388 +/- 65 ms. Two patients (2/51, 3.9%) had acute lead dislodgement within three days and needed reimplantation. During the long-term follow-up, all patients maintained good pacing function. Five patients (5/51, 9.8%) had occasions of sensing failure, as detected by 12-lead surface EKG or Holter monitor, which all resolved after reprogramming of the sensing threshold. Only 1 patient ( 1/51, 1.9%) developed Wenckebach AV block in the daytime as shown by EKG and was later upgraded to a DDDR pacemaker uneventfully. No patient became victim of chronic atrial fibrillation during the long-term follow-up. CONCLUSIONS: Our follow-up study again suggests that atrial demand pacemakers have good initial implantation and long-term results. The chance of developing AV conduction degeneration during follow-up is quite low (1.9%, average annual incidence 0.5%). AAI and AAIR pacemakers are a reliable and physiological approach to selected sick sinus syndrome patients and should be the pacemaker of choice in suitable cases.