Atrial Septostomy for Left Atrial Decompression During Extracorporeal Membrane Oxygenation by Inoue Balloon Catheter.

BACKGROUND: Refractory pulmonary edema is an infrequent but serious complication in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) for myocardial failure. Left atrial (LA) decompression in this setting is important. Although a few methods have been reported, the experience is mostly limited to children. We aimed to evaluate the feasibility of Inoue balloon catheter in percutaneous trans-septal LA decompression in adult cardiogenic patients.Methods and Results:We retrospectively analyzed 16 procedures of trans-septal LA decompression by Inoue balloon catheter in 15 VA-ECMO patients (aged 22-65 years, 6 men) with refractory pulmonary edema from May 2012 to December 2014. Mean left ventricular ejection fraction was 15%. The cause of cardiogenic shock included 7 cases of ischemic heart disease, 1 of dilated cardiomyopathy, 5 of myocarditis, and 2 of fatal ventricular arrhythmia.The procedures were performed 4.3 days after ECMO. Inoue balloon size was 24-27 mm. LA septostomy were successfully created in 14 patients. Procedure time on average was 36.8 min (range, 15-85 min). There were no procedure-related complications.Radiography on the next day showed rapid resolution of pulmonary edema. CONCLUSIONS: Trans-septal LA decompression by Inoue balloon catheter is a feasible alternative method for adult patients with refractory pulmonary edema under ECMO.

Inoue-Balloon Percutaneous Transvenous Mitral Valvuloplasty through the Left Femoral Vein in Anomalous Inferior Vena Cava.

UNLABELLED: Inoue-balloon percutaneous transvenous mitral valvuloplasty is conventionally performed via the right femoral vein. However, atrial transseptal access can be technically challenging. Herein, we describe a 54-year-old male who had balloon mitral valvuloplasty performed via the left femoral vein because of an anomalous inferior vena cava course, including the technical issues encountered using this approach. KEY WORDS: Anomalous inferior vena cava; Left femoral vein approach; Mitral valvuloplasty.

IVUS-guided rotational atherectomy for unexpandable paclitaxel-eluting stent: A case report and review of literature.

We describe a patient suffering from late stent thrombosis in a paclitaxel-eluting stent which had an underexpanded ring due to the three-hundred-sixty-degree circumferential calcified plaque. Intravascular ultrasound (IVUS) revealed rotational atherectomy could successfully ablate both the metallic ring and the calcified ring. The ablated segment was scaffolded with a new paclitaxel-eluting stent, well expanded and documented by IVUS. To our knowledge, this is the first case report of stent ablation for an unexpanded paclitaxel-eluting stent. From the Medline index, there were only six case reports of stent ablation. We review and summarize the operation details of stent ablation from these reports.

Concurrent antegrade transseptal Inoue-balloon mitral and aortic valvuloplasty.

BACKGROUND: The Inoue balloon has been in use for many years for mitral valvuloplasty. Aortic valvuloplasty using the Inoue balloon via transseptal approach was developed in the hope of providing better results with less potential vascular access complications. METHODS AND RESULTS: In this study, we present our experience in percutaneous valvuloplasty using the Inoue balloon in 14 patients with combined rheumatic mitral and aortic stenosis (AS) in a single stage procedure via antegrade transseptal approach. The study group was characterized by relatively young age (mean 37.5 ± 9.6 years). Aortic followed by mitral valvuloplasty via antegrade approach resulted in a fall of transaortic peak pressure gradient (PG) from 59.1 ± 11.2 mm Hg to 25.3 ± 12.5 mm Hg (P = 0.012) and mean from 49.0 ± 10.9 mm Hg to 16.6 ± 9.8 mm Hg (P = 0.043). Aortic valve areas increased significantly from 0.70 ± 0.25 cm(2) to 1.41 ± 0.48 cm(2) (P = 0.042). Mean transmitral PG decreased from 14.9 ± 2.1 mm Hg to 5.3 ± 1.5 with increase of mitral valve areas from 1.08 ± 0.45 to 1.92 ± 0.51 cm(2). The procedures were well tolerated without development of significant valvular regurgitation or thromboembolism. During follow-up, 2 patients died due to lung cancer and sudden death at months 48 and 100. Five patients received delayed surgery after mean duration of 73.4 ± 39.7 months. CONCLUSIONS: Concurrent antegrade, transseptal Inoue-balloon aortic and mitral valvuloplasty, is feasible and safe, and provides excellent immediate results as one-stage procedure. The study results also suggest that balloon aortic valvuloplasty can be more durable in younger patients with rheumatic AS than in elderly patients with degenerative, AS. However, the modified aortic valvuloplasty technique can be utilized only as bridging procedure to aortic valve replacement or recently developed transcatheter aortic-valve implantation in unstable hemodynamic status, and as a palliative procedure before noncardiac surgery.

Retrieval of dislodged coronary intravascular ultrasound catheter with embolic protection device.

A retained fractured segment of an intravascular ultrasound catheter in the coronary artery during percutaneous coronary intervention is a rare occurrence. We describe our experience with successful retrieval of a fractured IVUS catheter fragment in a previously stented left anterior descending artery using a distal embolic protection device.

Inhibitory effect of Magnolia officinalis and lovastatin on aortic oxidative stress and apoptosis in hyperlipidemic rabbits.

Oxidative stress and apoptosis are 2 major characteristics of the progression of atherosclerosis. Both lovastatin and Magnolia officinalis are hypocholesterolemic agents. Therefore, we investigated the effect of M. officinalis extract on the prevention of atherosclerosis in comparison with lovastatin. Twenty hyperlipidemic rabbits were served one of the following diets: a high-fat and cholesterol diet (cholesterol group, 10% corn oil and 0.5% cholesterol), a high fat and cholesterol diet supplemented with M. officinalis extract (300 mg/kg) or lovastatin (6 mg/kg). The plasma lipids, oxidative stress (measured by free radical, malondialdehyde, and oxidative DNA damage), and arterial lesions significantly decreased in the M. officinalis and lovastatin groups when compared with the cholesterol group. Moreover, the expressions of Fas ligand, caspase 8, and caspase 9 in the aortic arches were also markedly lowered after M. officinalis and lovastatin supplements. Therefore, the results indicate that the antiatherogenic effect of M. officinalis is involved with a suppression of oxidative stress and with the down-regulation of apoptosis-related gene expression in hyperlipidemic rabbits.

Elucidating the inhibitory mechanisms of magnolol on rat smooth muscle cell proliferation.

The pathological mechanism of percutaneous transluminal coronary angioplasty-induced restenosis has been attributed to outgrowth of vascular smooth muscle cells. Pretreatment with antioxidants has been shown to reduce restenosis. Magnolol, an active compound of Magnolia officinalis, has exhibited approximately 1,000 times more potent antioxidant effects than alpha-tocopherol. In this study, we demonstrate, using cytometric analysis, an approximate 61% reduction of smooth muscle cells progressing to the S-phase by 0.05 mg/ml of magnolol. A BrdU incorporation assay also showed a significant reduction (73%) of DNA synthesis using 0.05 mg/ml of magnolol. The protein level of the proliferating cell nuclear antigen was suppressed by approximately 48% using 0.05 mg/ml of magnolol. This was in agreement with the promoter activity of nuclear factor-kappa B, which was also attenuated by 0.05 mg/ml of magnolol. Since receptor interacting protein and caspase-3 protein expression levels were both increased by magnolol in a dose-dependent manner, the apoptotic pathway may mediate the inhibition of cell growth. Our finding that malondialdehyde formation was significantly inhibited by 0.05 mg/ml of magnolol further supported the antioxidant effect of magnolol. These studies suggest that magnolol might be a potential pharmacological reagent in preventing balloon injury-induced restenosis.

Pre-procedure duplex ultrasonography to assist cephalic vein isolation in pacemaker and defibrillator implantation.

BACKGROUND: Difficulty in isolating the cephalic vein contributes to failed pacemaker and intracardiac cardioverter-defibrillator (ICD) implantation via the cephalic venous approach. The deltopectoral groove is used as a rough landmark, but the vein is often not found here. We evaluated the benefit of pre-procedural duplex ultrasonography in isolating the cephalic vein. METHODS: We enrolled 80 consecutive patients undergoing new pacemaker or defibrillator implantation and performed duplex ultrasonography to localize the cephalic vein before implantation. The corresponding surface location in the infraclavicular region and the depth of the cephalic vein were identified and recorded if the vein was well visualized. Using the imaging results, we dissected the skin over the predicted location until the cephalic vein was isolated. We determined the depth and corresponding surface location of the proximal cephalic vein during surgery. Afterward, we compared localization of the vein using imaging, surgery, and the deltopectoral-groove method. The relationship between cephalic vein depth and body parameters was also evaluated after the procedure. RESULTS: All proximal cephalic veins were successfully isolated under the assistance of pre-procedural duplex ultrasonography. When the corresponding surface locations were compared, the location depicted on sonograms was closer to the surgical finding than the location determined by using the deltopectoral-groove method (0.5 +/- 3.9 vs. 4.9 +/- 9.6 mm; P < .001). The depth of the cephalic vein derived from duplex sonograms showed excellent correlation with the surgical findings (r = 0.93, P < 0.001). The cephalic vein depth and body mass index (BMI) also showed a linear relationship with good correlation (r = 0.70, P < 0.001). CONCLUSION: Pre-procedural duplex ultrasonography helped in localizing the proximal cephalic vein and isolating the cephalic vein. Surface localization of the proximal cephalic vein was superior with sonography than with the deltopectoral-groove method. There was a linear relationship with good correlation between BMI and cephalic vein depth.

Treatment of slow/no-reflow phenomenon with intracoronary nitroprusside injection in primary coronary intervention for acute myocardial infarction.

Slow/no-reflow phenomenon is a serious problem complicating primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) and is associated with a poor prognosis. From January 2002 to November 2002, 11 of the 70 consecutive patients with ST elevation AMI who were subjected to primary PCI using balloon angioplasty and/or stenting developed slow/no-reflow phenomenon (TIMI 1 flow in 2, TIMI 2 in 8, and TIMI 2.5 in 1). They were 10 men and 1 woman, aged 64 +/- 11 years (range, 46-81). The culprit vessels were six in the left anterior descending coronary artery, three in the right coronary artery, one in the left circumflex coronary artery, and one in saphenous vein graft. Multiple bolus doses (100 microg) of nitroprusside were injected into the index artery through the guiding catheter using a 3 ml syringe until the TIMI flow grade improved by at least one grade or the systolic pressure decline below 80 mm Hg (one patient). The total drug dose varied from 100 to 700 microg. Following the drug treatment, angiographic TIMI flow grade improved by at least one grade in 9 (82%) of the 11 patients (P = 0.007). The TIMI frame counts significantly decreased from 36 +/- 17 frame counts to 16 +/- 11 frame counts (P = 0.012). All patients were discharged without major adverse cardiovascular events. Intracoronary bolus injection of nitroprusside using a 3 ml syringe appears to be a feasible, safe, and effective technique for the management of slow/no-reflow phenomenon complicating primary PCI.

Unexpected loss of atrial tracking caused by interaction between temporary and permanent right ventricular leads during implantation of a biventricular pacemaker.

This report describes a patient who underwent implantation of an atriobiventricular pacemaker following AV junction ablation and insertion of a temporary right ventricular (RV) pacemaker. During implantation, intermittent loss of sinus P wave tracking occurred when the three permanent leads were connected to the generator. Analysis of marker annotation disclosed intermittent abnormal ventricular sensing that reinitiated postventricular atrial blanking and caused failure of P wave tracking. This phenomenon disappeared after removing the temporary RV lead, but not by turning off the temporary pacemaker. We assume that mechanical contact between the temporary and the permanent RV leads is the underlying mechanism.

The current status of stent placement in small coronary arteries < 3.0 mm in diameter.

Data accrued to date indicate that stent placement in small vessels (< 3.0 mm reference diameter) suffers from the same disadvantage as other non-stent interventional devices in that the restenosis rate is significantly higher than observed following intervention involving large vessels. Randomized trials comparing systematic bare metal stenting versus conventional balloon angioplasty in the setting of small coronary arteries, however, show that the former therapeutic modality is probably superior to the latter treatment in its acute and mid-term angiographic and clinical results. Balloon angioplasty, even if performed optimally with resultant stent-like luminal outcome, yields a restenosis rate that is at best equivalent to that observed with stent placement. Stent performance is influenced profoundly by stent design and configuration. Tubular and corrugated stents are better than coil or meshwire stent design. Stents with thin struts appear to yield a lower restenosis rate compared with thick-strut stents. Coating the surface of stents with gold, phosphorylcholine or heparin does not appear to confer any additional long-term benefit compared with bare stainless-steel stents. On the other hand, impregnation of stents with anti-proliferative drugs, with or without a carrier polymer, has produced a significantly lower risk of restenosis, without an increase in stent thrombosis rate, compared with uncoated metal stents in multiple randomized trials. However, whether the clinico-anatomic benefits of drug-eluting stents can be sustained for several years and whether there are any long-term deleterious effects from the antiproliferative drug or carrier polymer remains unclear at this stage.

Association between COL3A1 collagen gene exon 31 polymorphism and risk of floppy mitral valve/mitral valve prolapse.

BACKGROUND: Collagen structure is a key element in mitral valves. Collagen defects were proposed as the primary events causing floppy mitral valves (FMV). The role of collagen genetic variant in floppy mitral valve/mitral valve prolapse (FMV/MVP) has not been well studied. The purpose of this study is to investigate the possible relationship between the collagen gene polymorphisms and risk of FMV/MVP among the Chinese population in Taiwan. METHODS: We studied 100 patients with FMV/MVP diagnosed by echocardiography and 243 age- and sex-matched normal control subjects. The polymorphisms of exon 31 and exon 52 of the collagen type III-alpha1 gene (COL3A1) were identified by polymerase chain reaction (PCR)-based restriction analysis. RESULTS: There was a significant difference in either the genotype distribution (P<0.0001) or allelic frequencies (P<0.0001) between FMV/MVP cases and controls for COL3A1 exon 31 polymorphism. An odds ratio for risk of FMV/MVP associated with COL3A1 exon 31 GG genotype was 7.42 (95% confidence interval 4.40-12.52). An odds ratio for risk of FMV/MVP associated with COL3A1 exon 31 G allele was 2.28 (95% confidence interval 1.57-3.29). There was no significant difference in the distribution of COL3A1 exon 52 genotypes (P=0.31) and allelic frequencies (P=0.32) between FMV/MVP cases and controls. Further categorization of the FMV/MVP patients into mild and severe subgroups revealed no statistical difference from the controls for exon 31 or exon 52 polymorphism. CONCLUSIONS: This study shows that patients with FMV/MVP have higher frequency of COL3A1 exon 31 GG genotype that supports a role of the COL3A1 exon 31 polymorphism in determining the risk of FMV/MVP among the Chinese population in Taiwan.

Clinical impact of stent construction and design in percutaneous coronary intervention.

Convincing end point data demonstrating the anatomic and clinical superiority of stent placement compared with balloon angioplasty together with significant improvement in stenting technique and poststent management have resulted in an explosion in stenting procedures and the emergence of more than 40 stent types with disparate designs and material composition in clinical use. Structural nuances in design, composition, and coating of different stent models, however, have been shown to have a major influence on the risk of stent thrombosis, the degree of vessel wall injury, and subsequent intimal proliferation in the experimental model. There is now substantial amount of evidence to indicate that the same relationship between stent structural characteristics and vessel wall outcome holds true in humans. This article provides an up-to-date overview of the clinical impact of stent construction and design, including the clinical performance of drug-eluting stents.

Safety and outcomes of short-term multiple femoral venous sheath placement in cardiac electrophysiological study and radiofrequency catheter ablation.

Multiple intracardiac catheters are often necessary for electrophysiological study (EPS) and radiofrequency (RF) ablation therapy. Therefore, multiple venous sheath placement in one femoral vein is always required for multiple intracardiac catheter insertion. The vascular complications incurred by placement of multiple sheaths have not been fully studied. We utilized duplex ultrasonography to assess the femoral veins before and after the procedure. This study consisted of 52 patients (68 femoral veins) who underwent EPS and RF ablation therapy. Up to three sheaths were inserted into a single femoral vein. Nonocclusive deep vein thrombosis (DVT) occurred in 12/68 veins (17.6%) of 11 patients on the day following the procedure. Thrombosis regressed spontaneously in 11 veins and persisted in 1 vein at 1-week follow-up. The venous diameter significantly decreased the day after the procedure (8.7 +/- 1.2 mm vs 5.3 +/- 1.5 mm, P < 0.001), but recovered by the 1-week follow-up (7.9 +/- 1.7 mm, P = 0.07) in the 12 veins. Short-term placement of multiple venous sheaths in a single femoral vein appears to be safe. Nonetheless, nonocclusive DVT does occur in a significant number of patients. Although thrombosis regressed and the outcome appeared to be benign in most patients, close follow-up to avoid potential vascular complications is necessary.

Feasibility and accuracy of pre-procedure imaging of the proximal cephalic vein by duplex ultrasonography in pacemaker and defibrillator implantation.

BACKGROUND: Failure of the cephalic venous approach in pacemaker and defibrillator implantation is always due to the small size and difficulty in isolation of the cephalic vein. We propose that pre-procedure imaging of the proximal cephalic vein is valuable to achieve successful access of cephalic vein. However, the feasibility and accuracy of duplex ultrasonographic imaging of the proximal cephalic vein are unknown. METHODS: The study enrolled 30 consecutive patients who underwent new implantation of permanent pacemakers or defibrillators at our institute. An ultrasound probe scanned along the plane 2 cm beneath the inferior margin of the clavicle to locate the cephalic vein before device implantation. If the vein was well visualized, the venous diameter and the vertical depth were measured. The corresponding surface location of the vein on the chest wall was also identified and recorded by duplex ultrasonography. The echo-derived vertical depths and vascular findings were compared with those measured during surgery. RESULTS: All proximal cephalic veins were well visualized in the infraclavicular region by duplex ultrasonography. They were compressible, patent in color Doppler ultrasound imaging, and displayed phasic change of Doppler signal during respiration, indicating patency in all study veins. The average diameter of the target cephalic vein was 7.7 +/- 1.6 mm (range, 5.0-11.1 mm). The echo-derived vertical depth of the proximal cephalic veins was highly correlated with the depth measured during surgery (28.4 +/- 5.5 vs. 28.4 +/- 5.6 mm, r = 0.93, P < 0.0001). All target cephalic veins were isolated after exploration via the estimated surface location of the chest wall by pre-procedure duplex ultrasonography. Seven (23%) of the studied patients did not have their cephalic vein cannulated successfully. CONCLUSION: The target proximal cephalic vein in pacemaker and defibrillator implantation can be precisely imaged and localized by duplex ultrasonography. Although further studies are needed, our findings pave a way to further study and clarify the implantation problems of cephalic vein approach.

Inoue-balloon mitral valvuloplasty in double-orifice mitral stenosis.

We report 7 symptomatic patients with stenotic double-orifice mitral valve of incomplete bridge type. In each patient, the fibrous bridge tissue between the valve leaflets was successfully split using an Inoue balloon valvuloplasty technique with stepwise dilations applied only to the posteromedial orifice.

Association between angiotensinogen gene M235T polymorphism and mitral valve prolapse syndrome in Taiwan Chinese.

BACKGROUND AND AIM OF THE STUDY: It has been reported that patients with mitral valve prolapse syndrome (MVPS) also have a disorder in autonomic or neuroendocrine function which can cause many related symptoms. Although a potential role of the reninangiotensin system in the pathogenesis of MVPS has been addressed, the role of the angiotensinogen (AGT) genetic variant in MVPS has not been studied. Thus, a case-controlled study was performed to investigate the possible relationship between AGT gene polymorphisms and MVPS. METHODS: A total of 100 patients with MVP diagnosed by echocardiography and 100 age- and sex-matched normal control subjects was studied. AGT gene M235T and T174M polymorphisms were identified by polymerase chain reaction-based restriction analysis. RESULTS: There was a significant difference in the distribution of AGT gene M235T genotypes (p <0.001) and allelic frequencies (p <0.001) between MVPS cases and controls. An Odds Ratio (OR) for risk of MVPS associated with M235T TT genotype was 8.55 (95% CI 4.51-16.18). An OR for risk of MVPS associated with the T allele at the M235T locus of the AGT gene was 3.27 (95% CI 2.05-5.22). The T174M polymorphism of AGT gene showed no association with MVPS (p = 0.94). CONCLUSION: These findings suggest that the M235T polymorphism of the AGT gene is associated with MVPS in the Chinese population of Taiwan. The association of the TT genotype with MVPS is more noteworthy than an overall increase in the frequency of the T allele at the M235T locus.

Interactions of esmolol and adenosine in atrioventricular nodal-dependent supraventricular tachycardia: implication for the cellular mechanisms of adenosine.

INTRODUCTION: Cellular mechanisms of adenosine include a direct effect on the activation of the adenosine-sensitive potassium current (I(K,Ado)) and an indirect effect on antagonism of catecholamine-stimulated adenylate cyclase activity. However, previous studies evaluating the influence of catecholamine activity on the electrophysiologic effects of adenosine have yielded conflicting results. We tested the hypotheses that if adenosine exerts its atrioventricular (AV) nodal blocking effects directly by activating the I(K,Ado) potassium current, rather than indirectly by reversing the catecholamine effects, then pretreatment with beta-adrenergic blockade would not potentiate the effects of adenosine in terminating AV nodal-dependent supraventricular tachycardia (SVT). METHODS AND RESULTS: During sustained AV nodal reentrant tachycardia (AVNRT) or AV reentrant tachycardia (AVRT) in 28 patients, adenosine was rapidly injected in incremental doses of 1.5, 3, 6, 9, 12 and 18 mg to determine the lowest effective dose required for tachycardia termination before and immediately after the end of esmolol infusion. Esmolol infusion was started with loading doses of 500 /kg/min for 1 min and 150 microg/kg/min for 4 min, followed by a maintenance infusion of 50-100 microg/kg/min. Esmolol infusion was continued until the tachycardia was terminated or the maximal dose of 100 mg was reached. Adenosine was effective in terminating SVT in all 28 patients with a mean lowest effective dose of 96 +/- 54 microg/kg before esmolol. During esmolol infusion, tachycardia was reproducibly terminated in 8 patients (6 with AVNRT, 2 with AVRT) with a mean dose of 67 +/- 23 mg. In the other 20 patients with persistent tachycardia after 100 mg of esmolol infusion, the lowest effective dose of adenosine could be determined in 19 patients. In the remaining patient with AVRT, the maximal dose of adenosine (18 mg) was unable to terminate the tachycardia immediately after the end of esmolol infusion. In these 19 patients, esmolol infusion caused significant lengthening of the tachycardia cycle length from 338 +/- 36 to 372 +/- 51 ms (p < 0.0001) and reduction of the mean arterial blood pressure from 96 +/- 15 to 88 +/- 18 mm Hg (p = 0.034). Compared to the dosage that was determined before esmolol infusion, the lowest effective dose of adenosine remained the same in 13 patients after the end of esmolol infusion, whereas the dose increased in 5 and decreased in 1 patient. The mean lowest effective dose of adenosine was not significantly different before (98 +/- 54 microg/kg) and immediately after (115 +/- 56 microg/kg) the end of esmolol infusion (p = 0.054). CONCLUSIONS: Intravenous esmolol infusion (up to 100 mg total dose) usually fails to terminate AV nodal-dependent SVT. In the esmolol-resistant tachycardia, esmolol pretreatment does not produce a positive synergistic effect on the efficacy of adenosine-induced termination of SVT. Therefore, in this tachycardia adenosine may exert its effects on AV nodal conduction directly by activation of the I(K,Ado) potassium current, rather than by antagonizing the beta-adrenergic system.