Stent en y autoexpandible para el tratamiento de la estenosis traqueobronquial maligna. Estudio retrospective / Self-expanding y stent for the treatment of malignant tracheobronchial stenosis. Retrospective study

El tratamiento paliativo de la estenosis traqueobronquial maligna es difícil. Las experiencias publicadas con stent en Y autoexpandibles son escasas, por lo que es necesario evaluar si los resultados que ofrecen son mejores que los de otras prótesis alternativas. Presentamos una serie retrospectiva de 20 pacientes consecutivos con estenosis traqueobronquial maligna, a los que se insertó un stent en Y metálico y recubierto. Las variables analizadas fueron las siguientes: alivio de la disnea, complicaciones y supervivencia. Los stent se insertaron a través de un traqueoscopio rígido en las 24h siguientes al ingreso del paciente, de forma segura y sin dificultades. Todos los pacientes lograron un alivio eficaz de la disnea y no se observaron efectos adversos, tempranos o tardíos, relacionados con el stent. La mortalidad a los 30 días fue del 40%, con una mediana de supervivencia de 12,2 semanas. La inserción de stent en Y autoexpandibles es un procedimiento seguro y eficaz para el tratamiento paliativo de la estenosis traqueobronquial maligna. En la actualidad, este es nuestro stent de elección para este subgrupo de pacientes

Palliation of malignant tracheobronchial stenosis is challenging. Published experience with self-expanding Y-shaped stents is limited and it seems necessary to evaluate whether they improve clinical results with respect to alternative prostheses. We present a retrospective case series of 20 consecutive patients with malignant tracheobronchial stenosis that underwent placement of a single-unit, Y-shaped covered metallic stent. Outcomes were: safety of the procedure, palliation of dyspnea, complications, and survival. All stents were safely and easily placed using a rigid tracheoscope within 24hours of admission. Dyspnea was effectively palliated in all patients, and no early or late adverse stent-related events were observed. Thirty-day mortality was 40%. Median survival was 12.2 weeks. Placement of Y-shaped self-expanding stents is a safe and effective procedure for the palliation of malignant tracheobronchial stenosis, and is currently our stent of choice for this subgroup of patients

Self-expanding y stent for the treatment of malignant tracheobronchial stenosis. Retrospective study. / Stent en y autoexpandible para el tratamiento de la estenosis traqueobronquial maligna. Estudio retrospectivo.

Palliation of malignant tracheobronchial stenosis is challenging. Published experience with self-expanding Y-shaped stents is limited and it seems necessary to evaluate whether they improve clinical results with respect to alternative prostheses. We present a retrospective case series of 20 consecutive patients with malignant tracheobronchial stenosis that underwent placement of a single-unit, Y-shaped covered metallic stent. Outcomes were: safety of the procedure, palliation of dyspnea, complications, and survival. All stents were safely and easily placed using a rigid tracheoscope within 24hours of admission. Dyspnea was effectively palliated in all patients, and no early or late adverse stent-related events were observed. Thirty-day mortality was 40%. Median survival was 12.2 weeks. Placement of Y-shaped self-expanding stents is a safe and effective procedure for the palliation of malignant tracheobronchial stenosis, and is currently our stent of choice for this subgroup of patients.

Direct Flow Implantation in a Patient With Mechanical Mitral Prostheses.

We describe a case of Direct Flow (Direct Flow Medical Inc, Santa Rosa, CA) transcatheter aortic valve implantation in a patient with a mechanical valve in a mitral position.

Failure and off-pump replacement of Incor LVAD system.

An Incor (Berlin Heart AG, Berlin) left ventricular assist device (LVAD) was implanted; 6 months later the patient was admitted to our department for intravenous antibiotic therapy for a driveline infection. Two days after admission under direct echocardiographic monitoring, the pump failure was noted to be entirely dependent on the position of the cable. The pump was successfully replaced without cardiopulmonary bypass as a matter of urgency.

Left ventricular support by axial flow pump: the echocardiographic approach to device malfunction.

Axial flow pumps have gained increased acceptance in recent years as a bridge to heart transplantation and, more recently, as destination therapy. As left ventricular (LV) assist device dysfunction will be increasingly prevalent, the aim of our work was to introduce an echocardiographic management protocol as a guide to recognize the causes of pump failure. In this article we describe the echocardiographic approach to 5 episodes of malfunction of an axial flow pump (DeBakey, MicroMed Technology Inc, Houston, Tex) in 4 patients: 4 episodes caused by thrombosis of LV assist device and one caused by abnormal increase of systemic vascular resistance. In our experience, echocardiography played a pivotal role in clinical management of LV assist device failure. It allowed us to: assess patency and position of inflow and outflow cannulae; research the source of thromboembolic material; assess adequate LV filling and unloading; and optimize right ventricular function, volume replacement therapy, and pharmacologic support.

[Comorbidity in surgical myocardial revascularization: risk factors or contraindications for surgery]. / Comorbilità nella rivascolarizzazione miocardica chirurgica: fattori di rischio, controindicazioni.

BACKGROUND: The worsening evolution of patients undergoing surgical myocardial revascularization makes it difficult the stratification of the preoperative mortality risk, a correct evaluation of results and the comparison of results of different centers. The aim of the study was to evaluate the prognostic weight of comorbidity in surgical myocardial revascularization. METHODS: We evaluated the characteristics of preoperative morbidity in 4999 patients who underwent surgical myocardial revascularization during four different periods (1979-1980, 1991-1992, 1994-1998, 1999-2002). We also evaluated the in-hospital results. RESULTS: By comparing the four different periods, an increase in older age, female sex, comorbidity, three-vessel disease, and severe left ventricular dysfunction was observed. Surgical mortality decreased to 2.3%. Multivariate analysis of the 1999-2002 period showed that only renal insufficiency was a risk factor for in-hospital mortality. CONCLUSIONS: Although the preoperative risk is higher, nowadays hospital mortality is reduced thanks to new cardiac-surgical techniques and approaches that increasing the capacity of controlling comorbidity in the pre-, intra- and postoperative course. For a correct decision-making process it is crucial to assess how much comorbidity may influence the long-term follow-up in these patients independently of surgical myocardial revascularization.

[The use of a "transgastric oblique" transesophageal echocardiographic view to visualize the right ventricular inflow-outflow tract. Clinical applications]. / La proiezione ecocardiografica transesofagea "transgastrica obliqua" per la visualizzazione del tratto di afflusso-efflusso ventricolare destro. Applicazioni nella pratica clinica.

This paper describes the transesophageal echocardiographic "oblique transgastric" view to assess the right ventricular inflow-outflow tract. With this approach it is possible to view the right atrium, tricuspid valve, right ventricular inflow and outflow tracts, and the main pulmonary artery. In 2 clinical cases we evaluated the clinical feasibility of this approach in the diagnostic phase; in 31 patients who underwent cardiac transplantation we examined the advantages of this noninvasive hemodynamic monitoring. An advantage of transgastric view compared with esophageal standard views at 30-60 degrees, is the feasibility to obtain the velocity-time integral of the outflow tract systolic flow to calculate cardiac output by the pulsed Doppler sample volume orientation, which in this view is parallel to pulmonary arterial flow; moreover, it is possible to evaluate pulmonary artery pressures from pulmonary and tricuspid regurgitation.