Asunto(s)
Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Disección de la Aorta Torácica , Procedimientos Endovasculares , Humanos , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Resultado del Tratamiento , Stents , Estudios RetrospectivosRESUMEN
BACKGROUND: Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. METHODS: Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. RESULTS: For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P < .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). CONCLUSION: COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications.
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COVID-19 , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/etiología , Estudios Retrospectivos , Pandemias , Factores de Tiempo , Intervención Coronaria Percutánea/efectos adversos , Tiempo de TratamientoRESUMEN
The clinical impact of prosthesis-patient mismatch (PPM) in patients with small aortic annuli who underwent transcatheter aortic valve (AV) implantation with either balloon-expandable (BE) or self-expanding (SE) valves remains controversial. We assessed in-hospital and intermediate clinical outcomes in 573 patients with transfemoral transcatheter AV implantation with a small AV annulus, defined as an AV annulus area ≤430 mm2. A total of 337 patients treated with a 23-mm BE valve (SAPIEN 3, Ultra) were compared with 236 patients treated with a 26-mm SE valve (Evolut series). Valve-in-valve cases were excluded, and late echo follow-up (mean 674 ± 438 days) was assessed in a subset of 292 patients (51.0%). Well-matched BE and SE cohorts did not differ with respect to major in-hospital outcomes, other than a borderline increase in vascular complications and composite bleeding in patients with SE. Patients with BE had a higher incidence of severe PPM on discharge echocardiography (16.9% vs 6.8%, p <0.002). The mean AV gradient at 30 days was higher for patients with BE (12.2 ± 4.2 vs 6.2 ± 7.9 mm Hg, p <0.001) and at late follow-up (14.0 ± 8.2 vs 7.2 ± 3.5 mm Hg, p <0.001). The follow-up left ventricular ejection fraction and incidence of >mild aortic insufficiency were similar. All-cause mortality for the 2 cohorts was similar, with an overall mean (95% confidence interval) survival time of 61.2 months (57.8 to 64.5; p = 0.98). There were no significant survival differences between combined patients with BE and SE with no, moderate, or severe PPM, with an overall mean (95% confidence interval) survival time of 32.5 (30.5 to 34.5) months combining valve types (p = 0.23). In conclusion, despite an increased incidence of PPM with higher mean AV gradients that persist on late echocardiography in the BE cohort, patients with BE and SE with small aortic annuli have similar clinical outcomes at intermediate follow-up. Moderate and severe PPM had no impact on survival at a mean follow-up of 32.5 months.
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Estenosis de la Válvula Aórtica , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Estenosis de la Válvula Aórtica/cirugía , Estudios de Seguimiento , Volumen Sistólico , Prótesis Valvulares Cardíacas/efectos adversos , Resultado del Tratamiento , Diseño de Prótesis , Hemodinámica , Función Ventricular Izquierda , Válvula Aórtica/cirugíaRESUMEN
Previous reports comparing transcarotid (TC) versus transfemoral (TF) approaches for patients undergoing transcatheter aortic valve replacement have had inconsistent conclusions. We compared in-hospital and 1-year clinical outcomes, changes in quality of life, and direct hospital costs for 138 TC versus 1,926 TF procedures. Propensity matching based on the Society of Thoracic Surgery Predicted Risk of Mortality was used to compare 130 patients who underwent TC with 813 patients who underwent TF. Matched TC versus TF cohorts did not differ with respect to in-hospital mortality (0.0% vs 1.4%, p = 0.380), stroke (2.3% vs 2.5%, p = 0.917), major vascular complications (0.8% vs 2.2%, p = 0.268), composite bleeding complications (4.6% vs 6.4%, p = 0.647), requirement for permanent pacemaker (14.6% vs 12.9%, p = 0.426), postoperative hospital length of stay (3.3 ± 3.4 vs 3.1 ± 3.3 days, p = 0.467), or direct hospital costs ($52,899 ± 9,560 vs $50,464 ± 10,997, p = 0.230). Similarly, at 1-year, patients who underwent TC versus patients who underwent TF did not differ with respect to all-cause mortality (7.6% vs 6.4%, p = 0.659), hospital readmission (20.0% vs 23.9%, p = 0.635), or quality of life as measured by the Kansas City Cardiomyopathy Questionnaire score (84.0 ± 17.1 vs 88.4 ± 13.9, p = 0.062). Patients who underwent TC and TF did not differ with respect to in-hospital complications, length of hospital stay, and direct hospital costs, as well as 1-year mortality, readmission, and quality of life. These data add to ongoing support for the TC approach as the optimal alternative access for patients with transcatheter aortic valve replacement deferred from a transfemoral approach.
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Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Estenosis de la Válvula Aórtica/cirugía , Calidad de Vida , Arteria Femoral/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/cirugía , Válvula Aórtica/cirugía , Factores de RiesgoRESUMEN
With the COVID-19 pandemic, the fear among patients of contracting it has made them reluctant to seek medical attention on a timely basis even for emergent conditions. We present a case of post infarction ventricular septal rupture due to delayed presentation as a consequence of the fear of COVID-19. (Level of Difficulty: Intermediate.).
RESUMEN
A 60-year-old male presented 12 months after CABG surgery with a large pulsatile sternal mass. CT scan of the chest demonstrated a pseudoaneurysm originating from the mid saphenous vein graft to the PDA measuring 7.7 x 7.2 x 6.0 cm. After a multidisciplinary consultation, a decision was made to place a Jostent GraftMaster to completely seal the communication of the extravasation.
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Aneurisma Falso/cirugía , Materiales Biocompatibles Revestidos , Enfermedad de la Arteria Coronaria/cirugía , Oclusión de Injerto Vascular/cirugía , Politetrafluoroetileno , Vena Safena/trasplante , Stents , Aneurisma Falso/diagnóstico , Aneurisma Falso/etiología , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico , Oclusión de Injerto Vascular/complicaciones , Oclusión de Injerto Vascular/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Vena Safena/diagnóstico por imagen , Vena Safena/cirugía , Tomografía Computarizada por Rayos XAsunto(s)
Cateterismo Cardíaco , Cardiomiopatía Hipertrófica/diagnóstico , Estenosis Subaórtica Fija/diagnóstico , Cardiopatías Congénitas/diagnóstico , Obstrucción del Flujo Ventricular Externo/diagnóstico , Cardiomiopatía Hipertrófica/complicaciones , Estenosis Subaórtica Fija/complicaciones , Ecocardiografía , Femenino , Cardiopatías Congénitas/complicaciones , Hemodinámica , Humanos , Persona de Mediana Edad , Ventriculografía con Radionúclidos , Obstrucción del Flujo Ventricular Externo/etiologíaRESUMEN
BACKGROUND: The CorMatrix (CorMatrix Cardiovascular, Roswell, Ga) biologic extracellular patch derived from porcine small intestinal mucosa provides a biologic scaffold for cellular ingrowth and eventual tissue regeneration. It has been used in a variety of applications, including cardiac and vascular repair procedures. METHODS: CorMatrix was used as a patch arterioplasty for femoral artery repair in conjunction with endarterectomy for seven separate procedures in six patients (one patient underwent staged, bilateral femoral procedures). RESULTS: Patients were a median age of 67 years (interquartile range, 3.6 years). Six of seven procedures (86%) were performed on male patients. There were no operative deaths. Three of seven procedures (43%) resulted in significant early complications. Two procedures (29%) resulted in catastrophic biologic extracellular matrix patch disruption (11 and 19 days after initial procedure), requiring emergency exploration, patch removal, and definitive repair with vein patch arterioplasty. Both patches demonstrated an absence of growth on culture. One procedure (14%) resulted in groin pseudoaneurysm formation. Use of the CorMatrix patch was suspended upon recognition of significant complications. CONCLUSIONS: Use of CorMatrix patch in the femoral artery position demonstrates a high incidence of early postoperative complications, including catastrophic patch disruption and pseudoaneurysm formation.
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Aneurisma Falso/etiología , Endarterectomía/efectos adversos , Matriz Extracelular/trasplante , Arteria Femoral/cirugía , Claudicación Intermitente/cirugía , Mucosa Intestinal/trasplante , Enfermedad Arterial Periférica/cirugía , Anciano , Aneurisma Falso/diagnóstico por imagen , Animales , Biopsia , Endarterectomía/métodos , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/patología , Xenoinjertos , Humanos , Claudicación Intermitente/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Porcinos , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler DúplexRESUMEN
Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis minimizes the risk of intracranial bleeding compared with systemic full-dose fibrinolytic therapy for pulmonary embolism (PE). However, major bleeding is nevertheless a potential complication. We analyzed the 150-patient SEATTLE II trial of submassive and massive PE patients to describe those who suffered major bleeding events following ultrasound-facilitated, catheter-directed, low-dose fibrinolysis and to identify risk factors for bleeding. Major bleeding was defined as GUSTO severe/life-threatening or moderate bleeds within 72 hours of initiation of the procedure. Of the 15 patients with major bleeding, four (26.6%) developed access site-related bleeding. Multiple venous access attempts were more frequent in the major bleeding group (27.6% vs 3.6%; p<0.001). All patients with major bleeding had femoral vein access for device delivery. Patients who developed major bleeding had a longer intensive care stay (6.8 days vs 4.7 days; p=0.004) and longer hospital stay (12.9 days vs 8.4 days; p=0.004). The frequency of inferior vena cava filter placement was 40% in patients with major bleeding compared with 13% in those without major bleeding ( p=0.02). Massive PE (adjusted odds ratio 3.6; 95% confidence interval 1.01-12.9; p=0.049) and multiple venous access attempts (adjusted odds ratio 10.09; 95% confidence interval 1.98-51.46; p=0.005) were independently associated with an increased risk of major bleeding. In conclusion, strategies for improving venous access should be implemented to reduce the risk of major bleeding associated with ultrasound-facilitated, catheter-directed, low-dose fibrinolysis. ClinicalTrials.gov Identifier: NCT01513759; EKOS Corporation 10.13039/100006522.
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Cateterismo Periférico/efectos adversos , Fibrinolíticos/efectos adversos , Hemorragia/inducido químicamente , Embolia Pulmonar/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Fibrinolíticos/administración & dosificación , Hemorragia/diagnóstico , Hemorragia/epidemiología , Humanos , Incidencia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Embolia Pulmonar/diagnóstico , Punciones , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Intervencional , Estados Unidos/epidemiología , Filtros de Vena Cava/efectos adversosRESUMEN
OBJECTIVES: This study conducted a prospective, single-arm, multicenter trial to evaluate the safety and efficacy of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis, using the EkoSonic Endovascular System (EKOS, Bothell, Washington). BACKGROUND: Systemic fibrinolysis for acute pulmonary embolism (PE) reduces cardiovascular collapse but causes hemorrhagic stroke at a rate exceeding 2%. METHODS: Eligible patients had a proximal PE and a right ventricular (RV)-to-left ventricular (LV) diameter ratio ≥0.9 on chest computed tomography (CT). We included 150 patients with acute massive (n = 31) or submassive (n = 119) PE. We used 24 mg of tissue-plasminogen activator (t-PA) administered either as 1 mg/h for 24 h with a unilateral catheter or 1 mg/h/catheter for 12 h with bilateral catheters. The primary safety outcome was major bleeding within 72 h of procedure initiation. The primary efficacy outcome was the change in the chest CT-measured RV/LV diameter ratio within 48 h of procedure initiation. RESULTS: Mean RV/LV diameter ratio decreased from baseline to 48 h post-procedure (1.55 vs. 1.13; mean difference, -0.42; p < 0.0001). Mean pulmonary artery systolic pressure (51.4 mm Hg vs. 36.9 mm Hg; p < 0.0001) and modified Miller Index score (22.5 vs. 15.8; p < 0.0001) also decreased post-procedure. One GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries)-defined severe bleed (groin hematoma with transient hypotension) and 16 GUSTO-defined moderate bleeding events occurred in 15 patients (10%). No patient experienced intracranial hemorrhage. CONCLUSIONS: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis decreased RV dilation, reduced pulmonary hypertension, decreased anatomic thrombus burden, and minimized intracranial hemorrhage in patients with acute massive and submassive PE. (A Prospective, Single-arm, Multi-center Trial of EkoSonic® Endovascular System and Activase for Treatment of Acute Pulmonary Embolism (PE) [SEATTLE II]; NCT01513759).
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Cateterismo Periférico , Fibrinolíticos/administración & dosificación , Embolia Pulmonar/tratamiento farmacológico , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Terapia por Ultrasonido , Enfermedad Aguda , Adulto , Anciano , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/instrumentación , Cateterismo Periférico/mortalidad , Diseño de Equipo , Femenino , Fibrinolíticos/efectos adversos , Hemorragia/inducido químicamente , Humanos , Hipertensión Pulmonar/etiología , Hipertrofia Ventricular Derecha/etiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Embolia Pulmonar/complicaciones , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidad , Factores de Riesgo , Índice de Severidad de la Enfermedad , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/instrumentación , Terapia Trombolítica/mortalidad , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Terapia por Ultrasonido/efectos adversos , Terapia por Ultrasonido/instrumentación , Terapia por Ultrasonido/mortalidad , Estados Unidos , Dispositivos de Acceso VascularAsunto(s)
Angioplastia de Balón/métodos , Aorta Abdominal , Arteriopatías Oclusivas/cirugía , Enfermedad de la Arteria Coronaria/complicaciones , Stents , Aortografía , Arteriopatías Oclusivas/diagnóstico por imagen , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea , Factores de Riesgo , Índice de Severidad de la Enfermedad , Tomografía Computarizada por Rayos XRESUMEN
Chronic mesenteric ischemia (CMI) is a rare condition that is usually the result of atherosclerotic obstructive disease affecting the mesenteric arteries. The classic triad of post-prandial pain, food aversion and weight loss is not always present, often leading to low clinical suspicion for CMI and underdiagnosis. Non-invasive evaluation for CMI usually starts with mesenteric arterial duplex scanning, followed by computed tomography angiography, magnetic resonance angiography or conventional angiography, the latter being the gold standard for establishing its diagnosis. However, angiography alone has been demonstrated in coronary and other vascular beds to be inaccurate in predicting the physiologic and hemodynamic significance of a certain subset of atherosclerotic stenoses. We present the case of a patient with risk factors and symptoms suggestive of CMI who underwent angiography. However, angiography was equivocal and invasive physiologic testing was required to confirm the diagnosis and guide revascularization.
RESUMEN
Median arcuate ligament syndrome (MALS) is a rare clinical entity. This condition typically affects women between the ages of 20 and 40 years and causes symptoms of abdominal pain, primarily post-prandial, as well as nausea, vomiting and weight loss. MALS is considered a diagnosis of exclusion. Typically, mesenteric arterial duplex ultrasonography, computed tomography (CT), and magnetic resonance (MR) are highly suggestive, and conventional contrast angiography confirmatory. We explore the role of fractional flow reserve and intravascular ultrasound in the evaluation of MALS. In order to illustrate the utility of these tools, we present the case of a 47-year-old symptomatic woman who underwent angiography, complemented by assessment of fractional flow reserve and intravascular ultrasound. These data convincingly demonstrated the dynamic nature of the obstructive characteristic of MALS.
RESUMEN
Technical advances in temporary ventricular assist devices (VADs) continue to progress, allowing for percutaneous implantation during times of hemodynamic instability. However, device delivery systems, i.e., sheaths, lag in their ability to sustain the mechanical demands of these VADs for extended periods. We propose both a novel technique and the implementation of an emergency preparedness plan to be enacted specifically during those times when delivery systems fail thereby leading to potentially catastrophic bleeding complications.
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Cardiomiopatías/cirugía , Falla de Equipo , Exsanguinación/etiología , Corazón Auxiliar/efectos adversos , Trasplante de Corazón , Humanos , Masculino , Persona de Mediana EdadRESUMEN
As composition and design have improved the integrity and durability of peripheral stents, vascular stent fracture and embolization have become less frequent complications of endovascular intervention. However, this phenomenon still remains a possibility with potentially catastrophic consequences, either from damage to cardiac structures or from disruption of vessel integrity, infarction, and thrombosis. Advancements in the tools for foreign body retrieval have allowed the skilled interventionalist to intercede without the need for surgical intervention. We report the case of retrieval of a self-expandable SMART (Cordis, Florida) stent that was deployed for relief of superior vena cava syndrome but fractured and embolized to the right ventricle.
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Remoción de Dispositivos/métodos , Ventrículos Cardíacos , Falla de Prótesis/efectos adversos , Embolia Pulmonar/etiología , Stents/efectos adversos , Adulto , Humanos , Masculino , Síndrome de la Vena Cava Superior/terapiaRESUMEN
BACKGROUND: Complete device and lead removal is recommended for management of infected implantable cardiac device. Management of large lead vegetation (2 cm) is still in debate. METHODS: We report a series of patients involving percutaneous extraction of large vegetations (>2 cm) from ICD/pacing leads using the AngioVac Cannula in patients with infective endocarditis. This approach was used to debulk the ICD/pacing lead vegetations in order to minimize the risk of septic pulmonary embolism during lead explantation. CONCLUSION: AngioVac Cannula can be used safely and effectively as an adjunctive method for patients with large lead vegetation.
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Cateterismo Cardíaco/instrumentación , Catéteres , Desfibriladores Implantables , Remoción de Dispositivos/instrumentación , Electrodos Implantados , Endocarditis Bacteriana/cirugía , Cuerpos Extraños/cirugía , Atrios Cardíacos/cirugía , Marcapaso Artificial , Infecciones Relacionadas con Prótesis/cirugía , Succión/instrumentación , Anciano de 80 o más Años , Bacteriemia/diagnóstico , Bacteriemia/microbiología , Bacteriemia/cirugía , Conducta Cooperativa , Desfibriladores Implantables/microbiología , Ecocardiografía , Ecocardiografía Transesofágica , Electrodos Implantados/microbiología , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/microbiología , Diseño de Equipo , Femenino , Cuerpos Extraños/diagnóstico , Cuerpos Extraños/microbiología , Atrios Cardíacos/microbiología , Ventrículos Cardíacos/microbiología , Ventrículos Cardíacos/cirugía , Humanos , Comunicación Interdisciplinaria , Masculino , Staphylococcus aureus Resistente a Meticilina , Persona de Mediana Edad , Marcapaso Artificial/microbiología , Pacientes , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/cirugía , Staphylococcus aureus , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/microbiología , Infecciones Estreptocócicas/cirugía , Streptococcus agalactiaeRESUMEN
Vascular closure devices are commonly used to obtain arterial access site closure after cardiovascular procedures. They are popular as they decrease time to hemostasis and ambulation while improving patient comfort by eliminating need for compression. However, complications due to vascular closure devices are not uncommon. We report a case of possible intravascular distal embolization of water-soluble PEG polymer that is deployed extravascular using the Mynx vascular closure device.
Asunto(s)
Angiografía Coronaria/instrumentación , Embolia/etiología , Arteria Femoral/cirugía , Técnicas Hemostáticas/instrumentación , Anciano de 80 o más Años , Diseño de Equipo , Seguridad de Equipos , Femenino , Humanos , PolietilenglicolesRESUMEN
Acute pulmonary embolism (PE) is a common and potentially lethal condition. Anticoagulation is considered the mainstay therapy while systemic thrombolytic therapy is reserved only for patients who are hemodynamically unstable. However, therapy for PE with evidence of right ventricular strain is not well-defined. We report a case of PE treated successfully with an ultrasound-assisted catheter-directed thrombolytic therapy.