Abnormal distortion of aortic corevalve bioprosthesis with suicide left ventricle, aortic insufficiency, and severe mitral regurgitation during transcatheter aortic valve replacement.

We present a patient with critical degenerative aortic stenosis, mitral annular and aortomitral continuity calcification, and senile sigmoid septal hypertrophy who underwent transcatheter aortic valve replacement using the CoreValve bioprosthesis. Immediately after predilation of the aortic valve (18-mm balloon), the patient developed severe hypotension and dynamic left ventricular outflow tract (LVOT) obstruction with systolic anterior motion of the anterior mitral leaflet, causing severe mitral regurgitation. After deployment of a 26-mm bioprosthesis, a transesophageal echocardiogram and left ventriculogram showed that the frame of the bioprosthesis appeared distorted and underexpanded. On the mitral side of the aorta (side of the aortomitral curtain between 12:00 and 3:00, echo short axis view), we found moderate periprosthetic aortic insufficiency with worse mitral regurgitation. The left ventricle was small and hyperdynamic (ejection fraction >85%). The patient soon developed complete heart block, atrial fibrillation, and ventricular tachycardia. She was resuscitated with aggressive intravenous fluids, vasopressors, and an emergently placed atrioventricular sequential pacemaker. We postdilated the 26-mm bioprosthesis with a 22-mm Z-Med balloon and subsequently with a 25-mm balloon. Each balloon was inflated to its nominal volume and pressure and conformed the nitinol frame of the valve to the net circular shape and expected diameter. However, as soon as each balloon was deflated, the surrounding aortic root anatomy visibly recoiled and the frame returned to its smaller diameter with a distorted shape. A second 26-mm CoreValve bioprosthesis was then deployed in a "valve-in-valve" configuration. Soon after, the patient's hemodynamics improved, her clinical condition stabilized, and she completely recovered. © 2016 Wiley Periodicals, Inc.

Percutaneous coronary intervention versus coronary artery bypass graft in chronic kidney disease: Optimal treatment options.

Chronic kidney disease (CKD) is ubiquitous in the world and may eventually progress to end-stage renal disease. CKD is associated with a greater risk of coronary artery disease (CAD) which is the leading cause of mortality in this population. Current invasive treatment options include percutaneous coronary intervention or coronary artery bypass graft. We performed a PubMed search to ascertain the optimal treatment for coronary artery disease in CKD. Our review of the current literature supports the superiority of coronary artery bypass grafting which reduces repeat revascularizations, improves angina symptoms, and increases long-term survival.

The development and application of the implantable cardioverter defibrillator.

Several years ago, implantable defibrillators were recommended only for survivors of cardiac arrest. With improvement of surgical techniques and advancement in technology, defibrillator implantation is now considered an outpatient procedure. Clinical trials have now demonstrated improvement in survival in high risk patients who receive defibrillators which has greatly increased the number of defibrillators implanted. This manuscript reviews important features of the development of implantable defibrillators and reviews current indications for use.

Advances in percutaneous coronary intervention in patients with chronic kidney disease.

Coronary artery disease is the number one cause of death in patients with chronic kidney disease (CKD). However,patients with impaired renal function are much less likely than patients with normal renal function to undergo left heart catheterization and coronary intervention. Patients that do receive invasive strategies experience more bleeding and higher rates of ischemic events. In this review, we examine advances in percutaneous coronary intervention--including antiplatelet therapy and drug-eluting stents--and their impact on patients with CKD.

Management of coronary artery disease in patients with chronic kidney disease.

Patients with chronic kidney disease (CKD) are considered to belong to the highest risk group for the development of cardiovascular events. These patients should be subject to aggressive risk-factor modification. However, management of coronary artery disease in patients with CKD can be uniquely challenging. Many of the medications used in the treatment and prevention of coronary artery disease are metabolized or excreted by the kidney. Thus, patients with CKD are more likely to experience adverse effects from any attempt to aggressively modify risk factors for coronary artery disease. Little is known regarding revascularization in patients with CKD. Patients with CKD may benefit from off-pump strategies during coronary artery bypass. Percutaneous coronary intervention in patients with CKD is associated with lower procedural success and increased peri-procedural myocardial infarction, ischemia, and target vessel revascularization. In this review, we discuss the unique challenges of managing coronary artery disease in patients with CKD.

Utility of echocardiography in the evaluation of coronary artery disease in patients with end-stage renal disease.

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular events. Echocardiography is an integral part of the evaluation of coronary artery disease. Chronic kidney disease has a predictable and unique effect on the myocardium and the epicardial circulation that may be detected by echocardiography. In particular dobutamine stress echocardiography has proved to be an invaluable tool in the detection of cardiovascular disease in patients with CKD. Here, we review the usefulness of echocardiography in the detection and evaluation of coronary artery disease in patients with CKD.

Assessing cardiovascular disease in the dialysis patient.

Cardiac causes account for nearly half of all deaths in patients with end-stage renal disease (ESRD). Coronary artery disease (CAD) is present in 38% - 40% of patients starting dialysis. Both traditional and chronic kidney disease-related cardiovascular risk factors contribute to this high prevalence rate. In patients with ESRD, CAD--particularly acute myocardial infarction--is underdiagnosed. Dobutamine stress echocardiography and, to a lesser extent, stress myocardial perfusion imaging have proved useful in screening for CAD in such patients. Coronary artery calcium scoring is less useful. Acute myocardial infarction is associated with high short- and long-term mortality in dialysis patients. Cardiac troponin I appears to be more specific than cardiac troponin T or CK-MB in the diagnosis of acute myocardial infarction.

Changing conduction abnormalities in a dialysis patient with fever.

A patient on hemodialysis with severe aortic valve disease and presumed arteriovenous fistula infection was found to have new-onset atrial fibrillation and alternating left and right bundle branch block patterns on serial electrocardiograms. These findings prompted transesophageal echocardiography, which revealed a large abscess involving the intervalvular fibrosa and the posterior cusp of the bicuspid aortic valve. Hence, basic bedside diagnostic skills remain important in the era of sophisticated imaging techniques and laboratory analyses.