Giant Coronary Aneurysm with Coronary-Pulmonary Artery Fistula in a Jehovah's Witness.

With an incidence of 3 in 100 million, giant coronary artery aneurysm (CAA) with coronary artery fistula (CAF) is a very rare condition. To prevent rupture, giant CAA with CAF should be swiftly treated. We present a Jehovah's Witness patient with giant CAA and coronary-pulmonary artery fistula. We resected the giant CAA in one piece, while ligating the CAF, without allogeneic blood transfusion. Due to rarity of these conditions, many thoracic surgeons lack direct experience in its surgical procedures. Herein, we share footage of this surgery as an example of how to safely resect CAA with minimal bleeding.

Transcatheter aortic valve implantation with a balloon-expandable prosthesis in a patient with single coronary artery: a case report.

Background: Single coronary artery is a rare coronary artery anomaly with an incidence of <0.03%. The coexistence of coronary artery anomalies with severe aortic stenosis is extremely rare. Due to the singularity of the coronary artery orifice, the most concerning risk of transcatheter aortic valve implantation (TAVI) in such patients is coronary occlusion, which may very well be life-threatening. Case summary: An 83-year-old female complaining of chest pain was referred to our hospital for severe aortic stenosis. The multi-slice computed tomography showed a congenital single coronary artery originating from the right sinus of Valsalva. The left coronary artery branched off of the right coronary artery, and passed between the aorta and main pulmonary artery. The heart team of the hospital decided to perform TAVI via femoral artery with a balloon-expandable prosthesis, with coronary angioplasty devices on standby in case of coronary occlusion. The TAVI procedure was performed successfully without coronary occlusion. Discussion: Although there have been some case reports of TAVI in patients with single coronary artery, little is known about the safety of TAVI in such cases, and which device (such as the balloon-expandable or the self-expandable prosthesis) is preferable. From this particular case, and accumulation of past and various TAVI experience, the balloon-expandable prosthesis can be a safe device choice in carefully selected patients with coronary artery anomalies.

Evolut Self-Expanding Transcatheter Aortic Valve Replacement in Patients with Extremely Horizontal Aorta (Aortic Root Angle ≥ 70°).

Because of its rigidity and non-steerability, the presence of a horizontal aortic root poses a major anatomical issue during transcatheter aortic valve replacement (TAVR) with Evolut self-expanding valve. Previous studies have elucidated the difficulties of coaxial implantation of the self-expanding valve in patients with horizontal aorta, often resulting in increased complications and a lower device success rate. To date, most patients with extremely horizontal aorta (aortic root angle ≥ 70°) have been excluded from major TAVR clinical trials. Therefore, available data on TAVR with Evolut in this challenging anatomy are limited, and standardized treatment strategies and clinical results remain unknown. Herein, we report a clinical case series of TAVR with Evolut in extremely horizontal aorta. Among seven patients (aged 80-92 years; STS score, 12.6% ± 7.9%) who underwent TAVR with Evolut system, aortic root angle ranged from 71° to 83° (mean, 75.1°± 4.5°). All patients achieved device success with dedicated strategies and were clinically stable at 3-month follow-up. None of the patients had more than mild paravalvular leakage (PVL) at any point during follow-up.Complications in three patients included complete atrioventricular block requiring a permanent pacemaker implantation, cerebral infarction because of atrial fibrillation 3 days after TAVR, and cardiac tamponade requiring pericardiocentesis. In this case series, Evolut self-expanding TAVR in extremely horizontal aorta was effective and feasible with a high device success rate. Based on anatomical features, some dedicated strategies majorly contribute to the success of this procedure. Large-scale multicenter studies are required to confirm our findings.

Left Ventricular Outflow Tract Migration of a Balloon-Expandable Prosthesis During Transcatheter Aortic Valve Implantation.

Valve migration into the left ventricular outflow tract (LVOT) during transcatheter aortic valve implantation (TAVI) is a life-threatening complication. An 89-year-old female patient was admitted for TAVI due to severe symptomatic aortic stenosis. After deployment of a balloon-expandable prosthesis, the prosthesis had migrated into the LVOT. The prosthesis was reimpacted to the aortic annulus by a balloon-assisted recapture procedure. Immediately after recapturing the prosthesis with an oversized balloon, the patient's vital signs deteriorated due to acute aortic regurgitation (AR), and a prompt valve-in-valve (V-in-V) procedure allowed us to stabilize the patient's condition. This is the first reported case of a V-in-V procedure using an oversized balloon and a larger prosthesis to treat migration of the initial prosthesis into the LVOT. Balloon recapture and V-in-V procedure using an oversized balloon and larger prosthesis for a migrated balloonexpandable prosthesis into the LVOT is feasible, but hemodynamic support should be prepared before recapture and Vin-V because overdilatation of the first prosthesis might cause hemodynamic collapse due to severe AR.

[Discrete Subaortic Stenosis in an Adult; Report of a Case].

Discrete subaortic stenosis (DSS) is a well-described cause of isolated left ventricular outflow tract obstruction( LVOTO) in children. But prevalence, rate of progression and postoperative data in adults are limited. We report a case of a 30-year-old woman, who was referred to our institution because of chest pain and loss of consciousness. Echocardiography revealed DSS with LVOTO (peak gradient 81 mmHg) and mild aortic regurgitation. Increased age at the time of diagnosis, female sex and preoperative left ventricular outflow tract(LVOT) gradient ≥80 mmHg were thought to be predictors for reoperation, therefore the obstructing membrane was circumferentially excised and concomitant localized myectomy of the ventricular septum was performed to achieve complete relief of the LVOT obstruction. Her postoperative course was uneventful, and she was discharged on the 5th postoperative day.

The Speckle Tracking Imaging for the Assessment of Cardiac Resynchronization Therapy (START) study.

BACKGROUND: We sought to identify the feasibility of speckle tracking echocardiography (STE) to predict cardiac resynchronization therapy (CRT) responders in a prospective multicenter study. METHODS AND RESULTS: Patients who were newly implanted with a CRT device were enrolled. Time (T) from QRS to maximum peak radial and circumferential strain (CS) in 6 segments on the left ventricular (LV) short-axis plane, and to the maximum peak of longitudinal strain in 18 segments on 3 apical LV planes was measured (Tmax). In segments with multiple peaks on the time-strain curves, time to the first peak (Tfirst) was also assessed. Difference in T between the earliest and latest segment and standard deviation (SD) of T in each strain component were assessed. CRT responders were defined as having LV end-systolic volume reduction >15% at 6 months after CRT. Clinical outcomes were assessed with a composite endpoint of death from cardiac causes or unplanned hospitalization for heart failure. Among 180 patients, 109 patients were identified as responders. Tfirst-SD of CS >116 ms was selected as the best independent predictor of CRT responders (P<0.001, hazard ratio=9.83, 95% confidence interval 3.78-25.6). In addition, Tfirst-SD of CS was associated with the clinical endpoints. CONCLUSIONS: This prospective multicenter study revealed the high feasibility of dyssynchrony assessment by STE, which may improve the ability to predict CRT responders.

Impact of energy loss index and valvuloarterial impedance in patients with aortic stenosis using three-dimensional echocardiography.

BACKGROUND: Energy loss index (ELI) and valvuloarterial impedance (Z(va)) have been evaluated with a lack of three-dimensional (3D) information regarding the left ventricular outflow tract (LVOT) and sino-tubular junction (STJ). Our aim of this study is to compare the difference of ELI and Z(va) between two-dimensional (2D) and 3D echocardiography. METHODS: In 74 patients with moderate-to-severe aortic stenosis, the effective orifice area index (EOAI: EOA/body surface area) was calculated by continuity equation based on both 2D transthoracic echocardiography (2DTTE) and 3D transesophageal echocardiography (3DTEE). The areas of the LVOT and the STJ were calculated with the assumption of π × (dimension/2)(2) by 2DTTE and were measured directly by 3DTEE. Severe AS was defined as EOAI or ELI <0.6 cm(2) /m(2) or Z(va) ≥ 4.5 mmHg/mL per m(2) . RESULTS: Both the LVOT and STJ were elliptical, and LVOT was more elliptical than STJ. The ELI by 3DTEE (0.58 cm(2) /m(2) [median]) was larger than the other 3 values: EOAI on 2DTTE = 0.41, P < 0.01; EOAI on 3DTEE = 0.49, P < 0.01; and ELI on 2DTTE = 0.49, P < 0.01. Furthermore, Z(va) by 2DTTE, 4.7 mmHg/mL per m(2), was larger than that by 3DTEE (3.8, P < 0.01). CONCLUSIONS: 2DTTE underestimated EOAI and ELI relative to 3DTEE and overestimated Z(va) relative to 3DTEE.

Aortic annular sizing for transcatheter aortic valve replacement using cross-sectional 3-dimensional transesophageal echocardiography.

OBJECTIVES: This study compared cross-sectional three-dimensional (3D) transesophageal echocardiography (TEE) to two-dimensional (2D) TEE as methods for predicting aortic regurgitation after transcatheter aortic valve replacement (TAVR). BACKGROUND: Data have shown that TAVR sizing using cross-sectional contrast computed tomography (CT) parameters is superior to 2D-TEE for the prediction of paravalvular aortic regurgitation (AR). Three-dimensional TEE can offer cross-sectional assessment of the aortic annulus but its role for TAVR sizing has been poorly elucidated. METHODS: All patients had severe symptomatic aortic stenosis and were treated with balloon-expandable TAVR in a single center. Patients studied had both 2D-TEE and 3D imaging (contrast CT and/or 3D-TEE) of the aortic annulus at baseline. Receiver-operating characteristic curves were generated for each measurement parameter using post-TAVR paravalvular AR moderate or greater as the state variable. RESULTS: For the 256 patients studied, paravalvular AR moderate or greater occurred in 26 of 256 (10.2%) of patients. Prospectively recorded 2D-TEE measurements had a low discriminatory value (area under the curve = 0.52, 95% confidence interval: 0.40 to 0.63, p = 0.75). Average cross-sectional diameter by CT offered a high degree of discrimination (area under the curve = 0.82, 95% confidence interval: 0.73 to 0.90, p < 0.0001) and mean cross-sectional diameter by 3D-TEE was of intermediate value (area under the curve = 0.68, 95% confidence interval: 0.54 to 0.81, p = 0.036). CONCLUSIONS: Cross-sectional 3D echocardiographic sizing of the aortic annulus dimension offers discrimination of post-TAVR paravalvular AR that is significantly superior to that of 2D-TEE. Cross-sectional data should be sought from 3D-TEE if good CT data are unavailable for TAVR sizing.

Echocardiographic evaluation of iatrogenic atrial septal defect after catheter-based mitral valve clip insertion.

The geometries and sizes of persistent iatrogenic atrial septal defects (IASDs) after transseptal puncture during catheter-based mitral valve clip insertion (MVCI) have not been detailed. In this study, 11 IASDs were investigated in 10 patients who underwent MVCI using a guide catheter (24Fr proximally and 22Fr at the atrial septum). The diameters of the long and short axes and the area at maximum and minimum during a cardiac cycle were measured after MVCI using real-time 3-dimensional (RT3D) transesophageal echocardiography (TEE). A circular shape was assumed on 2-dimensional TEE, resulting in an area calculation of π × (dimension/2)(2). The anatomic geometries of IASDs were visualized in a 3-dimensional en face view of the atrial septum. Furthermore, 1 month after MVCI, IASDs were evaluated using echocardiography. The IASDs had a variety of irregular geometries. The mean long-axis diameter was 1.0 ± 0.24 cm, the mean short-axis diameter was 0.51 ± 0.22 cm, and the mean area was 0.40 ± 0.24 cm(2) on RT3D TEE. The diameters and area changed significantly between the maximal and minimal values during the cardiac cycle. Importantly, 2-dimensional TEE underestimated the maximal diameters of IASDs (0.54 ± 0.17 vs 1.0 ± 0.24 cm by RT3D TEE, p <0.01) and the maximal areas of IASDs (0.25 ± 0.15 vs 0.40 ± 0.23 cm(2) by RT3D TEE, p <0.05). One month after MVCI, the smallest and the second smallest IASDs had closed, and the other 9 remained open. In conclusion, RT3D TEE is useful to assess the irregular geometries of IASDs created during MVCI.

Cross-sectional computed tomographic assessment improves accuracy of aortic annular sizing for transcatheter aortic valve replacement and reduces the incidence of paravalvular aortic regurgitation.

OBJECTIVES: In an effort to define the gold standard for annular sizing for transcatheter aortic valve replacement (TAVR), we sought to critically analyze and compare the predictive value of multiple measures of the aortic annulus for post-TAVR paravalvular (PV) regurgitation and then assess the impact of a novel cross-sectional computed tomographic (CT) approach to annular sizing. BACKGROUND: Recent studies have shown clear discrepancies between conventional 2-dimensional (2D) echocardiographic and CT measurements. In terms of aortic annular measurement for TAVR, such findings have lacked the outcome analysis required to inform clinical practice. METHODS: The discriminatory value of multiple CT annular measures for post-TAVR PV aortic regurgitation was compared with 2D echocardiographic measures. TAVR outcomes with device selection according to aortic annular sizing using a traditional 2D transesophageal echocardiography-guided or a novel CT-guided approach were also studied. RESULTS: In receiver-operating characteristic models, cross-sectional CT parameters had the highest discriminatory value for post-TAVR PV regurgitation: This was with the area under the curve for [maximal cross-sectional diameter minus prosthesis size] of 0.82 (95% confidence interval: 0.69 to 0.94; p < 0.001) and that for [circumference-derived cross-sectional diameter minus prosthesis size] of 0.81 (95% confidence interval: 0.7 to 0.94; p < 0.001). In contrast, traditional echocardiographic measures were nondiscriminatory in relation to post-TAVR PV aortic regurgitation. The prospective application of a CT-guided annular sizing approach resulted in less PV aortic regurgitation of grade worse than mild after TAVR (7.5% vs. 21.9%; p = 0.045). CONCLUSIONS: Our data lend strong support to 3-dimensional cross-sectional measures, using CT as the new gold standard for aortic annular evaluation for TAVR with the Edwards SAPIEN device.

Time-dependent variation in coronary flow velocity reserve induced by adenosine triphosphate: comparison to low-dose dipyridamole.

BACKGROUND: Measuring the coronary flow velocity reserve (CFVR) by transthoracic Doppler echocardiography (TTDE) has been widely performed using adenosine. Although adenosine infusion is known to induce transient variation of hyperemia, the timing to measure the CFVR has not been well addressed. Therefore, we aimed to clarify the difference between the peak CFVR and at 2 min following adenosine triphosphate (ATP) infusion compared to the CFVR after low-dose dipyridamole infusion. METHODS AND RESULTS: A total of 26 patients with coronary artery diseases underwent TTDE. The coronary flow velocity (CFV) of the left anterior descending artery (LAD) was monitored during ATP infusion at 0.14 mg/kg/min. The CFVR was measured both at the first peak and at 2 min following ATP infusion, and after dipyridamole infusion at 0.56 mg/kg/min for 4 min. The first peak of hyperemia occurred 63.7 ± 8 s after starting ATP infusion. The value of the peak CFVR was significantly higher than the CFVR at 2 min following ATP stress, which was equivalent to the CFVR after dipyridamole infusion (2.30 ± 0.92, 1.83 ± 0.77, and 1.70 ± 0.68, respectively, P < 0.001). Applying a cut-off value of 2.0 to predict angiographic LAD stenosis, the CFVR at 2 min following ATP stress was significantly correlated to the angiographic findings. However, the peak CFVR after ATP infusion did not correlate with the angiographic findings. CONCLUSIONS: During ATP infusion, the peak CFVR was significantly higher than the CFVR at 2 min, which was equivalent to the CFVR after low-dose dipyridamole. This finding should be considered for the standardization of CFVR measurements.

[Cardiac resynchronization therapy].

Despite recent advances in pharmacologic treatment for heart failure, the prognosis of patients with chronic heart failure remains poor. One third of patients with chronic heart failure have intraventricular conduction delay. The ventricular mechanical dyssynchrony based on intraventricular conduction delay worsen ventricular systolic dysfunction. Cardiac resynchronization therapy(CRT) through biventricular pacing significantly improves symptoms, exercise tolerance, hemodynamics, hospitalization for heart failure and mortality. However, it is estimated that 30 % of patients do not respond to CRT. A direct assessment of mechanical dyssynchrony with echocardiography seems more important than QRS duration in selecting appropriate patients for CRT.