Aortic balloon valvuloplasty before transcatheter valve replacement in high-risk patients with aortic stenosis. Cardiac catheterization and echocardiographic hemodynamic study.

BACKGROUND: Balloon aortic valvuloplasty (BAV) has been revived as a bridge to transcatheter aortic valve replacement (TAVR). The aim of the current prospective study was to define a safe time period from BAV to TAVR and to determine hemodynamic variables that predict event-free survival after BAV. PATIENTS AND METHODS: The present prospective study included 68 consecutive patients with severe aortic stenosis who were treated initially with BAV from 2009 to 2012. Echocardiographic and invasive hemodynamic assessments were performed before BAV. The patients were followed up at regular intervals and events were defined as cardiac hospitalization or death. RESULTS: Invasive hemodynamic evaluation yielded more favorable results than echocardiographic assessment: aortic stenosis was less severe, cardiac output was higher, and pulmonary capillary wedge pressure (PCWP) was lower. Post-BAV event-free survival was 80.4 % at 30 days, 64.5 % at 6 months, 37 % at 1 year, 22.3 % at 2 years, and 9.3 % at 3 years. After excluding pre-discharge deaths (n = 7), the 30-day event-free survival rate was 90 %. Predictors of events after BAV were atrial fibrillation, cardiogenic shock, elevated euroSCORE (European System for Cardiac Operative Risk Evaluation), elevated PCWP, and elevated pulmonary artery systolic pressure. Invasively measured PCWP was the only independent predictor of events (hazard ratio, 1.07; 95 % confidence interval, 1.03-1.11; p = 0.001). CONCLUSION: A 30-day post-BAV period may be considered a bridge to TAVR. Furthermore, invasive assessment of PCWP before BAV is an independent hemodynamic predictor of events after BAV.

Embolization after percutaneous coronary intervention in acute coronary syndrome. Saphenous vein grafts versus native coronary arteries.

AIMS: The aim of this study was to assess the occurrence of distal embolization and to quantify the amount of embolic material captured during stent implantation in native coronary arteries, as compared with saphenous vein grafts (SVG) in patients at different time periods after an acute coronary syndrome. PATIENTS AND METHODS: In all, 104 patients presenting with unstable or stable angina underwent percutaneous coronary intervention (PCI) in 107 vessels and stent implantation in 112 lesions, 53 % of which were in SVG. RESULTS: Device deployment and retrieval was successful in 111 lesions. Embolic material was detected in 74 % of the protection devices. Early PCI, during a 2-week period after the last ischemic episode, was associated with larger embolic load, especially in the right coronary artery. The length of the lesion was the only preprocedural independent variable that was found to be a significant predictor for the presence of emboli (p = 0.002). The stent diameter and the maximum dilatation pressure were the two procedural variables found to be significant predictors for the presence of emboli (p = 0.025 and p = 0.008, respectively). The irregularity of the lesion and the number of stents deployed were found to have a predictive correlation to the total area of the embolic particles (p = 0.04 and p = 0.005, respectively). CONCLUSION: Distal embolization of atherosclerotic debris is a frequent phenomenon after PCI not only in SVG but also in native vessels. The amount of embolic material seems to be related to the atherosclerotic burden of the vessel and to the early timing of the procedure as related to acute coronary syndrome.

Pheochromocytoma crisis presenting with cardiogenic shock.

Pheochromocytoma is a catecholamine-secreting tumor of the adrenal glands whose typical presentation includes the triad of headache, palpitations, and diaphoresis. Pheochromocytoma crisis is an urgent medical condition whose diagnosis and management constitute a challenge for physicians. We present the case of a 55-year-old man who developed cardiogenic shock in the setting of a pheochromocytoma crisis. After stabilizing blood pressure with combined administration of α- and ß-blockers, the tumor was surgically removed. Our diagnostic and therapeutic challenges are discussed.

Coronary vessel perforation during balloon angioplasty: a case report.

Coronary perforation can be managed with prolonged balloon inflations, covered stents, or embolization of the vessel. We report on a case of a balloon-induced perforation of the distal left anterior descending artery, that was sealed by injecting preclotted autologous blood through the balloon catheter lumen at the site of the perforation. The patency of the distal vessel was maintained.

Stenting the distal anastomotic site of the left internal mammary artery graft: a case report.

The major problem associated with the long-term patency of the internal mammary artery graft is the early occurrence of stenosis usually at its distal anastomotic site; its management by balloon angioplasty has been associated with a high success rate. We report the case of an unsuccessful balloon angioplasty of an anastomotic stenosis of a left internal mammary artery graft that was successfully managed by stenting with one-half of a Palmaz-Schatz stent.

Use of half of the Palmaz-Schatz stent in a stent-related dissection.

The placement of a Palmaz-Schatz stent may be associated with the development of a dissection and this may increase the danger of coronary thrombosis. In this case report we describe the use of half of the Palmaz-Schatz stent to cover such a dissection. The use of the half stent, by reducing the amount of metal and stent overlapping, may reduce the incidence of thrombosis and restenosis.

Dynamic changes in left ventricular outflow tract flow velocities after amyl nitrite inhalation in hypertrophic cardiomyopathy.

Doppler echocardiography was performed in 21 patients with hypertrophic cardiomyopathy (HC), in nine patients with no evidence of left ventricular (LV) hypertrophy by two-dimensional echocardiography, and in five patients with systemic hypertension and concentric LV hypertrophy. The LV outflow tract (LVOT) peak velocity was recorded by continuous wave Doppler technique at rest and after amyl nitrite inhalation. The LVOT pressure gradient was calculated by the modified Bernoulli equation. A significant increase in heart rate and a drop in systolic blood pressure were observed in all patients after amyl nitrite inhalation; no adverse effects were encountered. The peak LVOT velocity and pressure gradient increased significantly after provocation in all patients, but the increase was much more pronounced in patients with HC (peak LVOT velocity increased from 2.2 +/- 0.8 to 4.3 +/- 1.0 m/sec and peak gradient increased from 22 +/- 17 to 78 +/- 36 mm Hg). The Doppler spectral signal in patients with HC demonstrated a characteristic contour, with peak velocity occurring in late systole. However, the observed increase in LVOT peak velocity was not statistically different between treated (with beta-blockers and calcium blockers) and untreated patients with HC. We conclude that LVOT peak velocity and pressure gradients in patients with HC can be readily assessed by Doppler echocardiography both at rest and after amyl nitrite inhalation. The dynamic changes in LVOT velocity induced by this provocation have certain characteristic features in obstructive HC but appear to be independent of the medical regimen used, at least in the dosages tested in our study.

Relation between myocardial thallium-201 kinetics during exercise and quantitative coronary angiography in patients with one vessel coronary artery disease.

This study examined the relation between the kinetics of thallium-201 and coronary stenosis in 30 patients with one vessel coronary artery disease; 25 patients had no visible collateral vessels. The myocardial thallium concentration in the postexercise images and percent washout were determined in the distribution of the diseased vessel and a normal vessel, and each was expressed as a ratio. Coronary stenosis was assessed as minimal diameter stenosis, minimal area stenosis and percent diameter stenosis. The correlations between the myocardial concentration ratio or washout ratio and the descriptors of coronary stenosis improved when the patients with collateral vessels were excluded. There were significant correlations between the myocardial thallium concentration ratio and minimal diameter stenosis (r = 0.73, p less than 0.001), minimal area stenosis (r = 0.72, p less than 0.001) and, to a lesser degree, percent diameter stenosis (r = -0.51, p less than 0.01). Similarly, there were significant correlations between washout ratio and minimal diameter stenosis (r = 0.50, p less than 0.01) and minimal area stenosis (r = 0.45, p less than 0.02) but not percent diameter stenosis (r = 0.37, p = 0.06). Thus, variation in thallium kinetics in relation to the severity of coronary stenosis can be demonstrated with conventional imaging in patients with one vessel disease. The myocardial thallium concentration and washout are physiologic expressions of the severity of perfusion deficit and are dependent on collateral flow. The myocardial thallium concentration ratio and washout ratio correlate better with minimal diameter and area stenosis than with percent diameter stenosis.

Coronary air embolism during coronary angioplasty.

A case is described in which the use of the Hartzler microcatheter during coronary angioplasty resulted in coronary air embolism. The recognition, prevention, and mechanism of this occurrence are discussed.

Coronary arteriographic findings in cocaine abuse-induced myocardial infarction.

A 31-year-old black man was admitted with an acute anterior myocardial infarction 20 minutes after IV cocaine abuse. Cardiac catheterization showed a totally occluded left anterior descending artery. Intracoronary and intravenous streptokinase resulted in thrombolysis: repeat angiography showed a normal anterior descending.

Determinants of abnormal blood pressure response to exercise in coronary artery disease.

This study assessed the determinants of exercise-induced abnormal systolic blood pressure (BP) response in 127 patients with documented coronary artery disease (CAD) who underwent exercise thallium-201 scintigraphy. Three types of systolic BP response to exercise were identified: an increase by more than 20 mm Hg (group I, n = 74); an increase by 20 mm Hg or less (group II, n = 36); and a decrease of at least 10 mm Hg (group III, n = 17). The 3 groups were not significantly different in age, gender or medications. The number of segments with perfusion defects was significantly higher in groups II and III than group I (group III, 2.9 +/- 1.5; group II, 2.9 +/- 2.1; and group I, 1.8 +/- 1.4, p = 0.009). Prior myocardial infarction, abnormal left ventricular ejection fraction, and multivessel CAD were more common in group III than in groups I and II. Stepwise discriminant analysis of 15 relevant clinical, angiographic and exercise scintigraphic descriptors showed that the number of thallium perfusion defects, abnormal LV ejection fraction at rest and multivessel CAD to be important predictors of hypotensive BP response. Multivariate analysis, however, showed that the number of thallium perfusion defects was the only important predictor of the hypotensive response. Thus, it is the functional significance of CAD assessed by the extent of thallium perfusion abnormalities rather than the extent of CAD or left ventricular dysfunction at rest that determines the systolic BP response to exercise.

Forward ejection fraction: a new index of left ventricular function in mitral regurgitation.

Previous studies have shown that a normal LVEF is not a reliable index of LV function in MR. We hypothesized that the forward EF, which is the forward stroke volume (measured by Fick or thermodilution) divided by end-diastolic volume (measured by contrast ventriculography) may be a useful index of LV function, since it represents LV emptying into the aorta. This index was examined in 54 patients with chronic MR who had normal EF (greater than or equal to 50%). There were significant correlations between the forward EF and the end-diastolic volume index (r = -0.69, p less than 0.001), end-systolic volume index (r = -0.64, p less than 0.001), cardiac index (r = 0.43, p less than 0.01), and the ratio of systolic pressure-to-end-systolic volume (r = 0.65, p less than 0.001). Patients were divided into two groups according to the forward EF: group I (n = 34) had forward EF less than or equal to 35%; and group II (n = 20) had forward EF greater than 35%. Of the 32 patients who subsequently underwent mitral valve replacement, 24 patients were in group I and eight patients were in group II. At a mean follow-up of 35 months, four patients died; all of them were in group I. Improvement in functional class occurred in 75% of surgical survivors (80% in group I and 63% in group II, p = NS). These preliminary data suggest that forward EF may be a useful index of LV performance in patients with MR who have normal EF.