RESUMO
Background: The frozen elephant trunk (FET) technique as a hybrid combining surgical and endovascular repair is an emerging concept to treat complex aortic dissection. Early experience showed technical feasibility and promising clinical outcomes. However, unsuspected complications still arise. Case summary: A 25-year-old male presented to the emergency department with a 2-day history of chest pain. After exclusion of acute coronary syndrome, a computed tomography angiography (CTA) revealed Type A (DeBakey Type I) aortic dissection. The patient underwent median stenotomy for complete replacement of the ascending aorta, the aortic arch, and FET. Early after rewarming, the patient became unstable due to severe left ventricular dysfunction. Soon veno-arterial extracorporal membrane oxygenation (VA-ECMO) was required for circulatory support. The cause of deterioration remained unclear until repeated CTA showed acute obstruction of the FET. Invasive exploration confirmed a trans-FET gradient of 100â mmHg, successfully managed by repeated balloon inflation with resolution of both obstruction and gradient. The patient recovered completely without any sequela. Discussion: While the mechanism of acute obstruction after FET remains subject to speculation, the rescue intervention of ballooning the obliteration on VA-ECMO was life-saving. Intraoperative ultrasound and videoscopic inspection may be instrumental before chest closure to avoid such critical events.
RESUMO
Novel dedicated devices allow transcatheter treatment of pure aortic regurgitation (AR). The JenaValve Trilogy Heart Valve System was introduced as the first dedicated and on-label AR transcatheter aortic valve replacement system, implementing a locator-based and calcium-independent anchoring mechanism. Here, we present the first-in-human transcatheter aortic valve replacement for pure AR via a transcaval access in a patient with prohibitive alternative arterial accesses.
RESUMO
BACKGROUND: Non-hyperemic pressure ratios (NHPRs) like resting full-cycle ratio (RFR), diastolic pressure ratio during entire diastole (dPR[entire]) and diastolic pressure ratio during wave-free period (dPR[WFP]) are increasingly used to guide revascularization. The effect of NHPRs on mid-term prognosis has not been well established. OBJECTIVE: We investigated the prognostic implications of NHRPs in patients whose revascularization was deferred based on fractional flow reserve (FFR) in a single-centre population. METHODS: NHPRs and FFR were calculated offline from pressure tracings by an independent core laboratory. Follow-up data were acquired through records of hospital visits or telephone interviews. The primary outcome was a vessel-oriented composite outcome (VOCO) (a composite of cardiac death, vessel-related myocardial infarction, and ischemia-driven revascularization) in deferred vessels at 2 years. RESULTS: 316 patients with 377 deferred lesions were analysed. Discordance of NHPRs and FFR was found in 13.0-18.3% of lesions. The correlation coefficient between NHPRs was 0.99 (95% confidence interval 0.99-1.00). At 2 years, VOCO occurred in 19 lesions (5.0%). Estimated glomerular filtration rate < 30 mL/min/1.73 m2 [hazard ratio (HR) 5.7, p = 0.002], previous myocardial infarction (HR 3.3, p = 0.018), diabetes (HR 2.7, p = 0.042), RFR ≤ 0.89 (HR 2.7, p = 0.041) and dPR[WFP] ≤ 0.89 (HR 2.7, p = 0.049) were associated with higher incidence of VOCO at 2 years in the univariable analysis. A non-significant trend was found for dPR[entire] (HR 1.9, p = 0.26). CONCLUSION: A positive RFR or dPR[WFP] were associated with a worse prognosis in deferred lesions, suggesting that the use of NHPRs in addition to FFR may improve risk estimation.
