Transvenous Inoue balloon aortic valvuloplasty with intra-aortic balloon pump in treating cardiogenic shock due to critical calcific aortic stenosis.

A 90-year-old female with severe peripheral vascular disease developed cardiogenic shock (CS) due to critical aortic stenosis (AS). The balloon aortic valvuloplasty was emergently performed via transvenous and transseptal antegrade approach (ante-BAV), which saved arterial accesses for intra-aortic balloon pump (IABP) and enabled us to use the Inoue balloon. The IABP augmented systemic perfusions and controlled left heart filling pressures. Multiple times of inflations with stepwisely increased balloon diameters were performed under IABP support (ante-Inoue-BAV + IABP), resulting in remarkable improvements both in clinical and hemodynamic conditions. The ante-Inoue-BAV + IABP efficaciously and safely treats elderly CS-AS for an emergent hemodynamic stabilization.

[Pericardial Fenestration in a Patient with Myocardial Metastasis and Cardiac Tamponade after Surgery for Esophageal Cancer;Report of a Case].

We report a case of pericardial fenestration in a patient with myocardial metastasis and cardiac tamponade after surgery for esophageal cancer. A 66-year-old man had been suffering from orthopnea, hypotension and general malaise due to cardiac tamponade and heart failure. Esophagectomy was performed with substernal gastric tube reconstruction for advanced esophageal carcinoma. Nine months after the operation, heart failure developed, and myocardial and pericardial metastasis was subsequently detected. Subxiphoidal pericardiocentesis was abandoned due to the substernal gastric tube, and pericardial fenestration was performed through a small left anterior thoracotomy at the 5th intercostal space. His symptoms were ameliorated immediately and the procedure contributed greatly to maintain his quality of life. Preoperative computed tomography was useful for revealing the anatomical positions of the gastric tube and important vessels.

The Efficacy and Safety of Antegrade Inoue-Balloon Aortic Valvuloplasty to Treat Calcific Critical Aortic Stenosis.

BACKGROUND: Critical aortic stenosis (AS) with severe calcific degeneration often resists conventional retrograde percutaneous balloon aortic valvuloplasty (PBAV). To enhance therapeutic efficacy, a novel PBAV technique has been developed by utilizing a single Inoue balloon via an antegrade approach, performing multiple inflations with step-up increases (M-PBAV) of balloon diameter to the size of the surgical valve ring. PATIENTS AND METHODS: A total of 405 non-surgical patients with critical AS were treated by M-PBAV and the acute therapeutic response and long-term clinical course were evaluated; some patients underwent the procedure on two or three occasions. RESULTS: In a total of 456 procedures, mean transaortic valve pressure gradient improved from an initial 63.6 ± 17.3 mm Hg to 22.7 ± 8.9 mm Hg post PBAV (P<.01). Mean aortic valve area increased from an initial 0.55 ± 0.15 cm² to 0.98 ± 0.20 cm² immediately after M-PBAV (P<.01). Clinical symptoms (New York Heart Association [NYHA] class) improved over time. Prior to M-PBAV, baseline NYHA class I-II was 9.1%, and NYHA class III-IV was 90.9%. At 12 months post M-PBAV, mortality was 17.1%, with repeat M-PBAV plus surgical AVR at 12.7%, 10.5% NYHA class III-IV, and 59.6% NYHA class I-II. At 24 months post M-PBAV, mortality was 25.8%, with repeat PBAV plus surgical AVR at 19.0%, 8.8% NYHA class III-IV, and 46.2% NYHA class I-II. Adverse events related to the procedure included critical AR (0.5%), cardiac tamponade (1.8%), intraprocedure hemodynamic compromise requiring percutaneous cardiopulmonary support (0.5%), and reversible cerebral ischemia (1.3%). No myocardial infarct or vascular complications occurred. CONCLUSION: M-PBAV enhanced the therapeutic efficacy and procedural safety of valvuloplasty to treat severely calcified critical AS, and diversified its clinical roles.

A case of severe aortic valve stenosis including triple-vessel ischemic heart disease in which multidisciplinary percutaneous coronary intervention and balloon aortic valvuloplasty relieved low cardiac output syndrome.

The patient was an 80-year-old man with low cardiac output syndrome associated with triple-vessel ischemic heart disease and severe aortic stenosis (AS). Deeming the patient unprepared for surgery because of his deteriorated general condition, we decided to perform revascularization with a percutaneous coronary intervention associated with intra-aortic balloon pump (IABP) and treat the severe AS with percutaneous balloon aortic valvuloplasty (BAV). Complete revascularization was successfully achieved and BAV was performed, improving the aortic valve area from 0.58 to 0.92 cm(2) and the pressure gradient from 41 to 26 mmHg. Postoperative hemodynamics improved, and the IABP was successfully removed.

First clinical experience of the looped Inoue balloon technique for antegrade percutaneous balloon aortic valvuloplasty.

Balloon aortic valvuloplasty (BAV) has played a limited role in the management of patients with severe aortic stenosis. However, BAV is being performed more frequently these days with the emergence of transcatheter aortic valve implantation (TAVI). We previously described a technique named "looped Inoue balloon technique" to simplify the antegrade transvenous BAV by making a loop in the left atrium using two stylets. We present a case in which the looped Inoue balloon technique was successfully applied. The patient was an 83-year-old woman with progressive dyspnea due to severe aortic stenosis. The aortic valve area was 0.39 cm(2) with a mean transvalvular gradient of 46 mmHg. The patient was deemed high risk for surgical aortic valve replacement or TAVI in view of the multiple comorbidities and frailty. Antegrade BAV using the looped Inoue balloon technique was performed. The procedure was successful without any complications. The post procedural aortic valve area increased to 1.15 cm(2) with a mean pressure gradient of 23 mmHg. This is the first report of clinical use of the looped Inoue balloon technique for antegrade BAV.

[Aortic valve replacement for recurrent aortic stenosis after percutaneous transluminal balloon aortic valvuloplasty( PTAV) in a cancer patient].

We report a case of aortic valve replacement( AVR) for recurrent aortic stenosis(AS) after percutaneous transluminal balloon aortic valvuloplasty( PTAV) in a patient with left renal pelvis carcinoma. A 65-year-old female had been suffering from shortness of breath and syncope due to severe AS. She was considered to be a candidate for AVR. Preoperative examination revealed advanced left renal pelvis carcinoma that was a critical comorbidity for AVR. Ureteronephrectomy was also considered to be a contraindication. Despite conservative treatment, her condition was deteriorated. Emergency PTAV was performed when she was transferred to our hospital with circulatory shock. Her symptoms were ameliorated and left ureteronephrectomy was conducted 8 month after the PTAV. She was readmitted to our hospital 16 month after the PTAV and AVR was performed successfully.Antegrade transseptal PTAV is a very useful palliative therapy for AS with severe comorbidities as a bridge to surgery.

Early cerebral circulatory disturbance in patients suffering subarachnoid hemorrhage prior to the delayed cerebral vasospasm stage: xenon computed tomography and perfusion computed tomography study.

Subarachnoid hemorrhage (SAH) causes dynamic changes in cerebral blood flow (CBF), and results in delayed ischemia due to vasospasm, and early perfusion deficits before delayed cerebral vasospasm (CVS). The present study examined the severity of cerebral circulatory disturbance during the early phase before delayed CVS and whether it can be used to predict patient outcome. A total of 94 patients with SAH underwent simultaneous xenon computed tomography (CT) and perfusion CT to evaluate cerebral circulation on Days 1-3. Cerebral blood flow (CBF) was measured using xenon CT and the mean transit time (MTT) using perfusion CT and calculated cerebral blood volume (CBV). Outcome was evaluated with the Glasgow Outcome Scale (good recovery [GR], moderate disability [MD], severe disability [SD], vegetative state [VS], or death [D]). Hunt and Hess (HH) grade II patients displayed significantly higher CBF and lower MTT than HH grade IV and V patients. HH grade III patients displayed significantly higher CBF and lower MTT than HH grade IV and V patients. Patients with favorable outcome (GR or MD) had significantly higher CBF and lower MTT than those with unfavorable outcome (SD, VS, or D). Discriminant analysis of these parameters could predict patient outcome with a probability of 74.5%. Higher HH grade on admission was associated with decreased CBF and CBV and prolonged MTT. CBF reduction and MTT prolongation before the onset of delayed CVS might influence the clinical outcome of SAH. These parameters are helpful for evaluating the severity of SAH and predicting the outcomes of SAH patients.

Resveratrol protects against experimental stroke: putative neuroprotective role of heme oxygenase 1.

Epidemiological and experimental reports have linked mild-to-moderate wine and/or grape consumption to a lowered incidence of cardiovascular, cerebrovascular, and peripheral vascular risk. This study revealed that resveratrol, an enriched bioactive polyphenol in red wine, selectively induces heme oxygenase 1 (HO1) in a dose- and time-dependent manner in cultured mouse cortical neuronal cells and provides neuroprotection from free-radical or excitotoxicity damage. This protection was lost when cells were treated with a protein synthesis or heme oxygenase inhibitor, suggesting that HO1 induction is at least partially required for resveratrol's prophylactic properties. Furthermore, resveratrol pretreatment dose-dependently protected mice subjected to an optimized ischemic-reperfusion stroke model. Mice in which HO1 was selectively deleted lost most, if not all, of the beneficial effects. Together, the data suggest a potential intracellular pathway by which resveratrol can provide cell/organ resistance against neuropathological conditions.

The use of percutaneous suture-mediated closure for the management of 14 French femoral venous access.

BACKGROUND: Little has been reported regarding the utility or outcomes of femoral venous vascular closure using arterial suture closure devices. We describe results using a pre-closure approach with a 6 French (Fr) Perclose Closer S device in patients who underwent antegrade aortic valvuloplasty using 14 Fr percutaneous femoral venous access catheters. METHODS: Forty-five patients underwent antegrade aortic valvuloplasty and suture-mediated closure with a 6 Fr Perclose device. A 6 Fr Closer S suture device was preloaded into the femoral vein after 6 Fr sheath access, prior to insertion of a 14 Fr venous sheath. Upon completion of the procedure, the 14 Fr femoral venous sheath was removed through the existing sutures. RESULTS: Of 45 patients (mean age 82.4 years; 17 males), immediate hemostasis was achieved with percutaneous suture closure in 43 (95.6%). Only 2 failures occurred which were subsequently successfully treated with manual compression. No late access site bleeding occurred from sutured sites. In all other patients, hemostasis using a 6 Fr Perclose suture-mediated device was successful and immediate. There was no need for transfusion, no clinical venous thrombosis, and no infections occurred at the access site. Two hospital deaths were documented from causes unrelated to suture-mediated closure. CONCLUSIONS: In conjunction with 14-Fr size percutaneous sheaths during antegrade aortic valvuloplasty, percutaneous suturemediated closure is a highly effective method for achieving hemostasis. This has simplified postprocedural management in terms of early mobilization and diminished late access site bleeding.

Successful closure of a giant true saphenous vein graft aneurysm using the Amplatzer vascular plug.

An 85-year-old man was found to have a 9 cm diameter true aneurysm of an obtuse marginal saphenous vein graft. The graft was fed by a relatively narrow neck from the proximal remnant of the obtuse marginal graft 10 years after prior coronary artery bypass graft surgery. An Amplatzer vascular plug was used successfully to occlude the neck of the aneurysm. Follow-up CT scan 1 month afterward demonstrated retained contrast in the aneurysm, demonstrating complete occlusion between the aorta and aneurysm sac. Pressure recordings from within the aneurysm sac suggest bidirectional flow in the neck as the mechanism for the maintained patency of the aneurysm. The use of a vascular plug is an effective method for aneurysm occlusion when the anatomy is suitable.

Effectiveness of short-term treatment with nocturnal oxygen therapy for central sleep apnea in patients with congestive heart failure.

OBJECTIVES: To evaluate the short term effects of inhalation of oxygen at night in 51 patients with congestive heart failure (CHF) and sleep apnea syndrome (SAS). METHODS: Fifty-one patients with stable CHF (31 males, 20 females, mean age 79.0 +/- 11.9 years; brain natriuretic peptide level of > 100 pg/ml) were evaluated between September 2003 and August 2004, using a Morpheus monitor. The complication rate of SAS in patients with CHF was assessed and apnea hypopnea index, oxygen desaturation index 3%, heart rate, and autonomic nerve activity under room air compared to supplemental O2 (2 l/min) over two consecutive nights. RESULTS: Thirty-eight (75%)of the CHF patients had SAS. Of these SAS patients, 49% suffered from central SAS and 51% had obstructive SAS. Apnea hypopnea index and oxygen desaturation index 3% improved remarkably with supplemental oxygen (p < 0.001), in particular, the central SAS group demonstrated prominent improvement (p < 0.001). Obstructive SAS patients exhibited no significant changes (p = 0.3356), but tended to exacerbate the episodes of sleep apnea. Total heart rate was decreased (p = 0.0079). Nevertheless, heart rate variability analysis showed little effect of nocturnal oxygen therapy on the autonomic nervous system during sleeping. CONCLUSIONS: Nocturnal oxygen therapy improved the number of sleep apnea episodes and decreased total heart rate during sleep time for the CHF patients with central SAS, despite little influence on the autonomic nervous system, based upon assessment of heart rate variability. Obstructive SAS might exacerbate the episodes of sleep apnea.

Percutaneous balloon aortic valvuloplasty: antegrade transseptal vs. conventional retrograde transarterial approach.

Percutaneous balloon aortic valvuloplasty (BAV) has been limited predominantly to a palliative treatment for poor surgical candidates with critical aortic stenosis and multiple high-risk or comorbid conditions. The most commonly used technique for BAV is the retrograde approach, in which the balloon is passed via the femoral artery using 12-14 Fr sheaths. We compared an antegrade transseptal approach using the Inoue balloon vs. the retrograde transarterial approach using conventional balloons. The antegrade group had an improved acute hemodynamic outcome, including 20% additional increase of aortic valve area and 20% greater reduction of transaortic valve gradient compared to the retrograde approach. Preclosure with the Perclose device was used for the 14 Fr venous access sites, resulting in immediate hemostasis, minimizing the need for transfusion, and diminishing the period of bed rest. The improved acute efficacy and relative ease of venous access for the antegrade approach facilitate BAV by eliminating the need for large-caliber arterial access sheaths. The antegrade approach also incorporates technical elements necessary for percutaneous aortic valve replacement and may have expanded applications as an adjunct to this developing therapy. The impact of improved acute results on the long-term clinical outcome for this patient group will require further study.

Transcatheter creation of atrial septal perforation using a radiofrequency transseptal system: novel approach as an alternative to transseptal needle puncture.

Indications for the transseptal approach to the left side of the heart have recently broadened, as it provides a therapeutic access for both left-sided catheter ablation and also percutaneous transvenous valvular intervention. Despite rising demand for transseptal procedures, the technique and device used for this purpose have remained essentially unchanged over the past 4 decades. The possibilities of failure of puncturing distorted and thickened atrial septal tissue or risks of complications related to cardiac perforation remain limitations of the technique. A new radiofrequency catheter provides an alternative approach to create a controlled transseptal perforation. We applied this technique to a series of patients and evaluated its feasibility as an alternative to conventional transseptal needle puncture.