High risk of coronary artery obstruction during TAVR, how to avoid it?

BACKGROUND: Coronary artery obstruction after percutaneous aortic replacement is a complication with high short-term mortality secondary to the lack of timely treatment. There are various predictors of coronary obstruction prior to valve placement such as the distance from the ostia, the degree of calcification, the distance from the sinuses; In such a situation some measures must be taken to prevent and treat coronary obstruction. CASE PRESENTATION: An 84-year-old male, with severe aortic stenosis and high surgical risk, who was treated with TAVR. However, during the deployment of the valve he presented hemodynamic instability secondary to LMCA obstruction. The intravascular image showed obstruction of the ostium secondary to the displacement of calcium that he was successfully treated with a chimney stent technique. CONCLUSIONS: The high degree of calcification and the left ostium near the annulus are conditions for obstruction of the ostium at the time of valve release; In this context, provisional stenting prior to TAVR in patients at high risk of obstruction should be considered as a safe prevention strategy to achieve the success of the procedure.

King Ghidorah technique for a trifurcation lesion in a very high-risk NSTEMI.

A 66-year-old male Jehovah's Witness arrived at the emergency room having experienced typical persistent angina.

Transcatheter aortic valve replacement planning with cardiac computed tomography in quadricuspid aortic valve stenosis: a case series.

Background: The presence of severe aortic stenosis in quadricuspid aortic valve (QAV) is an extremely rare combination, and it is unknown whether transcatheter aortic valve replacement (TAVR) is a safe option due to the low incidence. Case summary: We present two patients diagnosed with severe aortic stenosis with QAV morphology type 1 (Nakamura classification). All patients presented to our hospital for evaluation because of worsening functional class, dyspnoea, or syncope. During tomographic planning, the aortic annulus was measured at the level of the deepest sinus for the selection of the number of devices. Due to the presence of four cusps, the smallest cusp was excluded, and three sinuses were virtualized for placement of the pigtail catheter during the procedure. Without complications, a 23 mm Edwards SAPIEN 3 was deployed through the femoral artery in both patients. Control aortography showed no valve leakage or regurgitation. Discussion: In patients with QAV and aortic stenosis undergoing TAVR, similar to the tricuspid valve, tomographic planning can be used to ensure the success of the procedure. However, unlike the tricuspid valve, where the selection of the device number is based on the measurements of the aortic annulus at the level of the non-coronary sinus, in these QAV cases, we perform the measurements at the level of the deepest aortic sinus (right coronary sinus).

Valve-in-valve as a rescue treatment in retrograde migration of the transcatheter aortic valve to the left ventricle: a case report.

Background: The treatment of choice for patients with severe symptomatic pure native aortic valve regurgitation (PNAVR) is surgical aortic valve replacement (SAVR). However, not all patients are candidates for surgery because of comorbidities or are deemed high risk for surgery. In such cases, transcatheter aortic valve replacement (TAVR) has proved to be better than medical treatment. Case summary: A 78-year-old male with a history of ankylosing spondylitis was admitted with New York Heart Association III heart failure. The echocardiogram showed severe aortic regurgitation and a left ventricular ejection fraction of 52%. Because of high surgical risk and being refractory to medical RX, he was accepted for TAVR. The tomography of anatomical characteristics reported the absence of calcium and dilation of the aortic ring and aortic root. During the TAVR procedure, the patient experienced valve migration, but it was autonomously repositioned in the aortic annulus. As a rescue measure, a second valve was placed. Here, we present a case of valve migration to the left ventricle treated with a valve-in-valve procedure without the need for surgical treatment. Discussion: The absence of annulus calcification in PNAVR increases the risk of post-TAVR paravalvular leak and device embolization. Valve migration generally requires valve recovery and conversion to SAVR.

Percutaneous mitral and tricuspid edge-to-edge repair as a bridge therapy to heart transplantation in advanced heart failure secondary to human immunodeficiency virus: a case report.

Background: Patients with end-stage heart failure (HF) and severe pulmonary hypertension (PH) are not eligible for heart transplant due to high mortality risk. Percutaneous interventions as edge-to-edge repair of the mitral/tricuspid valves are a safe and effective therapy as a bridge for transplantation in patients who have contraindications to heart transplantations (HTs). Case summary: A 44-year-old man with a previous diagnosis of infection by human immunodeficiency virus (HIV) was admitted at the emergency room for exertional dyspnoea. He was diagnosed with a decompensated heart failure with reduced ejection fraction (HFrEF), severe mitral and tricuspid regurgitation, and high probability of PH. He presented poor response to guided medical treatment, even after implantable cardiac resynchronization therapy defibrillator (CRT-D). He was listed for a cardiac transplant, but after right catheterization, he was not an ideal candidate for transplantation, so it was decided to undergo percutaneous mitral and tricuspid edge-to-edge repair as a bridge to transplantation. The post-operative course was uneventful, with significant improvement in New York Heart Association functional class. The patient underwent a successful heart transplant 10 months after the procedure. Discussion: In patients with advanced HF due to HIV, HT is an adequate treatment option. When there are functional mitral and tricuspid regurgitation and severe PH, despite optimal treatment according to current guidelines, percutaneous mitral and tricuspid repair therapy appears to be safe and effective for control of severe PH as a bridge measure for cardiac transplantation.

Complete revascularization with PCI in STEMI patients with multivessel disease, when is the appropriate time? / Revascularización completa mediante ICP en pacientes con STEMI y enfermedad coronaria multivaso, ¿cuál es el momento adecuado?

Abstract Objective: The purpose was to compare the outcomes of patients with ST-elevation myocardial infarction and multivessel coronary artery disease undergoing one-time multivessel revascularization (OTMVR) versus in-hospital staged complete revascularization with percutaneous coronary intervention. Methods: This was a single-center, retrospective, observational, and cohort study, including data from January 2013 to April 2019. A total of 634 patients were included in the study. Comparisons were made between patients who underwent in-hospital staged complete revascularization versus OTMVR. The primary endpoint was all-cause in-hospital mortality, secondary endpoints included cardiovascular complications, all-cause new hospitalization, and mortality evaluated at 30 days and 1 year. In addition, we constructed a logistic regression model for determining the risk factors that predicted mortality. Results: Of the 634 patients, 328 were treated with staged revascularization and 306 with OTMVR. About 76.7% were men, with a mean age of 63.3 years. Less complex coronary lesions and a higher proportion of the left anterior descending artery as the culprit vessel were found in the OTMVR group. Compared with staged revascularization, the primary and secondary endpoints occurred less frequently with OTMVR strategy. Conclusions: OTMVR did not generate more complications and demonstrate better clinical outcomes than in-hospital staged revascularization.

Resumen Objetivo: El propósito fue comparar resultados de pacientes con infarto agudo de miocardio con elevación del segmento ST y enfermedad coronaria multivaso sometidos a revascularización completa de un solo momento frente a revascularización completa por etapas mediante intervención coronaria percutánea. Métodos: Estudio cohorte observacional, retrospectivo, unicéntrico, con datos de enero de 2013 a abril de 2019, incluyendo 634 pacientes. Se compararon resultados entre pacientes sometidos a revascularización completa por etapas frente a revascularización completa en un solo momento. El objetivo primario fue valorar mortalidad intrahospitalaria por cualquier causa y como objetivos secundarios se evaluaron a 30 días y 1 año las complicaciones cardiovasculares, hospitalizaciones y mortalidad. Se construyó un modelo de regresión logística para determinar los factores de riesgo que predijeron mortalidad. Resultados: De 634 pacientes, 328 fueron tratados con revascularización por etapas y 306 con revascularización en una intervención. El 76.7% fueron hombres, con una media de edad de 63.3 años. En el grupo de revascularización de un solo tiempo se encontraron lesiones coronarias menos complejas y una mayor proporción de la arteria descendente anterior como vaso culpable. Comparado con el grupo de revascularización por etapas, los objetivos primarios y secundarios ocurrieron con menos frecuencia en el grupo de revascularización en un solo tiempo. Conclusiones: Comparada con la revascularización intrahospitalaria por etapas, la revascularización en una intervención lleva a mejores desenlaces clínicos sin generar más complicaciones.

Complete revascularization with PCI in STEMI patients with multivessel disease, when is the appropriate time? / Revascularización completa mediante ICP en pacientes con STEMI y enfermedad coronaria multivaso, ¿cuál es el momento adecuado?

Objective: The purpose was to compare the outcomes of patients with ST-elevation myocardial infarction and multivessel coronary artery disease undergoing one-time multivessel revascularization (OTMVR) versus in-hospital staged complete revascularization with percutaneous coronary intervention. Methods: This was a single-center, retrospective, observational, and cohort study, including data from January 2013 to April 2019. A total of 634 patients were included in the study. Comparisons were made between patients who underwent in-hospital staged complete revascularization versus OTMVR. The primary endpoint was all-cause in-hospital mortality, secondary endpoints included cardiovascular complications, all-cause new hospitalization, and mortality evaluated at 30 days and 1 year. In addition, we constructed a logistic regression model for determining the risk factors that predicted mortality. Results: Of the 634 patients, 328 were treated with staged revascularization and 306 with OTMVR. About 76.7% were men, with a mean age of 63.3 years. Less complex coronary lesions and a higher proportion of the left anterior descending artery as the culprit vessel were found in the OTMVR group. Compared with staged revascularization, the primary and secondary endpoints occurred less frequently with OTMVR strategy. Conclusions: OTMVR did not generate more complications and demonstrate better clinical outcomes than in-hospital staged revascularization.

Objetivo: El propósito fue comparar resultados de pacientes con infarto agudo de miocardio con elevación del segmento ST y enfermedad coronaria multivaso sometidos a revascularización completa de un solo momento frente a revascularización completa por etapas mediante intervención coronaria percutánea. Métodos: Estudio cohorte observacional, retrospectivo, unicéntrico, con datos de enero de 2013 a abril de 2019, incluyendo 634 pacientes. Se compararon resultados entre pacientes sometidos a revascularización completa por etapas frente a revascularización completa en un solo momento. El objetivo primario fue valorar mortalidad intrahospitalaria por cualquier causa y como objetivos secundarios se evaluaron a 30 días y 1 año las complicaciones cardiovasculares, hospitalizaciones y mortalidad. Se construyó un modelo de regresión logística para determinar los factores de riesgo que predijeron mortalidad. Resultados: De 634 pacientes, 328 fueron tratados con revascularización por etapas y 306 con revascularización en una intervención. El 76.7% fueron hombres, con una media de edad de 63.3 años. En el grupo de revascularización de un solo tiempo se encontraron lesiones coronarias menos complejas y una mayor proporción de la arteria descendente anterior como vaso culpable. Comparado con el grupo de revascularización por etapas, los objetivos primarios y secundarios ocurrieron con menos frecuencia en el grupo de revascularización en un solo tiempo. Conclusiones: Comparada con la revascularización intrahospitalaria por etapas, la revascularización en una intervención lleva a mejores desenlaces clínicos sin generar más complicaciones.

Cardioversión eléctrica de taquicardia ventricular en el embarazo: reporte de un caso / Electrical cardioversion of ventricular tachycardia in pregnancy: case report

Resumen ANTECEDENTES: Las arritmias cardiacas son complicaciones frecuentes durante el embarazo, la mayor parte son benignas y no requieren tratamiento complejo. Las taquicardias ventriculares idiopáticas suelen ser hemodinámicamente estables y se asocian con buen pronóstico. CASO CLÍNICO: Paciente de 22 años, con embarazo de 23 semanas, que inició con mareo y palpitaciones, por lo que acudió al servicio de Urgencias. El electrocardiograma de 12 derivaciones mostró una taquicardia de QRS amplio, con latidos de fusión y disociación auriculoventricular; el ecocardiograma no reportó alteraciones. El diagnóstico definitivo fue taquicardia ventricular fascicular posterior idiopática. El tratamiento inicial consistió en verapamil y amiodarona por 48 horas; sin embargo, persistió la taquicardia, por lo que se decidió realizar una cardioversión eléctrica con 200 Joules, con lo que se obtuvo una reacción satisfactoria. La paciente permaneció asintomática hasta la semana 31 del embarazo, cuando inició nuevamente con palpitaciones; se documentó la misma taquicardia, por lo que se decidió realizar un nuevo procedimiento de cardioversión eléctrica con 200 Joules, que resultó efectiva y sin complicaciones adicionales para la paciente. CONCLUSIONES: La incidencia de taquicardia ventricular idiopática durante el embarazo es relativamente baja. La cardioversión eléctrica es una opción efectiva en pacientes embarazadas con resistencia al tratamiento farmacológico o inestabilidad hemodinámica.

Abstract BACKGROUND: Cardiac arrhythmias are frequent complications in pregnancy, the most of them are benign and don't need specific treatment. Idiopathic ventricular tachycardia usually is hemodynamically stable and associate with a good prognosis. CLINICAL CASE: A 22-year-old woman with a current pregnancy of 23.4 weeks of gestation that began with dizziness and palpitations, she went to the emergency department, a 12-lead electrocardiogram showed a wide QRS tachycardia with fusion beats and atrioventricular dissociation, the echocardiogram was reported normal. Posterior fascicular ventricular idiopathic tachycardia was concluded. Initially, Verapamil and Amiodarone were administered for 48 hours, with tachycardia persisting, so it was decided to perform electrical cardioversion with 200 Joules that was effective. She remained asymptomatic until the 31st week of gestation where she started again with palpitations, the same tachycardia was documented and it was decided to perform again electrical cardioversion with 200 joules, being effective and without complications. CONCLUSIONS: Idiopathic ventricular tachycardia occurs with low frequency in pregnancy. When pharmacological therapy is not effective or there is hemodynamic instability, electrical cardioversion is a viable option in the pregnant patient.