An unusual complication after transcatheter aortic valve implantation: a case report.

Background: Ventricular septal defect (VSD) is an unusual complication of transcatheter aortic valve implantation (TAVI). The risk factors are not well understood but may include oversizing, calcification amount and location, left-ventricular chamber morphology, and valve-in-valve (ViV) procedures. Percutaneous treatment is challenging but is usually the preferred option. Case summary: An 80-year-old woman with two previous surgical aortic valve replacements was admitted to our Cardiology Department for decompensated heart failure. New bioprosthesis degeneration (19 mm Mitroflow™, Sorin Group, Canada) was observed with severe intraprosthetic aortic regurgitation. After evaluation, the heart team chose to perform ViV TAVI. Because of the high risk of coronary obstruction, chimney stenting of both coronary arteries was performed. A 23 mm self-expandable Navitor™ valve (Abbott, IL, USA) was implanted, but the Mitroflow™ valve had to be cracked to minimize the persistent high gradient. During valve fracture, the non-compliant balloon broke and a small iatrogenic VSD appeared. However, the patient remained stable, so conservative management was selected. During follow-up, she developed severe haemolytic anaemia and heart failure; therefore, percutaneous closure of the iatrogenic VSD was performed twice, which was a difficult challenge. Discussion: A viable alternative to redo surgery is ViV TAVI. Risks include higher rates of prosthesis-patient mismatch and coronary obstruction. Occasionally, bioprosthetic valve fracture is required, particularly in small bioprostheses, to achieve low gradients. Anecdotally, fracture has led to annular rupture and VSD. Most VSDs are small and without clinical or haemodynamic repercussions; however, in symptomatic cases, percutaneous closure is a viable alternative to surgery.

Implante percutáneo de válvula pulmonar Melody por vía transhepática en paciente de ocho años / Percutaneous pulmonary Melody valve implantation through the transhepatic route in an 8-year-old patient

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Estimulación ventricular izquierda a través de la guía del implante percutáneo de válvula aórtica / Guidewire-driven left ventricular pacing during transcatheter aortic valve implantation

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Infecciones en dispositivos de estimulación cardiaca: diagnóstico y tratamiento en un centro de referencia / Infections in cardiac implantable electronic devices: diagnosis and management in a referral center

Introducción y objetivos: Las infecciones en dispositivos de electroestimulación cardiaca son cada vez más frecuentes debido a las indicaciones cada vez más amplias de estos sistemas. Algunos aspectos sobre su tratamiento son controvertidos y aportamos aquí nuestra amplia experiencia. Métodos: Se atendieron 325 infecciones (196 locales y 129 sistémicas) durante los años 1985 a 2015, el 28,5% de ellas procedentes de otros centros: 229 marcapasos, 69 desfibriladores automáticos implantables y 27 pacientes con terapia de resincronización cardiaca, con un seguimiento mínimo de 1 año tras el alta hospitalaria. Resultados: La tracción percutánea (TPC) fue la técnica utilizada más frecuentemente (n = 280), en infecciones tanto locales (n = 166) como sistémicas (n = 114), con una tasas de extracción completa del sistema del 82,5% del total y de curación, del 89%; las complicaciones fueron escasas (2 muertes achacables a la técnica). La mortalidad total fue del 1% en infecciones locales y el 8% en las sistémicas. Tras 212 TPC completas, se reimplantó un nuevo sistema contralateral en 209: en 152 de ellas en el mismo acto (73%) y en 57 en un segundo tiempo; no se apreciaron diferencias en el número de recidivas en el nuevo sistema (2 en 1 tiempo y 1 en 2 tiempos). Conclusiones: La TPC en manos expertas arroja buenos resultados en términos de eficacia, con escasas complicaciones. Se puede realizar el reimplante de dispositivos en un solo tiempo sin que ello conlleve un mayor riesgo de recidiva (AU)

Introduction and objectives: Infections in cardiac implantable electronic devices are increasing due to the expansion of the indications of these devices. The management of some aspects is controversial. Here, we report our broad experience. Methods: Between 1985 and 2015, 325 infections (196 local and 129 systemic) were registered; 28.5% of them were referred from other centers: 229 pacemakers, 69 implantable cardioverter-defibrillators, and 27 patients with cardiac resynchronization therapy. The follow-up was at least 1 year after hospital discharge. Results: Percutaneous traction (PCT) was the most frequent procedure (n = 280) in local (n = 166) and systemic infections (n = 114), with complete extraction of the system in 82.5% of the patients, clinical success in 89%, and few complications (2 deaths attributable to the technique). Overall mortality was 1% in local infections and 8% in systemic infections. After 212 complete PCT, a new device was placed in 209: of these, a contralateral system was implanted in the same procedure in 152 (73%) and in a second procedure in 57, with no differences in relapses (2 in the 1-stage procedure, and 1 in the 2-stage procedure). Conclusions: Percutaneous traction in experienced hands has good results with very few complications. It is possible to perform contralateral implantation of the new device on the same day without increasing the risk of relapse (AU)

Infections in Cardiac Implantable Electronic Devices: Diagnosis and Management in a Referral Center.

INTRODUCTION AND OBJECTIVES: Infections in cardiac implantable electronic devices are increasing due to the expansion of the indications of these devices. The management of some aspects is controversial. Here, we report our broad experience. METHODS: Between 1985 and 2015, 325 infections (196 local and 129 systemic) were registered; 28.5% of them were referred from other centers: 229 pacemakers, 69 implantable cardioverter-defibrillators, and 27 patients with cardiac resynchronization therapy. The follow-up was at least 1 year after hospital discharge. RESULTS: Percutaneous traction (PCT) was the most frequent procedure (n=280) in local (n=166) and systemic infections (n=114), with complete extraction of the system in 82.5% of the patients, clinical success in 89%, and few complications (2 deaths attributable to the technique). Overall mortality was 1% in local infections and 8% in systemic infections. After 212 complete PCT, a new device was placed in 209: of these, a contralateral system was implanted in the same procedure in 152 (73%) and in a second procedure in 57, with no differences in relapses (2 in the 1-stage procedure, and 1 in the 2-stage procedure). CONCLUSIONS: Percutaneous traction in experienced hands has good results with very few complications. It is possible to perform contralateral implantation of the new device on the same day without increasing the risk of relapse.

Severe thrombocytopenia induced by iodinated contrast after coronary angiography: The use of gadolinium contrast and intravascular ultrasound as an alternative to guide percutaneous coronary intervention.

Acute contrast-induced thrombocytopenia is a rare event with the use of modern low osmolarity iodinated contrast media. The pathophysiological mechanism that causes platelet counts to drop has not been identified, but an immunological mechanism is suspected due to cytotoxicity after previous exposure to contrast. We report the case of a 47-year-old male patient with acute severe thrombocytopenia due to iodinated contrast media exposure. His platelet count after the procedure with the highest amount of contrast was zero, which is the lowest reported platelet count to date. Percutaneous coronary revascularization under both intravascular ultrasound and gadolinium contrast guidance was performed without complications. The most feared complication after the use of gadolinium is nephrogenic systemic fibrosis, especially in patients on hemodialysis.

VERifyNow in DIabetes high-on-treatment platelet reactivity: a pharmacodynamic study on switching from clopidogrel to prasugrel.

INTRODUCTION: Diabetic patients with an acute coronary syndrome undergoing percutaneous coronary intervention frequently exhibit high platelet reactivity while on clopidogrel. We hypothesized that in diabetic patients undergoing percutaneous coronary intervention, who exhibit high-platelet-reactivity after standard treatment with clopidogrel, a 60-mg prasugrel loading dose is superior to standard treatment with clopidogrel for optimal P2Y12 inhibition within the first 24-36 h post-angioplasty. METHODS: VERDI was a prospective, randomized, single-centre, single-blind, parallel-design study (NCT01684813). Consecutive diabetic patients with an non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention and loaded with clopidogrel were considered for platelet reactivity assessment immediately before angioplasty with the VerifyNow assay measured in P2Y12 reaction units (PRU). Fifty of 63 screened patients (79.4%) had high platelet reactivity (PRU ≥ 208) and were randomized to receive a 60-mg prasugrel loading dose (n = 25) versus clopidogrel standard dose (n = 25). Platelet function was assessed again 24 hours post-angioplasty. RESULTS: Prasugrel achieved greater platelet inhibition than clopidogrel 24 hours post-angioplasty (median [interquartile range], 38 [9-72] vs 285 [240-337], respectively; P < 0.001). The non-high-platelet-reactivity rate (PRU < 208) at 24 h post-angioplasty (primary end point) was higher with prasugrel; 25 patients (100%) in the prasugrel group achieved optimal antiaggregation vs 4 patients (16%) in the clopidogrel group (P < 0.001). No significant acute bleeding was documented in either group. CONCLUSION: Among type 2 diabetic patients suffering an acute coronary syndrome with high-platelet-reactivity undergoing percutaneous coronary intervention, switching from clopidogrel to prasugrel was superior to standard treatment with clopidogrel for the achievement of optimal antiaggregation within the first 24 hours post-angioplasty.

Spontaneous coronary dissection and its long-term prognostic implications in a cohort of 19 cases.

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. It mainly affects women with no significant cardiovascular risk factors and its presentation varies from unstable angina to sudden death. Knowledge of the condition is based only on individual case reports and the lack of large case series means that its treatment and prognostic implications have not been fully established. We present data on 19 instances of spontaneous coronary artery dissection in 18 patients who were treated at our center between May 1998 and January 2009. The median follow-up period was 3.8 years (interquartile range: 1.3-4.6 years). Once the acute phase had passed, the prognosis was favorable and there were no implications for functioning. One patient presented with a relapse in another coronary artery and another patient gave birth without complications 3 years after the dissection.

Disección coronaria espontánea y sus implicaciones pronósticas a largo plazo en una cohorte de 19 casos / Spontaneous coronary dissection and its long-term prognostic implications in a cohort of 19 cases

La disección coronaria espontánea es una causa infrecuente de síndrome coronario agudo que afecta predominantemente a mujeres sin apenas factores de riesgo cardiovascular y cuya presentación varía desde la angina inestable hasta la muerte súbita. Los conocimientos de esta entidad se reducen a casos clínicos aislados, y la ausencia de grandes series hace que su tratamiento y sus implicaciones pronósticas no estén plenamente establecidos. Presentamos los datos de 19 casos en 18 pacientes atendidos en nuestro centro desde mayo de 1998 hasta enero de 2009, con una mediana [intervalo intercuartílico] de 3,8 [1,3-4,6] años de seguimiento. Una vez superada la fase aguda, el pronóstico fue favorable sin implicaciones funcionales. Una paciente presentó una recidiva en una coronaria diferente y otra paciente dio a luz sin complicaciones a los 3 años de la disección (AU)

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. It mainly affects women with no significant cardiovascular risk factors and its presentation varies from unstable angina to sudden death. Knowledge of the condition is based only on individual case reports and the lack of large case series means that its treatment and prognostic implications have not been fully established. We present data on 19 instances of spontaneous coronary artery dissection in 18 patients who were treated at our center between May 1998 and January 2009. The median follow-up period was 3.8 years (interquartile range: 1.3-4.6 years). Once the acute phase had passed, the prognosis was favorable and there were no implications for functioning. One patient presented with a relapse in another coronary artery and another patient gave birth without complications 3 years after the dissection (AU)

Angina vasospástica secundaria a tirotoxicosis / No disponible

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