Aortoseptal angle and pressure gradient reduction following balloon valvuloplasty in dogs with severe subaortic stenosis.

INTRODUCTION: To determine the relationship between aortoseptal angle (AoSA) and the short- and long-term systolic pressure gradient (PG) reduction following combined cutting and high-pressure balloon valvuloplasty (CB/HPBV) in dogs with severe subaortic stenosis. ANIMALS: Retrospective study of 22 client-owned dogs of various breeds with severe subaortic stenosis (mean left ventricular to aortic PG = 143 mmHg; range = 80-322 mmHg) that underwent CB/HPBV. MATERIALS AND METHODS: Initial angiographic and left apical and right-sided parasternal long-axis view echocardiographic video loops were used for measuring the angle between the plane of the interventricular septum and the longitudinal axis of the ascending aorta. The PG reduction ratio immediately after CB/HPBV and 6 and 12 months later were compared with AoSA. RESULTS: Weak correlations were observed for all instances of PG reduction ratio and AoSA type. Significantly greater mean differences of PG reduction ratio were observed for angles >160° than for angles <160° at 24 h (>160° mean: 54.45, standard error [SE]: ±3.8; <160° mean: 39.88, SE: ±2.09), 6 months (>160° mean: 57.73, SE: ±10.9; <160° mean: 28.22, SE: ±3.42), and 12 months (>160° mean: 76.11, SE: ±17.5; <160° mean: 27.61, SE: ±6.44; p=0.003). CONCLUSIONS: Dogs with AoSA >160° on right-sided parasternal long-axis view echocardiograms responded with a greater PG reduction following CB/HPBV than did dogs with AoSA <160°. This suggests that AoSA is associated with long-term outcomes of CB/HPBV, and measurement could help in the evaluation of dogs that are candidates for CB/HPBV.

Evaluación de la seguridad de la endarterectomía carotídea en nuestro servicio / Safety assessment of the carotid endarterectomy in our unit

OBJETIVO: El objetivo de este estudio es evaluar la seguridad de la endarterectomía carotídea (EAC) en pacientes sintomáticos y asintomáticos en nuestro servicio. PACIENTES Y MÉTODOS: Este estudio retrospectivo incluye un total de 266 procedimientos realizados en pacientes tanto sintomáticos como asintomáticos, con carácter programado. La seguridad se evaluó en términos de tasa de ictus/muerte e infarto agudo de miocardio (IAM) perioperatorio. RESULTADOS: Entre enero de 2005 y diciembre de 2012 se realizaron 266 EAC en 238 pacientes. La tasa de ictus/muerte global a los 30 días de la cirugía fue del 3%, siendo la de pacientes sintomáticos de un 4,5% y la de asintomáticos un 2,8%. Se observó un mayor riesgo de sangrado en pacientes tratados previamente con clopidogrel (OR: 3,85; IC: 1,05-11). CONCLUSIONES: Atendiendo a los criterios de calidad necesarios para realizar una EAC podemos concluir que, en nuestro servicio, este procedimiento es seguro y garantiza sus ventajas terapéuticas

OBJECTIVE: The aim of this study is to assess the safety of carotid endarterectomy (CEA) in symptomatic and asymptomatic patients in our department. PATIENTS AND METHODS: This retrospective study included a total of 266 programmed procedures performed in both symptomatic and asymptomatic patients. Safety was evaluated in terms of perioperative rate of stroke/death and acute myocardial infarction (AMI). RESULTS: Between January 2005 and December 2012, 266 CEAs were performed in 238 patients. The overall rate of stoke/death at 30 days after surgery was 3%, 4,5% in symptomatic patients and 2,8% in the asymptomatic cohort. An increased risk of bleeding was observed in patients previosly treated with clopidogrel (OR: 3,85 CI 1,5-11). CONCLUSIONS: Considering the quality criteria required to perform a carotid endarterectomy we can conclude that in our department, this procedure is safe and ensures its therapeutic benefits

Alcohol septal ablation as a bail-out procedure for suicide left ventricle after transcatheter aortic valve implantation.

With the advent of transcatheter aortic valve implantation (TAVI), many AS patients, formerly considered inoperable, can receive effective treatment. The relief of the left ventricular pressure overload could lead, in some cases, to the occurrence of dynamic intracavity pressure gradients (DIG) with deleterious clinical impact. This phenomenon resembles the physiology seen in hypertrophic obstructive cardiomyopathy. We report a case in which alcohol septal ablation was used as a bail-out therapy for the acutely developed intracavity obstruction after TAVI. Potential dynamic intracavity gradients should always be excluded in the acutely deteriorated patient postoperatively. Alcohol septal ablation can be considered as a salvage therapeutic tool when other therapies are ineffective to treat subvalvular obstruction.

Seguimiento a largo plazo tras el tratamiento percutáneo del tronco coronario izquierdo no protegido en pacientes de alto riesgo no aptos para cirugía de revascularización / Long-term follow-up after percutaneous treatment of the unprotected left main stenosis in high risk patients not suitable for bypass surgery

Introducción y objetivos. La intervención coronaria percutánea en pacientes con estenosis de tronco coronario izquierdo no protegido se recomienda en los casos que no son candidatos a cirugía de revascularización aortocoronaria. El seguimiento a largo plazo de estos pacientes continúa siendo incierto. Métodos. Se incluyó en el estudio a todos los pacientes consecutivos con un nuevo diagnóstico de estenosis de tronco coronario izquierdo no protegido tratados con implantación de stents. La indicación de la intervención coronaria percutánea se estableció según los criterios de asistencia estándar, teniendo en cuenta las condiciones clínicas y anatómicas desfavorables para la utilización de la cirugía de revascularización aortocoronaria. El objetivo de valoración principal es la aparición de eventos cardiacos adversos mayores, incluidos los casos de muerte, infarto agudo de miocardio no mortal y revascularización de la lesión diana. Resultados. Se incluyó en el análisis a un total de 226 pacientes consecutivos, de los que se trató a 202 (89,4%) con implantación de stents liberadores de fármacos. La media de edad era 72,1 años, el 41,1% de los pacientes tenían disfunción renal y las medias de la puntuación SYNTAX y del EuroSCORE fueron 28,9 y 7,4 respectivamente. Se alcanzó éxito angiográfico en el 99,6% de los pacientes y éxito de la intervención en el 92,9%. A los 3 años, las tasas de eventos cardiacos adversos mayores, muerte, infarto agudo de miocardio no mortal y revascularización de la lesión diana fueron del 36,2, el 25,2, el 8,4 y el 8,0% respectivamente. La revascularización de la lesión diana se observó con mayor frecuencia en los casos en que se habían implantado ≥ 2 stents, en comparación con los pacientes en quienes se había utilizado un solo stent (el 18,5 frente al 5,8%; p=0,03), así como en los pacientes en quiens se utilizaron stents metálicos sin recubrimiento, en comparación con los tratados con stents liberadores de fármacos (el 13,0% frente al 7,9%; p=0,24). Se observó una trombosis de stent definida en 2 pacientes (0,9%) y una trombosis de stent probable en 7 (3,1%). El sexo femenino, el deterioro de la función del ventrículo izquierdo y el uso de stents sin recubrimiento mostraron una relación significativa con la mortalidad por todas las causas. Conclusiones. Los pacientes de alto riesgo con una estenosis de tronco coronario izquierdo no protegido tratados con una intervención coronaria percutánea presentaron una tasa elevada de eventos cardiacos adversos mayores en el seguimiento a largo plazo. El sexo femenino, el deterioro de la función del ventrículo izquierdo y el uso de stents sin recubrimiento fueron factores predictivos de mal pronóstico (AU)

Introduction and objectives. Percutaneous coronary intervention is recommended in patients with unprotected left main stenosis non suitable for coronary artery bypass graft. Long-term follow-up of those patients remains uncertain. Methods. All patients with de novo unprotected left main stenosis treated with stent implantation were consecutively enrolled. Percutaneous coronary intervention was indicated according to the standards of care, taking into account clinical and anatomical conditions unfavorable for coronary artery bypass graft. The primary end point was the occurrence of major adverse cardiac events, a composite of death, nonfatal acute myocardial infarction, or target lesion revascularization. Results. Of 226 consecutive patients included, 202 (89.4%) were treated with drug-eluting stents. Mean age was 72.1 years, 41.1% had renal dysfunction, and mean Syntax score and EuroSCORE were 28.9 and 7.4, respectively. Angiographic and procedural success was achieved in 99.6% and 92.9% of patients. At 3.0 years, the rates of major adverse cardiac events, death, nonfatal acute myocardial infarction and target lesion revascularization were 36.2%, 25.2%, 8.4%, 8.0%, respectively. Target lesion revascularization was more frequently observed when ≥2 stents were implanted rather than a single stent (18.5% vs 5.8%, P=.03); and with bare metal stents rather than drug-eluting stents (13.0% vs 7.9%, P=.24). Definite stent thrombosis was observed in 2 patients (0.9%) and probable stent thrombosis in 7 (3.1%). Female sex, impaired left ventricular function, and use of bare metal stents were significantly related with all-cause mortality. Conclusions. High-risk patients with unprotected left main stenosis treated with percutaneous coronary intervention presented with a high rate of major adverse cardiac events at long-term follow-up. Female sex, impaired left ventricular function, and use of bare metal stents were predictors of poor prognosis (AU)

Indicaciones de prótesis aórtica percutánea después del estudio PARTNER / Indications for transcatheter aortic valve replacement based on the PARTNER trial

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Diffuse alveolar damage in a young cat.

A 10-month-old cat was diagnosed with congenital subvalvular aortic stenosis. To resolve its hypoxia, oxygen therapy was administered a couple of times a week during two months. The oxygen partial pressure in the chamber was maintained between 30 and 35%, and the time for one procedure was 12-24 hr. The animal died due to severe respiratory failure. At necropsy, the lungs were voluminous and had a rubbery texture. Histologically, large type II pneumocytes with occasional atypia had diffusely proliferated within the lungs. Interstitial fibrosis was not observed, although some alveolar septa were thickened along with fibrinous exudates and neutrophilic infiltration. The histology of these lesions was consistent with diffuse alveolar damage (DAD), which might have been partially due to oxygen toxicity.

Hipertrofia septal severa: ¿es necesariamente una contraindicación para la implantación transcatéter de prótesis de Edwards-Sapien? / Severe septal hypertrophy: is it necessarily a contraindication for the transcatheter implantation of an edwards-sapien prosthesis?

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Treatment of severe valvular aortic stenosis and subvalvular discrete subaortic stenosis and septal hypertrophy with Percutaneous CoreValve Aortic Valve Implantation.

BACKGROUND: Percutaneous aortic valve implantation (PAVI) is a procedure gaining popularity and becoming more widely used for the treatment of patients with severe aortic stenosis who are at high risk for surgery. Here we show, for the first time, that a successful and complete elimination of both valvular and subvalvular pressure gradients can be achieved with a slight modification of the valve implantation technique. METHODS AND RESULTS: A 91-year-old woman presented with shortness of breath at rest, effort angina, and pulmonary congestion. Echocardiography revealed calcified aortic stenosis with a peak gradient of 75 mm Hg across the valve, and discrete subaortic stenosis (DSS) and marked hypertrophy of the basal septum with systolic anterior motion of the mitral valve (SAM). The intra ventricular gradient had a dynamic pattern across the DSS and the septal hypertrophy and measured 75 mm Hg. The total gradient across the left ventricular outflow (valvular and subvalvular) was 125 mmHg. PAVI with a 23 mm CoreValve was performed with an intentional lower positioning of the valve towards the LV outflow tract; so that the valve struts cover the subaortic membrane and part of the thickened basal septum. At the end of the procedure, the SAM disappeared, and the left ventricular ouflow was widely open. At 1 month follow up the patient was asymptomatic, no pressure gradient was measured between the LV apex and the aorta. CONCLUSIONS: This is the first report of successful treatment of severe valvular aortic stenosis and combined subvalvular aortic stenosis due to DSS and septal hypertrophy with SAM with percutaneous aortic valve implantation.

Restrictive ventricular septal defect and critical subaortic stenosis in tetralogy of Fallot.

INTRODUCTION: Tetralogy of Fallot is characterized by a non-restrictive malalignment ventricular septal defect (VSD), an overriding aorta and right ventricular outflow tract obstruction resulting from anterior deviation of the infundibular septum. Due to the large VSD, systolic pressures are equal in both ventricles. In rare cases, redundant tricuspid valve tissue may prolapse into the VSD resulting in restriction of the defect size and causing suprasystemic pressure in the right ventricle. Subaortic obstruction by prolapse of the redundant tricuspid tissue into the left ventricular outflow tract, although theoretically possible in this situation, has not been described yet in the literature. CASE REPORT: We report on a newborn with tetralogy of Fallot presenting with cyanosis and severe arterial hypotension a few hours after birth. Echocardiography revealed redundant hammock-like accessory tricuspid valve tissue almost completely occluding the originally large VSD. Suprasystemic pressure in the right ventricle resulted in protrusion of tricuspid valve tissue across the VSD and thereby caused severe left ventricular outflow tract obstruction. Emergency pulmonary balloon valvuloplasty performed for decompression of the right ventricle, reduced prolapse of tricuspid tissue into the left ventricular outflow tract and resulted in significant improvement of pulmonary and systemic blood flow. CONCLUSION: In tetralogy of Fallot, accessory tricuspid valve tissue may obstruct the VSD as well as the left ventricular outflow tract resulting in a life threatening condition in newborns shortly after birth.

Magnetic resonance imaging changes in a patient with migraine attack and transient global amnesia after cardiac catheterization.

The presence of magnetic resonance imaging (MRI) abnormalities in patients with transient global amnesia has been an interesting phenomenologic finding. Several theories surround the occurrence of this syndrome, but little is known about its true physiopathology. We present a case of transient global amnesia after cardiac catheterization associated with migraine headache and MRI changes compatible with an ischemic insult. A discussion on potential explanations for this finding is made, as well as a review of the pertinent literature.

Survival times in dogs with severe subvalvular aortic stenosis treated with balloon valvuloplasty or atenolol.

OBJECTIVE: To determine survival times in dogs with severe subvalvular aortic stenosis (SAS) treated by means of balloon valvuloplasty or with atenolol, a beta-adrenoceptor blocking drug. DESIGN: Prospective study. ANIMALS: 38 dogs < 24 months old with severe SAS (peak systolic pressure gradient > or = 80 mm Hg). PROCEDURE: 10 dogs underwent balloon valvuloplasty and were reexamined 6 weeks later to determine the feasibility of the procedure. The remaining 28 dogs were randomly assigned to undergo balloon valvuloplasty (n = 15) or to be treated with atenolol long term (13) and were reexamined annually for 9 years or until the time of death. RESULTS: For the first 10 dogs, mean pressure gradient 6 weeks after balloon valvuloplasty (mean +/- SD, 119 +/- 32.6 mm Hg) was significantly decreased, compared with mean baseline pressure gradient (167 +/- 40.1 mm Hg). Median survival time for dogs that underwent balloon valvuloplasty (55 months) was not significantly different from median survival time for dogs treated with atenolol (56 months). CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that balloon valvuloplasty can result in a significant decrease in the peak systolic pressure gradient in dogs with severe SAS, at least for the short term. No clear benefit in survival times was seen for dogs that underwent balloon valvuloplasty versus dogs that were treated with atenolol.

[Percutaneous balloon dilatation of discrete subaortic stenosis]. / Perkutane Ballondilatation einer umschriebenen Subaortenstenose.

Discrete subaortic stenosis is an uncommon congenital cardiac disorder in which the left ventricular outflow tract is narrowed. We report about the diagnostic procedures and the successful balloon dilatation of a 49-year old, highly symptomatic male patient suffering from discrete subvalvular aortic stenosis.

[Percutaneous dilatation of subaortic stenosis in an adult: a 3-year follow-up]. / Dilatation percutanée d'un rétrécissement aortique sous-valvulaire chez un adulte. Suivi à 3 ans.

Subaortic stenosis is usually diagnosed in the first years of life and treated surgically. The authors report the case of stenosis by a subaortic membrane diagnosed in an adult, treated by percutaneous balloon dilatation with a satisfactory outcome at 3 years.

Intussusception of the catheter sheath: a nonemergency.

Percutaneous balloon dilatation angioplasty is a common therapeutic modality in patients with congenital heart disease. We report three cases of the catheter sheath telescoping into the hub of the sheath after removal of the balloon catheter. Although initially it appeared as though the sheath was torn, in actuality it was intact. We report this problem so others can avoid needless searching and concern for the "missing" catheter tip.

[Balloon valvuloplasty of a discrete subvalvular aortic stenosis]. / Ballonvalvuloplastie einer diskreten subvalvulären Aortenstenose.

We describe the successful percutaneous balloon valvuloplasty of a discrete subaortic stenosis in an adult patient. The maximal gradient of 160 mm Hg (mean 100) was reduced to 45 and 33 mm Hg respectively. The procedure required only one overnight hospital stay.

Aortic/mitral obstruction and coarctation of the aorta.

The prevalence, anatomy and physiology, clinical manifestations, laboratory findings, and management of patients with aortic/mitral obstruction and coarctation of the aorta are assessed. Subaortic stenosis reviewed includes discreet membranous and tunnel subaortic stenosis as well as hypertrophic obstructive cardiomyopathy. The discussion of valvular aortic stenosis includes both congenital and acquired forms of the disease. Supravalvular aortic stenosis is described along with coarctation of the aorta. Mitral valvular stenosis includes the congenital as well as acquired variety with focus on the congenital lesion. Current opinion regarding the medical, the cardiac catheterization, interventional, and the surgical approaches to therapy is presented.

Balloon dilation of congenital subaortic stenosis in the dog.

Balloon dilation during cardiac catheterization was evaluated for the treatment of congenital subaortic stenosis (SAS) in nine dogs. Under general anesthesia, bilateral cardiac catheterization was performed through the right jugular vein and carotid artery. Thermodilution cardiac output, and left ventricular and aortic root pressures and angiograms were obtained before and after balloon dilation. Balloons measuring 18-20 mm in diameter and 30-40 mm in length were positioned across the stenosis and three inflations 4-5 minutes apart were performed. There was no significant change in cardiac output, aortic pressure, or degree of aortic regurgitation after balloon dilation. For the entire group balloon dilation resulted in significant decreases in left ventricular systolic pressure (-61.2 +/- 37.2 mm Hg [mean change +/- SD], range -14 to -123), mean systolic pressure gradient (-39.6 +/- 24.4 mm Hg, range -8.4 to -72.2), and peak systolic pressure gradient (-64.3 +/- 46.5 mm Hg, range -17 to -143). Calculated left ventricular outflow cross-sectional area increased significantly (+.4 +/- .5 cm2, range -.06 to + 1.30). Clinical signs improved in the five symptomatic dogs. Individual hemodynamic responses varied widely, but the magnitude of improvement correlated with the severity of obstruction. Three dogs showed a decrease of 60% or greater (> or = 100 mm Hg), and six dogs showed a decrease of 25-50% (17-71 mm Hg) in peak systolic gradient after balloon dilation. Complications were frequent but most were transient and manageable. These preliminary results suggest that balloon dilation can acutely decrease outflow resistance in dogs with SAS and may be effective therapy for some affected dogs.