Intentional bioprosthetic tricuspid valve fracture to facilitate transcatheter valve-in-valve deployment.

While transcatheter valve-in-valve (ViV) implantation may reduce the number of lifetime surgical reinterventions in some patients with congenital heart disease, in other patients the bioprosthetic valve ring can lead to patient-prosthesis mismatch due to reduction of internal diameter if a transcatheter valve is implanted. A 49-year-old woman with multiple prior cardiac surgeries presented with heart failure due to bioprosthetic tricuspid valve stenosis. Initial predilation valvuloplasty suggested conventional ViV implant would produce patient-prosthesis mismatch, therefore, we intentionally fractured the bioprosthetic valve ring to facilitate optimal hemodynamics with implantation of a 29 mm transcatheter valve.

Torque device suture technique to achieve hemostasis in large-bore venous access.

OBJECTIVES: To describe and compare a novel technique using a torque device to manage figure-of-eight suture tension for venous access hemostasis in patients who have undergone atrial septal defect (ASD) or patent foramen ovale (PFO) closure. BACKGROUND: Large bore venous access has become increasingly important in transcatheter procedures, but management of hemostasis can be time-consuming and/or resource intensive. As such, various techniques have sought to provide cost effective and safe alternatives to manual compression. We describe a modification of the figure-of-eight suture technique wherein we apply a torque device to manage variable suture tension instead of tying a knot and compare it to the standard figure-of-eight suture technique. METHODS: We performed a retrospective study of 40 consecutive patients who underwent ASD or PFO closure, 20 of whom underwent standard figure-of-eight technique and 20 of whom underwent figure-of-eight with torque device modification. Bleeding Academic Research Consortium definitions were used to categorize bleeding events. RESULTS: The groups were similar in age, gender, weight, aspirin use, platelet count, procedure time, hemoglobin, and international normalized ratio. Standard figure-of-eight suture had seven patients with bleeding, with six classified as BARC II and one as BARC I. Figure-of-eight plus torque device had three patients with bleeding, with two classified BARC II and one as BARC I. There were no incidences of hematoma in either group. CONCLUSION: The torque device suture technique is a unique modification of the figure-of-eight suture technique to achieve venous hemostasis. In addition, the modification allows secure and variable suture tension as well as easy removal by nursing staff.

Septic Shock Caused by Rocky Mountain Spotted Fever in a Suburban Texas Patient with Pet Dog Exposure: A Case Report.

BACKGROUND Rocky Mountain spotted fever (RMSF) is associated with high mortality and requires prompt identification and treatment to ensure better outcomes. CASE REPORT We describe an advanced case of RMSF in a 45-year-old female patient with pet dog exposure who presented with altered mental status, dyspnea, and ataxia progressing to septic shock and acute hypoxic respiratory failure requiring intubation and mechanical ventilation. CONCLUSIONS This case illustrates the importance of keeping RMSF in the differential diagnosis in patient populations outside of the usual geographic areas of incidence in the appropriate clinical setting.