Successful Rescue Transaortic Valve Replacement Using Edwards Sapien 3 Following Failed Evolut R Implantation in a Degenerated Surgical Bioprosthesis: A Case Report.

This study examines a complex scenario of structural valve degeneration (SVD) in a high surgical-risk patient with a previously implanted 25 mm Carpentier-Edwards (CE) Perimount Magna Ease 3300 (Irvine, CA: Edwards Lifesciences) surgical bioprosthetic valve (SAV), the patient presented with both paravalvular leak (PVL) and central prosthetic valve insufficiency (PVI). The patient was considered for a transaortic valve-in-valve (ViV) intervention with a self-expanding 29 mm Evolut R valve (Minneapolis, MN: Medtronic). The case describes a ViV intervention complicated by the malpositioning of the Evolut R valve secondary to micro-dislodgement into the left ventricular outflow tract (LVOT) after deployment and subsequent migration into the LVOT during an attempted bioprosthetic valve fracture (BVF) of the SAV that aimed to decrease transvalvular gradients. The resulting acute severe PVL resulted in significant hemodynamic deterioration, necessitating emergent intervention by implanting a balloon-expandable 26 mm Edwards SAPIEN 3 valve (Irvine, CA: Edwards Lifesciences), effectively averting the need for a surgical valve explant. This study illuminates the intricacies and emergency management strategies in transcatheter aortic valve replacement (TAVR) procedures, particularly in high-risk patients with SVD, and offers critical insights into the challenges and solutions in ViV implantations.

Uncovering an Easily Overlooked Cause of Dyspnea: Partial Anomalous Pulmonary Venous Connection of the Right Pulmonary Vein to the Superior Vena Cava Leading to Right Heart Enlargement.

This case report describes a rare variant of partial anomalous pulmonary venous connections (PAPVCs) in a patient who presented with an insidious progression of dyspnea on exertion as an adult, leading to the diagnosis of PAPVC. The patient had an anomalous right upper pulmonary vein connecting to an anomalous pulmonary-azygos trunk that connected to the cranial superior vena cava (SVC), producing a large left-to-right extracardiac shunt. The diagnosis of PAPVC was made after evaluating for causes of right heart chamber enlargement. This case highlights the importance of considering PAPVC as a potential cause of unclear etiology for exertional dyspnea, right-sided chamber enlargements, and intact atrial septum. The onset and severity of symptoms in patients with PAPVC depend on various factors, including the number of pulmonary veins, site of connection, pulmonary vascular resistance, atrial compliance, and the presence of other congenital heart defects. Therefore, clinicians should maintain a high level of suspicion for PAPVC in patients with these types of symptoms.

Assembling the Puzzle: Taking into Account Clinical Presentation and Predictive Scores.

Syncope is a common cause of emergency department visits. Physicians must scrutinize for life-threatening causes to avoid patient morbidity and mortality. Clinical decision rules are used to stratify risks and guide the course of action, including the need for further testing. This is the case of a 83-year-old man was brought to the emergency department after a 5-minute episode of sudden loss of consciousness. Vital signs showed hypotension and physical examination was unremarkable. Despite Wells score of 0, clinical suspicion for pulmonary embolism persisted, for which further testing was pursued. D-dimer was elevated at 13.77 mcg/mL and a chest computed tomography with angiography showed an extensive bilateral pulmonary embolism involving the distal right and left main pulmonary arteries. He was started on full-dose anticoagulation. This case exemplifies the need of high clinical suspicion along with the importance of applying predictive scores for diagnosing unusual causes of syncope.

Myocardial Infarction After Lumbar Surgery: A Critical Meta-Analysis of Cohort versus Database Studies for a Rare Complication.

BACKGROUND: One potentially fatal complication of spine surgery is myocardial infarction (MI). There is still uncertainty of the true incidence of MI within subsets of spine surgeries. The aim of this study was to survey the contemporary spine literature and ascertain the true incidence of MI after lumbar spine surgery, as well as to provide commentary on the inherent assumptions made when interpreting cohort versus database studies on this topic. METHODS: A systematic search of 4 electronic databases from inception to November 2020 was conducted following PRISMA guidelines. Articles were screened against prespecified criteria. MI incidence was then estimated by random-effects meta-analyses of proportions based on cohort versus database studies. RESULTS: A total of 34 cohort studies and 32 database studies describing 767,326 lumbar procedures satisfied all criteria for selection. There were 12,170 (2%) cases from cohort studies and 755,156 (98%) cases from database studies. Cohort studies reported a significantly older patient cohort (P < 0.01) and longer follow-up period than did database studies (P < 0.03). Using cohort studies only, the incidence of MI was 0.44% (P heterogeneity < 0.01), whereas using database studies only, the incidence of MI was 0.41% (P heterogeneity < 0.01). These 2 incidences were statistically different (P interaction = 0.01). Bias analysis indicated that cohort studies were more vulnerable to small-study biases than were database studies. CONCLUSIONS: Although infrequent, the incidence of MI after lumbar spine surgery is unequivocally nonzero. Furthermore, the literature on this topic remains skewed based on study type, and translation of academic findings into practice should be wary of this.

Thinking Outside the 'Cage'.

A patient with persistent chest pain and previous mitral valve replacement had no recurrence of pain once target international normalized ratio was reached.