Acute Prosthetic Aortic Valve Obstruction Leading to Free Aortic Insufficiency Veno-Arterial Extracorporeal Membrane Oxygenation as a bridge to surgery.

INTRODUCTION: Mechanical prosthetic valve thrombosis (PVT) and obstruction is a lifethreatening event. The significant morbidity and mortality associated with this condition warrants rapid diagnostic evaluation and treatment. CASE REPORT: A 66-year-old female patient with a history of aortic valve replacement 13 years before, was admitted to our intensive cardiac care unit with symptoms and signs of prosthetic aortic valve dysfunction. During cardiac angiography, she collapsed and fluoroscopy showed an immobile disc, stopped in an open position and causing free aortic regurgitation. Cardio-pulmonary resuscitation (CPR) was initiated and a VA-ECMO was inserted as a bridge to emergent cardiac surgery. Surgery was then performed and the patient was successfully discharged with no neurological impairment. DISCUSSION: We present a case where Veno-Arterial Extracorporeal Membrane Oxygenation (VA- ECMO) was successfully used as a bridge to emergent surgery in a cardiac arrest patient due to prosthetic valve thrombosis. CONCLUSIONS: This case illustrates how a relative contraindication (severe aortic insufficiency) to VA-ECMO may, in the end, be an indication in a very particular scenario.

Transcatheter aortic valve implantation and requirements of pacing over time.

BACKGROUND: A permanent pacemaker (PPM) implantation is common after transcatheter aortic valve implantation (TAVI). We sought to evaluate requirements of pacing and incidence of pacemaker dependency during the first year after TAVI. METHODS: From August 2007 until May 2011, 65 patients underwent TAVI with self-expandable prosthesis. Five patients paced at baseline and two procedure-related deaths were excluded. Evaluation of ventricular pacing percentage (VP%) and look for spontaneous rhythm were performed at 3, 6, and 12 months. RESULTS: PPM implantation was required in 19/58 patients (33%). Mean VP% decreased between assessments (59% at 3 months, 48% at 6 months, 50% at 12 months), but overall VP% at 1 year was high (57% ± 43%) and most patients were paced ≥10% of time. A favorable annulus-to-aorta angle was associated with lower pacing requirements (60% of patients paced ≤10% of time vs 10% of patients paced >10% of time presented an angle ≤30°, P = 0.039). Pacemaker dependency was established in 27% of patients and could be predicted by the presence of porcelain aorta (odds ratio = 30, confidence interval 95% 1-638, P = 0.029). New postprocedural left bundle branch block (LBBB) had a negative impact on 1-year survival (58% vs 82% in non-LBBB group, P = 0.111). PPM implantation had no impact on 1-year survival. CONCLUSIONS: One third of patients required PPM after TAVI and full recovery of advanced conduction abnormalities seems unlikely. Unfavorable aortic root orientation may hinder the deployment of the valve and contribute to the continued impairment of the conduction system. Porcelain aorta was a strong predictor of pacemaker dependency.

[Transcatheter aortic valve-in-valve implantation for failed aortic bioprosthesis]. / Implantação percutânea de válvula aórtica sobre bioprótese cirúrgica degenerada.

Percutaneous valve replacement for severe aortic stenosis has been shown to be an alternative treatment option for high surgical risk patients. We describe our first valve-in-valve procedure in a patient with a degenerated aortic bioprosthesis and severe regurgitation.

Catastrophic presentation of peripartum cardiomyopathy: a case report of a challenging diagnosis.

Background: Peripartum cardiomyopathy (PPCM) usually affects women in the last month of pregnancy or in the first months following delivery and typically presents with signs and symptoms of heart failure (HF), although catastrophic presentations may be the initial manifestation. Case summary: A 36-year-old woman reported intense fatigue that began after delivery. Three months following delivery, she suffered a cardiac arrest at home, in shockable rhythm, with a total estimated time of 70 min before return of spontaneous circulation. Electrocardiogram presented diffuse ST-segment depression and transthoracic echocardiography showed severe left-ventricle (LV) dysfunction with global hypokinesis. In the catheterization laboratory, she underwent a triple rule out (no aortic, coronary, or pulmonary vascular disease); ventriculography was not suggestive of Takotsubo syndrome. She was transferred to the cardiac intensive care unit, under invasive mechanical ventilation and vasopressor support. A presumptive diagnosis of PPCM was made and bromocriptine and heparin were started. In three days, she was weaned from haemodynamic support and extubated, with good neurologic outcome. Cardiac magnetic resonance showed no signs of inflammation or fibrosis. Cardiomyopathy genetic test was negative. PPCM diagnosis was assumed, HF therapy was introduced and a cardioverter-defibrillator was implanted. At 2.5 months follow up, she presented HF NYHA Class II and recovered LV function. Discussion: We present a case of a woman, three months after delivery, who developed a catastrophic manifestation of PPCM. This case raises awareness about atypical presentations of PPCM, whose diagnosis should be considered in the appropriate clinical context, but ultimately, remains a diagnosis of exclusion.

Rescue percutaneous repair of ischemic acute severe mitral regurgitation.

Acute severe mitral regurgitation (MR) because of secondary left ventricular impaired regional contractility can present with severe acute heart failure, associated with a high risk for rapid decompensation, pulmonary edema and cardiogenic shock. Frequently, in these highly unstable patients, surgical risk can be prohibitive. Evidence for percutaneous repair of acute MR is scarce, but a few case series show that this approach could be safe and effective for bailing out hemodynamically unstable patients. We report a case of an 84-year-old man with acute ischemic severe MR post-acute myocardial infarction (MI), who remained hemodynamically unstable despite coronary revascularization, positive pressure non-invasive ventilation, vasodilator therapy and intra-aortic balloon pump (IABP) support. In heart team discussions, he was considered a high risk surgical candidate. We decided on rescue off-label percutaneous mitral valve repair with a MitraClip device (Abbott Vascular, Santa Clara, California), with good clinical result, allowing weaning from the supports and discharge seven days after the procedure. At one-year follow-up, the patient maintained a MV repair results and had a good functional status. In unstable patients with acute ischemic MR, percutaneous MV repair could be a rescue therapeutic option to consider, allowing hemodynamic compensation with potential persistent MR improvement up to one-year follow-up.

Combined percutaneous treatment of severe aortic stenosis and left main disease in a high surgical risk patient.

We report the case of a 77-year-old man with heart failure (NYHA class IV), angina (CCS class III) and multiple comorbidities. The evaluation showed severe aortic sten osis and left main coronary disease. Due to the very high perioperative risk, conventional surgery was denied. It was therefore decided to perform a combined percutaneous intervention. First, left main PCI was successfully performed. A few days later, a percutaneous aortic valve prosthesis was implanted via a femoral approach using the CoreValve ReValving system. Immediately after prosthesis implantation, the control angiogram showed severe paravalvular aortic regurgitation, which was corrected by implanting another percutaneous aortic prosthesis inside the first one (valve-in-valve procedure). During follow-up the patient experienced a remarkable improvement in hemodynamic and clinical status. We demonstrate that the combination of two different percutaneous interventions in severe aortic and coronary disease is feasible and can be a suitable alternative approach in high surgical risk patients.

[Multislice computed tomography in the selection of candidates for transcatheter aortic valve implantation]. / Tomografia computorizada multicorte na avaliação de candidatos a implantação de prótese aórtica percutânea.

Transcatheter aortic valve implantation is an emerging treatment option for severe symptomatic aortic stenosis in patients considered unsuitable for surgical valve replacement. The authors review the use of multislice computed tomography in the selection of candidates for transcatheter aortic valve replacement, procedural support and post-interventional follow-up. A single-center experience of the role of this imaging technique is also described. Multislice computed tomography is an essential imaging tool in the selection and exclusion of candidates for transcatheter aortic valve implantation, providing evaluation of coronary anatomy and the relationship of the coronary ostia with the aortic valve structure, and accurate analysis of the valve annulus and aortic root, left ventricular outflow tract, aorta and peripheral vascular access routes. Multislice computed tomography is also central to the choice of appropriate prosthesis size. In addition, it guides arterial puncture by image fusion techniques and enables correct prosthesis apposition to be verified. This review aims to describe the role of computed tomography in this increasingly common interventional valve procedure, providing an overview of current knowledge and applications.

Fighting the pandemic with collaboration at heart: Report from cardiologists in a COVID-19-dedicated Portuguese intensive care unit.

INTRODUCTION AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) spread quickly around the world. Although mainly a respiratory illness, there is growing interest in non-respiratory manifestations, particularly cardiovascular ones. At our center, mobilization of cardiologists with intensive care training was needed. Our aim is to describe patients with severe COVID-19 admitted to a Portuguese intensive care unit (ICU), the cardiovascular impact of the disease and the experience of cardiologists working in a COVID-19 ICU. METHODS: Data from adult patients with COVID-19 admitted to the ICU of Centro Hospitalar de Vila Nova de Gaia/Espinho between 16 March 2020 and 21 April 2020 were analyzed retrospectively. RESULTS: Thirty-five patients were admitted. Mean age was 62.6±6.0 years and 23 (65.7%) were male. Dyslipidemia was the most common cardiovascular risk factor (65.7%, n=23), followed by hypertension (57.1%, n=20). Mean ICU stay time was 15.9±10.0 days. Patients had high rates of mechanical ventilation (88.6%, n=31) and vasopressor support (88.6%, n=31). Low rates of new onset left systolic dysfunction were detected (8.5%, n=2). One patient required venoarterial extra-corporeal membrane oxygenation. Mortality was 25% (n=9). Acute myocardial injury and N-terminal pro-B-type natriuretic peptide (NT-proBNP) elevation was detected in 62.9% (n=22). Patients that died had higher NT-proBNP compared to those discharged alive (p<0.05). Care by cardiologists frequently changed decision making. CONCLUSIONS: The cardiovascular impact of COVID-19 seems relevant but is still widely unknown. Studies are needed to clarify the role of cardiac markers in COVID-19 prognosis. Multidisciplinary care most likely results in improved patient care.

Impella support for cardiogenic shock and high-risk percutaneous coronary intervention: A single-center experience.

INTRODUCTION AND OBJECTIVES: The use of mechanical circulatory support is increasing in cases of cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI). The Impella® is a percutaneous ventricular assist device that unloads the left ventricle by ejecting blood to the ascending aorta. We report our center's experience with the use of the Impella® device in these two clinical settings. METHODS: We performed a single-center retrospective study including all consecutive patients implanted with the Impella® between 2007 and 2019 for CS treatment or prophylactic support of HR-PCI. Data on clinical and safety endpoints were collected and analyzed. RESULTS: Twenty-two patients were included: 12 were treated for CS and 10 underwent an HR-PCI procedure. In the CS-treated population, the main cause of CS was acute myocardial infarction (five patients); hemolysis was the most frequent device-related complication (63.7%). In-hospital, cumulative 30-day and one-year mortality were 58.3%, 66.6% and 83.3%, respectively. In the HR-PCI group, all patients had multivessel disease (mean baseline SYNTAX I score: 44.1±13.7). In-hospital, 30-day and one-year mortality were 10.0%, 10.0% and 20.0%, respectively. There were no device- or procedure-related deaths in either group. CONCLUSION: The short- and long-term results of Impella®-supported HR-PCI were comparable to those in the literature. In the CS group, in-hospital and short-term outcomes were poor, with high mortality and non-negligible complication rates.

Fighting the pandemic with collaboration at heart: Report from cardiologists in a COVID-19-dedicated Portuguese intensive care unit.

INTRODUCTION AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) spread quickly around the world. Although mainly a respiratory illness, there is growing interest in non-respiratory manifestations, particularly cardiovascular ones. At our center, mobilization of cardiologists with intensive care training was needed. Our aim is to describe patients with severe COVID-19 admitted to a Portuguese intensive care unit (ICU), the cardiovascular impact of the disease and the experience of cardiologists working in a COVID-19 ICU. METHODS: Data from adult patients with COVID-19 admitted to the ICU of Centro Hospitalar de Vila Nova de Gaia/Espinho between 16 March 2020 and 21 April 2020 were analyzed retrospectively. RESULTS: Thirty-five patients were admitted. Mean age was 62.6±6.0 years and 23 (65.7%) were male. Dyslipidemia was the most common cardiovascular risk factor (65.7%, n=23), followed by hypertension (57.1%, n=20). Mean ICU stay time was 15.9±10.0 days. Patients had high rates of mechanical ventilation (88.6%, n=31) and vasopressor support (88.6%, n=31). Low rates of new onset left systolic dysfunction were detected (8.5%, n=2). One patient required venoarterial extra-corporeal membrane oxygenation. Mortality was 25% (n=9). Acute myocardial injury and N-terminal pro-B-type natriuretic peptide (NT-proBNP) elevation was detected in 62.9% (n=22). Patients that died had higher NT-proBNP compared to those discharged alive (p<0.05). Care by cardiologists frequently changed decision making. CONCLUSIONS: The cardiovascular impact of COVID-19 seems relevant but is still widely unknown. Studies are needed to clarify the role of cardiac markers in COVID-19 prognosis. Multidisciplinary care most likely results in improved patient care.

INTRODUÇÃO E OBJETIVOS: A doença pelo novo coronavirus (COVID-19) espalhou-se rapidamente pelo globo. Embora tenha atingimento essencialmente respiratório, existe interesse nas manifestações extrarrespiratórias, nomeadamente nas cardiovasculares. No nosso centro, foi necessária a mobilização de cardiologistas com experiência em cuidados intensivos para enfrentar este desafio. O objetivo desta investigação é descrever a população internada com COVID-19 grave numa UCI portuguesa, o impacto cardiovascular desta doença e a nossa experiência enquanto cardiologistas numa UCI COVID-19. MÉTODOS: Dados de adultos com COVID-19 internados na UCI do Centro Hospitalar de Vila Nova de Gaia/Espinho entre 16/03/2020 e 21/04/2020 foram analisados retrospetivamente. RESULTADOS: Foram internados 35 doentes. A média de idade foi 62,6±6,0 anos e 23 (65,7%) doentes eram homens. A dislipidemia foi o fator de risco cardiovascular mais prevalente (65,7%, n=23), seguida pela hipertensão (57,1%, n=20). O tempo médio de internamento em UCI foi 15,9±10,0 dias. A necessidade de ventilação mecânica (88,6%, n=31) e suporte vasopressor (88,6%, n=31) foi alta, mas poucos doentes desenvolveram disfunção sistólica de novo (n=2,85%). A mortalidade foi de 25% (n=9). Foi detetada lesão miocárdica aguda e elevação do NT-proBNP em 62,9% (n=22) dos doentes, sendo os níveis de NT-proBNP mais elevados nos doentes que faleceram (p<0,05). A participação de cardiologistas na UCI alterou frequentemente a decisão clínica. CONCLUSÃO: O impacto cardiovascular da COVID-19 parece relevante mas é parcamente conhecido, sendo necessários mais estudos para clarificar o papel dos marcadores cardíacos no prognóstico da COVID-19. As equipas multidisciplinares provavelmente melhoram os cuidados de saúde prestados a estes doentes.

Long-term outcomes after radiofrequency catheter ablation of the atrioventricular node: The experience of a Portuguese tertiary center.

INTRODUCTION: In patients with supraventricular arrhythmias and high ventricular rate, unresponsive to rate and rhythm control therapy or catheter ablation, atrioventricular (AV) node ablation may be performed. OBJECTIVES: To assess long-term outcomes after AV node ablation and to analyze predictors of adverse events. METHODS: We performed a detailed retrospective analysis of all patients who underwent AV node ablation between February 1997 and February 2019, in a single Portuguese tertiary center. RESULTS: A total of 123 patients, mean age 69±9 years and 52% male, underwent AV node ablation. Most of them presented atrial fibrillation at baseline (65%). During a median follow-up of 8.5 years (interquartile range 3.8-11.8), patients improved heart failure (HF) functional class (NYHA class III-IV 46% versus 13%, p=0.001), and there were reductions in hospitalizations due to HF (0.98±1.3 versus 0.28±0.8, p=0.001) and emergency department (ED) visits (1.1±1 versus 0.17±0.7, p=0.0001). There were no device-related complications. Despite permanent pacemaker stimulation, left ventricular ejection fraction did not worsen (47±13% vs. 47%±12, p=0.63). Twenty-eight patients died (23%). The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome (OR 1.8, 95% CI 1.24-2.61, p=0.002). CONCLUSIONS: Despite pacemaker dependency, the clinical benefit of AV node ablation persisted at long-term follow-up. The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome. AV node ablation should probably be considered earlier in the treatment of patients with supraventricular arrhythmias and HF, especially in cases that are unsuitable for selective ablation of the specific arrhythmia.

Incidence and predictors of permanent pacemaker requirement after transcatheter aortic valve implantation with a self-expanding bioprosthesis.

BACKGROUND: Previous reports have suggested the occurrence of cardiac conduction disorders and permanent pacemaker (PPM) requirement after transcatheter aortic valve implantation (TAVI). Based on a single-center experience, we aim to assess the incidence of postprocedural conduction disorders, need for PPM, and its determinants after TAVI with a self-expanding bioprosthesis. METHODS: From August 2007 to October 2009, 32 consecutive patients underwent TAVI with the Medtronic CoreValve (MCV) System (Medtronic Inc., Minneapolis, MN, USA). Three patients paced at baseline and two cases of procedure-related mortality were excluded. We analyzed the 12-lead electrocardiogram at baseline, immediately after procedure and at discharge. Requirements for PPM were documented and potential clinical, electrophysiological, echocardiographic, and procedural predictors of PPM requirement were studied. RESULTS: After TAVI, eight patients (29.6%) required PPM implantation due to high-grade atrioventricular (AV) block. The prevalence of left bundle branch block increased from 13.8% to 57.7% directly after implantation (P = 0.001). Need for PPM was correlated to the depth of prosthesis implantation (r = 0.590; P = 0.001). At a cutoff point of 10.1 mm, the likelihood of pacemaker could be predicted with 87.5% sensitivity and 74% specificity and a receiver operator characteristic curve area of 0.86 ± 0.07 (P = 0.003). Of the seven patients with preexisting right bundle branch block (RBBB), four (57.1%) required PPM implantation after TAVI. CONCLUSIONS: High-grade AV block requiring PPM implantation is a common complication following TAVI and could be predicted by a deeper implantation of the prosthesis. Patients with preexisting RBBB also seem to be at risk for the development of high-grade AV block and subsequent pacemaker implantation.

Percutaneous aortic valve implantation.

INTRODUCTION: Percutaneous aortic valve implantation is an emerging procedure for the treatment of patients with severe aortic stenosis. METHODS: The procedure was performed in patients with severe symptomatic aortic stenosis, who had been refused for aortic valve replacement surgery. A self-expanding bioprosthesis within a nitinol frame delivered by an 18F catheter was used. Most of the procedures were performed through a femoral artery approach and under local anesthesia and sedation. RESULTS: Thirty-two patients were treated, mean age 80 years, with various comorbidities and mean logistic EuroSCORE of 22%. The procedure was successful in all patients, with a significant improvement in transvalvular gradients. Two patients died due to procedure-related complications. The most common complications were vascular access related and high-degree atrioventricular block requiring permanent pacemaker. No events were reported after one month follow-up, with most patients showing improvement in functional capacity. After 23 months of follow-up (mean 13 months) five additional deaths had occurred. No prosthesis-related events were observed. CONCLUSIONS: Percutaneous aortic valve implantation is safe and improves quality of life in patients with severe symptomatic aortic stenosis. It may be an alternative therapeutic option for patients with high risk features for aortic replacement surgery.

[Hybrid approach to structural cardiac disease: three clinical cases]. / Tratamento híbrido de doença estrutural cardiac: a propósito de três casos clínicos.

Structural cardiac diseases can be successfully treated by a multidisciplinary team using a hybrid strategy. We report a small series of complex cases were the team effort of cardiologists, cardiac surgeons and anaesthesiologists allowed a favourable result.

Cardiac intensive care in Portugal: The time for change. / Cuidados intensivos cardíacos em Portugal: projetar a mudança.

In recent years, the number of patients requiring acute cardiac care has increased, with progressively more complex cardiovascular conditions, often complicated by acute or chronic non-cardiovascular comorbidities, which affects the management and prognosis of these patients. Coronary care units have evolved into cardiac intensive care units, which provide highly specialized health care for the critical heart patient. In view of the limited human and technical resources in this area, we consider that there is an urgent need for an in-depth analysis of the organizational model for acute cardiac care, including the definition of the level of care, the composition and training of the team, and the creation of referral networks. It is also crucial to establish protocols and to adopt safe clinical practices to improve levels of quality and safety in the treatment of patients. Considering that acute cardiac care involves conditions with very different severity and prognosis, it is essential to define the level of care to be provided for each type of acute cardiovascular condition in terms of the team, available techniques and infrastructure. This will lead to improvements in the quality of care and patient prognosis, and will also enable more efficient allocation of resources.

The effects of transcatheter aortic valve implantation on cardiac electrical properties.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is associated with cardiac electrical disturbances. However, beyond the risks of pacemaker implantation, few studies have performed a detailed assessment of the effects of TAVI on several cardiac electrical properties. OBJECTIVES: To assess the frequency and type of electrocardiographic disturbances following TAVI, according to the type of prostheses and to assess predictors of these disturbances. METHODS: We performed a detailed retrospective analysis of all electrocardiograms in patients who underwent TAVI, before and after the procedure, at a tertiary center from August 2007 to October 2016. Patients with permanent pacemakers were excluded. RESULTS: We included 182 patients (78±8 years; 56% female) and self-expanding prostheses (SEP) were implanted in 54%. Most patients (80%) were in sinus rhythm at baseline. After TAVI, 21% of patients developed new-onset atrial fibrillation and there was a significant increase in PR interval at discharge (186±41 ms vs. 176±32; p=0.003), which was not maintained after at six-month follow-up (181±35 ms, p=0.06). There was also a significant increase in QRS duration at discharge (129±28 ms vs. 114±25 at baseline p<0.0001), which persisted at six-months (122±28 ms, p<0.0001). New-onset left-bundle branch block (LBBB) was observed in 25% of patients. The depth of valve implantation was a predictor of new LBBB at discharge after multivariate analysis (OR 37.6, 95% CI 14.6-65.2, p=0.001). CONCLUSIONS: The main electrocardiographic disturbances post TAVI were PR prolongation, increased QRS and new-onset LBBB. These disturbances were more pronounced in patients undergoing SEP implantation and tended to improve at six-month follow-up. The depth of valve implantation was a predictor of conduction disturbances.

[Subclavian artery access for transcatheter aortic valve implantation]. / Abordagem da artéria subclávia para inplantação transcatéter de válvula aórtica.

Transcatheter aortic valve implantation has been increasingly reported as an alternative to the surgical management of aortic stenosis in patients who are contraindicated for surgery. Transcatheter technical limitations for vascular access in some patients created the need for alternative approaches as is the case of the subclavian artery access. The authors report their experience and results in a group of four patients treated with transcatheter aortic valve implantation through subclavian artery access.

Balloon Aortic Valvuloplasty in Patients Admitted for Cardiogenic Shock with Severe Aortic Stenosis: A Retrospective Analysis of 14 Cases.

Introduction Balloon aortic valvuloplasty (BAV), introduced in 1986, quickly lost its wide adoption due to the high incidence of restenosis after the procedure and due to improved skills in transcatheter aortic valve implantation (TAVI). It has seen a re-emergence in the last few years as bailout therapy in critical care patients presenting with cardiogenic shock (CS) and severe aortic stenosis (AS), who are temporarily unable to tolerate such a procedure as TAVI or surgery for valve replacement. Methods We did a retrospective analysis of every BAV performed between January 1, 2008, and November 11, 2018, in our hospital and identified those admitted to the cardiac intensive care unit (CICU) due to cardiogenic shock with severe aortic stenosis, as defined in the European Society of Cardiology Guidelines. Procedures were categorized as emergent (within 24h after the decision to intervene) and urgent (24h after the decision was made but before discharge). Results During this period, of 98 BAV performed, 14 were performed on patients with CS with severe AS, nine of them being emergent. The patients' mean age was 76.2±7.2 years, with 6 (43%) of them being female. On the day of BAV, the mean Euroscore II and sequential organ failure (SOFA) were, respectively, 19±7% and 8.0±2.4 in emergent cases and 11±5% and 4.8±2.9 in urgent cases. In patients deemed emergent, there was a tendency for a decrease in SOFA in the days following the procedure, although not statistically significant (p>0.05). Clinically significant aortic regurgitation did not occur in any patient, neither were there any major post-procedure complications. Thirty-day mortality was 33% in emergent cases and 0% in urgent cases. In emergent cases, four were later submitted to TAVI and one had surgery for aortic valve replacement surgery. Only one patient in the urgent group was regarded as a candidate for TAVI. Discussion and conclusion Emergent cases presented with higher scores of severity and procedure risk and had greater mortality. In this group, a greater proportion of survivors was later deemed fit for definite procedures. This highlights that presenting status does not seem to influence the prognosis of those extremely high-risk patients once the acute event is promptly treated. Nevertheless, the low sample size precludes generalization of the findings. BAV as bailout treatment may be safe in patients presenting with CS and severe AS, allowing patient survival for elective definitive treatment.

Right single coronary artery as an incidental finding in Takotsubo syndrome and acute heart failure: Case report and review of the literature.

INTRODUCTION: Single coronary artery (SCA) with no associated congenital heart disease is a rare congenital anomaly. Most cases are asymptomatic and incidental findings, but SCA can cause ischemia, congestive heart failure, and sudden cardiac death (SCD). CASE REPORT: A 44-year-old woman presented with Takotsubo cardiomyopathy and cardiogenic shock. Selective cannulation of the left coronary artery (LCA) was not possible on coronary angiography (CA); an SCA was revealed arising from the right sinus, continuing distally as the circumflex artery and thereafter as the left anterior descending artery. Coronary computed tomography angiography (CCTA) confirmed left main atresia and no coronary stenosis. Cardiac magnetic resonance imaging (MRI) showed diffuse myocardial edema and no perfusion defects. The patient's clinical course was favorable under conservative management. DISCUSSION: Our paper describes an incidental finding of right SCA. We report a Lipton type R-I, in which a dominant right SCA supplies the entire myocardium. It is the rarest SCA presentation, with an incidence of 0.0008%; only 15 cases have been reported in the literature, all of which were studied by CA. Of these 15, one had SCD, five angina, one ventricular arrhythmia and one complicated acute coronary syndrome. CCTA confirmed the diagnosis in seven patients, MRI in one and transesophageal echocardiography in another. Nine patients had coronary lesions. Two underwent coronary artery bypass grafting, one percutaneous intervention and 11 conservative treatment. CONCLUSION: Right SCA with congenital absence of the LCA is one of the rarest coronary artery anomalies. In a significant percentage of patients it is associated with ischemia and can be life-threatening. CCTA and MRI are the modalities of choice for diagnosis and risk stratification.

Computed tomography-guided pericardiocentesis: a systematic review concerning contemporary evidence and future perspectives.

BACKGROUND: Pericardial effusion (PE) can develop in several pathological scenarios, and is often initially evaluated by means of echocardiography. Computed tomography (CT) has been used as an aid in the management of patients presenting with PE, in selected cases. The role of CT-guided pericardiocentesis in contemporary practice, however, remains not fully ascertained. We aimed at presenting a systematic review concerning the state-of-the-art of this technique. METHODS: A systematic review of published data on the use of CT for guiding pericardiocentesis was carried out (search performed on PubMed, ISI Web of Knowledge and Scopus databases). RESULTS: From title and abstract analysis, 14 articles were included that met the prespecified criteria. After full-text analysis, six articles were excluded. The eight articles under analysis included a total of 635 procedures performed in 571 patients. CT guidance was mostly used in a postoperative setting (364 procedures). Most procedures were done mainly for therapeutic purposes (528 procedures). Success rates ranged from 94% to 100%. Complications ranged from 0% to 7.8%. CONCLUSION: CT-guided pericardiocentesis is a useful technique in the approach to PE, in several clinical scenarios. Its use can be especially relevant in the postoperative period, as well as in individuals with suboptimal image quality (as assessed by echocardiography, for the moment the first choice in the approach to most cases of PE).