Objectives: The aim of this study was to describe the incidence and clinical impact of left atrial appendage thrombus (LAAT) in a population referred for transcatheter aortic valve replacement (TAVR) and to examine the role of cardiac computed tomography (CCT) in the diagnosis of LAAT.
A 78-year-old woman with a history of coronary artery bypass grafting underwent transapical transcatheter aortic valve replacement with a Sapien XT (Edwards, Irvine, California) prosthesis that was complicated by an apical left ventricular pseudoaneurysm (LVPA). Unsuccessful attempts at closure included percutaneous, retrograde transaortic placement of a 12-mm Amplatzer Ventricular Septal Defect occluder (St. Jude Medical, Minneapolis, Minnesota) and surgical CorMatrix (CorMatrix, Roswell, Georgia) patch repair on cardiopulmonary bypass, both with residual expanding and/or recurrent LVPA. A novel transcatheter approach was performed to exclude the left ventricular apex and flow into the LVPA. Using computed tomography–fluoroscopy fusion imaging (HeartNavigator, Philips, Best, the Netherlands), percutaneous transapical access was performed adjacent to the true apical site of the LVPA. The 26-mm Amplatzer septal and 35-mm Amplatzer cribriform occluders were positioned and deployed with the distal disks overlapping, excluding the apical cavity, and the proximal disks positioned on the epicardial surface.
A 67-year-old woman (frail, body mass index of 18, forced expiratory volume1 of 0.86, Society of Thoracic Surgeons score of 12%) was referred for transcatheter correction of a severely degenerated bioprosthetic (29-mm Edwards Perimount Bovine Pericardial, Edwards Lifesciences, Irvine, California) mitral valve. Transesophageal echocardiography (TEE) confirmed severe bioprosthesis degeneration (Figure 1). A hybrid approach was used whereby paravalvular leak (PVL) was treated percutaneously followed by transseptal mitral valve-in-valve replacement (Figure 2). TEE confirmed complete correction of degenerated bioprosthetic mitral regurgitation (MR) (Figure 3). The patient was discharged with complete resolution of symptoms on follow-up.
A 62-year-old man was admitted for acute transient ischemic attack due to spontaneous dissection of proximal left internal carotid artery (ICA) (Figure 1A). Initially managed conservatively, 72 h later, the patient had a massive left hemispheric stroke (National Institutes of Health Stroke Scale (NIHSS) score of 22). After a discussion by the brain team (neurologist, vascular surgeon, interventionist), urgent endovascular treatment to restore cerebral flow was planned. Angiography showed long occlusive dissection of the left ICA to the petrous sinus (Figures 1A to 1C) without adequate contralateral flow (Figures 1D and 1E). Carotid artery stenting combining proximal protection to avoid debris dislodgment and a parallel wire technique to re-enter to the true lumen distal to the dissection was successfully performed without complications (Figures 2 and 3). The neurological status improved to NIHSS score of 3, with a modified Rankin Scale score of 2 at 60 days.
A 72-year-old man had undergone angioplasty of the left main stem (LMS) with an implantation of a first-generation drug-eluting stent (DES) (3.5 × 18-mm Cypher stent, Cordis, Johnson & Johnson, Bridgewater, New Jersey) (Figure 1A). Post-procedural intravascular ultrasound (IVUS) had shown a well-expanded stent (Figures 1A′ and 1Aa–c). Four years later, both angiography and IVUS exhibited no significant in-stent restenosis (ISR) or stent recoil (Figures 1B, 1B′, and 1Ba′–c′). At 7 years, he presented with acute coronary syndrome (ACS) while still on long-term dual antiplatelet therapy. A subsequently obtained coronary angiogram exhibited severe ISR at the midshaft of LMS (Figure 1C). Pre-procedural optical coherence tomography (OCT) showed a massive low-intensity neointimal plaque including microvessels, indicating neoatherosclerosis, within the stent (Figures 1C′′ and 1a′′–g′′). In addition, a plaque rupture was noted at distal shoulder of the plaque with white thrombi (Figures 2A and 2B). There was no evidence of malapposed struts. Successful revascularization was performed using a new-generation DES.
A 84-year-old woman with known hepatic cancer, severe pulmonary hypertension, and atrial fibrillation on phenprocoumon was admitted for recurrent congestive heart failure in our institution. Nine years earlier, she underwent mitral valve replacement with a 25-mm Perimount Magna (Edwards Lifesciences, Irvine, California) due to severe insufficiency (Figures 1A to 1F). On admission, the patient was in New York Heart Association (NYHA) functional class IV with concomitant leg edema. Echocardiography demonstrated good left ventricular function, a dilated left atrium, and severe mitral valve stenosis with a mean gradient of 29 mm Hg and a valve orifice area of 1.01 cm2 (Figures 2A and 2B).
A 52-year-old woman with uncontrolled angina underwent coronary angiography, which showed stenosis of the left anterior descending and first diagonal bifurcation (Figure 1A). Culotte stenting was performed using a 2.5 mm × 18 mm Xience ProX drug-eluting stent (Abbott Vascular, Abbott Park, Illinois) in the diagonal, followed by a 3.5 mm × 18 mm Xience Prime drug-eluting stent (Abbott Vascular) in the left anterior descending artery. However, it was impossible to deflate the stent balloon using the indeflator. The undeflatable stent balloon completely obstructed the distal left main stem (Figure 1B). No defect was visible in the stent assembly. The patient developed severe chest pain and hypotension, and was treated for ventricular fibrillation. We could not burst the balloon using a Confianza Pro 12 guidewire (Asahi Intecc Co., Aichi, Japan) or by overinflating to 28 atm. The stuck balloon was unresponsive to significant pulling. Finally, we cut the hypotube using sterile scissors (Figure 1C), optimizing the patency of the lumen using the stiff end of a coronary guidewire.
After our initial publication of the first in human transapical implantation of an inverted transcatheter (SAPIEN valve, Edwards Lifesciences, Irvine, California) in the native mitral position (1), we now report a 2-year clinical and echocardiographic follow-up with transesophageal echocardiographic images from the same patient. There has been a further report of successful implantation of transcatheter valve percutaneously as well for native mitral valve stenosis
A 69-year-old woman presented with chest heaviness. She had no remarkable medical history and no history of Kawasaki disease or other inflammatory disease. Echocardiography showed a large paracardiac mass in the lateral free wall of the right atrium. Dual-source 64-slice cardiac computed tomography angiography (CCTA) showed a giant right coronary artery (RCA) pseudoaneurysm (4.4 × 4.5 cm) (Figure 1A). Coronary angiography revealed a large pseudoaneurysm in the RCA with 90% stenosis
A 73-year-old man referred for primary percutaneous coronary intervention (pPCI) presented with complete occlusion of the proximal left anterior descending artery (LAD) (Online Video 1). Aspiration thrombectomy was performed with an Export AP catheter (forward-facing tip, 1.09-mm inner lumen diameter, 1.73-mm outer diameter; Medtronic Cardiovascular, Santa Rosa, California), thus removing a red thrombus (Figure 1) and restoring distal Thrombolysis In Myocardial Infarction grade III flow. Milking (i.e., muscular bridge) was then observed in the mid-LAD (Online Video 2). After stent implantation in the proximal LAD, the ST-segment leveled out and chest pain remitted.
A 71-year-old man was admitted for acute coronary syndrome. Six weeks earlier, he had a Promus Premier 3.0 × 12-mm (Boston Scientific, Natick, Massachusetts) drug-eluting stent (DES) implanted in the obtuse marginal (OM) artery for unstable angina. On repeat coronary angiography, haziness (Figure 1A, Online Video 1) in the ostial stented region was observed; however Thrombolysis In Myocardial Infarction flow grade was good. Optical coherence tomography (OCT) revealed a nonexpanded stent (star with struts marked with +) within and protruding out of the deployed stent.
A 67-year-old male patient with history of ischemic cardiomyopathy and functional mitral regurgitation (FMR) treated with coronary artery bypass surgery and mitral annuloplasty with ring insertion in 2007, presented with right-heart failure symptoms, severe liver congestion, and hepatic encephalopathy. Echocardiography revealed a severe left-ventricular dysfunction (ejection fraction 24%), a dilated right ventricle with reduced systolic right ventricular function (tricuspid annular plane systolic excursion, 13 mm), moderate-to-severe tricuspid regurgitation, and moderate-to-severe transvalvular FMR (vena contracta: 0.7 cm; proximal isovelocity surface area: 0.9 cm; effective regurgitant orifice area: 0.3 cm2; regurgitant volume: 45 ml/beat). FMR relapse was caused by posterior detachment of the surgical annuloplasty ring (nonradiopaque St. Jude Seguin 28-mm ring) (Figure 1A, Online Videos 1 and 2). Due to the high surgical risk (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation]: 33%), comorbidities, and previous cardiac surgery, the Heart Team opted for percutaneous transcatheter mitral valve repair with the MitraClip device (Abbott Vascular, Abbott Park, Illinois). After assessment of the typical central regurgitant jet (Figure 1B), FMR was significantly reduced to trace after implantation of 2 clips (Figure 1E, Online Video 3). No mitral stenosis was observed after the procedure (Figure 1F). The patient demonstrated clinical improvement in the following days, with normalization of renal and liver functions, as well as resolution of the hepatic encephalopathy.
A 68-year-old man with atrial fibrillation was evaluated for ligation of the left atrial appendage (LAA) via the LARIAT Suture Delivery Device (SentreHEART, Redwood City, California). The CHA2DS2-VASc score was 4 for hypertension, cerebrovascular accident, and age. He was intolerant of anticoagulation due to recurrent gastrointestinal hemorrhage. Imaging revealed an anteriorly directed LAA of chicken wing morphology, with a secondary lobe near the ostium
An 84-year-old woman with severe aortic stenosis presented for transapical transcatheter aortic valve replacement because her aorta was severely calcified and tortuous.
A 71-year-old woman with chest pain consulted us 1 week after an emergent operation for a small intestine perforation. She had previously undergone percutaneous coronary intervention (PCI) twice for the left anterior descending artery. The first was performed with a bare-metal stent 5 years earlier, and the second was performed for in-stent restenosis (ISR) treated with a biolimus A9–eluting stent. Angiography revealed 99% restenosis at the same location as that of the previous ISR (Figure 1A, Online Video 1); therefore, PCI was performed. Immediately after initial dilation using a semicompliant 2.0-mm balloon, the coronary flow abruptly disappeared (Figure 1B, Online Video 2).
Cookies Sociales
Son esos botones que permiten compartir el contenido del sitio web en sus redes sociales (Facebook, Twitter y Linkedin, previo tu consentimiento y login) a través de sistemas totalmente gestionados por dichas redes sociales, así como los recursos (pej. videos) y material que se encuentra en nuestra web, y que de igual manera se presta y gestiona completamente por un tercero.
Si no acepta estas cookies, no podrá compartir nuestro contenido a través de los botones, y en su caso, no podrás visualizar el contenido de terceros que hayamos incrustado en el sitio.
No las utilizamos