Objectives The aim of this study was to evaluate the interaction between hospital endovascular lower extremity revascularization (eLER) volume and outcomes after eLER for critical limb ischemia (CLI).
Plaque neovascularization has been recognized as a common feature of plaque vulnerability. We observed neovascularization around the yellow plaque using a coronary angioscopy (CAS) in a patient with acute myocardial infarction (1). Three months after coronary intervention, we performed coronary angiography, followed by CAS and optical coherence tomography (OCT). Coronary angiography showed no restenosis, and the CAS image revealed a red network structure of capillaries around the yellow plaque as they were before (Figure 1, left; Video 1).
Development of a subclavian vein–left internal mammary artery (LIMA) arteriovenous fistula (AVF) is a rare but potentially fatal complication of pacemaker implantation and extraction (1-3). An 83-year-old woman with ischemic cardiomyopathy (left ventricular ejection fraction 35%-40%) status post coronary artery bypass grafting with LIMA graft to the left anterior descending coronary artery (LAD) developed progressive and recurrent heart failure exacerbations in the month following percutaneous extraction of a left-sided cardiac resynchronization therapy implantable cardioverter-defibrillator. This was the second device extraction from the left subclavian vein, with the first performed 18 months earlier using a laser. She was subsequently referred for right and left heart catheterization to evaluate her filling pressures and to rule out obstructive coronary disease. Right and left heart filling pressures were borderline, with a mean right atrial pressure of 7 mm Hg and pulmonary capillary wedge pressure of 12 mm Hg. Cardiac output was normal, with a cardiac index of 2.69 L/min/m2. Coronary angiography revealed a large AVF between the proximal LIMA and the left subclavian vein (Figure 1). Minimal flow was seen in the LIMA beyond the AVF (Video 1), and the distal LAD was seen instead to fill via left-to-right collateral vessels.
A 79-year-old woman with stable angina was admitted to our hospital. Coronary angiography revealed an extremely tortuous right coronary artery with severe ostial stenosis and several moderate stenoses (Figure 1A, Video 1). A long drug-eluting stent (Synergy 2.75/48 mm, Boston Scientific) was delivered to cover the stenoses. Pre–stent dilatation angiography demonstrated that the vessel was completely straightened, and several new stenoses appeared, representing the accordion phenomenon (Figure 1B, Video 2). Because the slitlike appearance remained after stent deployment and guidewire removal (Figure 1C, Video 3), we performed optical coherence tomography (Dragonfly Opstar, Abbott Vascular) (Video 4).
Acquired Gerbode defect (left ventricle [LV] to right atrium [RA] communication) following transcatheter aortic valve replacement (TAVR) is a rare procedural complication related to annular injury (1). Proposed developing mechanisms include direct lesion of the membranous septum due to asymmetric, heavily calcified aortic valve leaflets, LV outflow tract calcifications, use of balloon-expandable valve, and aggressive post-dilation
Percutaneous coronary intervention (PCI) for a chronic total occlusion (CTO) lesion is still one of the most challenging procedures. Especially in the case of a stumpless CTO lesion of a side branch, it is often difficult to straightly advance a guidewire because of the obtuse bifurcation angle. On the other hand, it is known that the proximal optimization technique (POT) is known to facilitate wire recrossing into the side branch by pushing the strut to the side branch after stenting in the main branch (1,2). We have recently experienced a challenging case of stumpless CTO of a side branch, in which POT in the main branch enabled a wire to be advanced into the CTO lesion. The patient was a 70-year-old man with worsening angina pectoris. Coronary angiography showed severe stenosis of the proximal left anterior descending artery (LAD) and a stumpless CTO lesion of the first diagonal branch (Figures 1A and 2A). Although we tried to advance several wires with using antegrade escalation strategy, any wires could not get caught in the entry point and ended up with advancing into the LAD. Therefore, the proximal part of the LAD was dilated using a 3.0-mm balloon (NSE ADVANCE, Goodman, Nagoya, Japan) with the distal shoulder of the balloon positioned exactly at the carina of the bifurcation as in POT (Figure 1B). As a result, we could make the entry to the CTO lesion of the side branch (Figures 1C and 2C). Intravascular ultrasound images in the LAD showed that the CTO entry of the side branch changed before and after the POT (Figures 2B and 2D). This allowed the CTO wire to be advanced into the lesion and successfully be advanced into distal true lumen (Figure 1D). After we dilated the occluded diagonal branch with a drug-coated balloon, we deployed a drug-eluting stent in the LAD (Figure 1E). One month later, coronary angiography showed good blood flow in the diagonal branch
Objectives This study sought to determine if percutaneous coronary intervention (PCI) prior to transcatheter aortic valve replacement (TAVR) in patients with significant coronary artery disease would produce noninferior clinical results when compared with no PCI (control arm).
Endocarditis following transcatheter aortic valve replacement (TAVR) for aortic stenosis portends a poor prognosis. An elderly woman presented with several months of lethargy, 15-kg weight loss, and dyspnea, 8 years after transapical TAVR with a 23-mm Edwards Lifesciences SAPIEN valve. Transthoracic echocardiography demonstrated the SAPIEN valve, with a mobile echodense mass arising from the prosthetic leaflets. Transesophageal echocardiography and cardiac computed tomography revealed features suggestive of advanced TAVR valve endocarditis (Figures 1, 2 and 3, Videos 1, 2, and 3). Enterococcus faecalis bacteremia was established, confirming the diagnosis of TAVR endocarditis, and antimicrobial therapy alone was pursued.
We herein present a 76-year-old man with dyspnea on exertion. He has a medical history of coronary artery disease with prior intervention, bicuspid aortic valve (Figure 1), severe aortic stenosis (peak/mean gradient 60/37 mm Hg, valve area of 0.7 cm2), and pacemaker implantation due to second-degree atrioventricular block. Additionally, he has DeBakey type 1 aortic dissection (primary entry tear in the mid-ascending aorta) status post-replacement of the ascending aorta with 32 Vascutek graft starting above the sinotubular junction.
An 81-year old woman, hospitalized due to New York Heart Association functional class III dyspnea, was diagnosed with true severe aortic stenosis (AS) and concomitant asymmetrical septal hypertrophy, causing borderline left ventricular outflow tract obstruction (LVOTO) (Figure 1A). Coronary angiography was normal. The invasively measured gradient was 64 mm Hg over the valve (Figure 2A). A multidisciplinary heart team recommended transcatheter aortic valve replacement (TAVR), which was performed successfully using a 26-mm self-expandable device (CoreValve Evolut R, Medtronic), without a relevant residual gradient (Figure 2B).
A 78-year-old woman, with history of dual coronary artery bypass grafting in 2009, had undergone transcatheter ACURATE neo aortic bioprosthesis (Boston Scientific) implantation in 2018 with no immediate complications. Two years later, in 2020, she was diagnosed with prosthetic valve endocarditis, with cerebral and splenic embolization, and mild prosthetic dysfunction, only medically treated. Six months after this, she was admitted with non–ST-segment elevation myocardial infarction. Left heart catheterization with aortic angiogram (Figure 1) was performed, showing contrast opacification of an abnormal structure outside the normal contour of the ascending aorta. Additional selective catheterization revealed the presence of a 15 by 12-mm pseudoaneurysm, in close relation with the upper extremity of one of the aortic bioprosthesis’s struts (Figure 2). Both the saphenous vein and internal mammary artery bypass were patent, with no lesions.
A 70-year-old man with previous rheumatic valvular heart disease and a left ventricular assist device (LVAD) was admitted for low-flow alarms. Six years ago, he underwent LVAD implantation, bioprosthetic aortic valve replacement, and mitral commissurotomy. He complained of new-onset dyspnea New York Heart Association (NYHA) functional class III and fatigue. LVAD interrogation showed low-flow alarms, reduction of mean flow, and no suctions. Low-flow alarms occurred more at night and after Valsalva maneuvers. He had mild signs of pulmonary congestion and high N-terminal pro–B-type natriuretic peptide values (2,880 ng/L); his mean arterial pressure was 80 mm Hg. An echocardiogram showed a normal right ventricular function, closed aortic bioprosthesis without regurgitation, and extensive degeneration of the mitral valve. Transesophageal echocardiogram confirmed moderate-to-severe mitral stenosis with a mean gradient of 6 mm Hg (Figure 1) and the patient was treated with percutaneous balloon valvuloplasty with transseptal approach. Several dilatations were performed (Figure 2, Video 1) with a 28-mm INOUE-BALLOON catheter (Toray Industries), achieving an increase of mitral valve area from 1.02 to 1.97 cm2 with a drop in mean gradient to <1 mm Hg (Figure 3). After the procedure, the patient’s exertional dyspnea improved to NYHA functional class II, and no low-flow alarm occurred.
Introduction Valve-in-valve transcatheter aortic valve replacement (TAVR) is an established option for failed bioprostheses. Nonetheless, some drops of bitterness remain. Coronary obstruction and prosthesis–patient mismatch still are issues, particularly in small-sized valves with externally mounted leaflets, low coronary ostia, or small roots with weakly pronounced sinus. Recently, an innovative approach, called BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction), was published in an initial small series (1). Currently, a larger multicenter registry compiled about 200 procedures, confirming feasibility and safety (2). The second innovative approach, SURPLUS (surgical resection of prosthetic valve leaflets under direct vision), described surgical resection of Evolut R leaflets (Medtronic) followed by implantation of S3 (Edwards Lifesciences) under direct visualization (3). Herein, we report OPEN-BASILICA using the example of a failed 21-mm Mitroflow (Sorin Group) in a high-risk patient (STS-PROM [Society of Thoracic Surgeons Predicted Risk of Mortality] score = 6.06%). The prosthesis was heavily calcified (dPmax/mean 75/44 mm Hg, aortic valve area 0.5 cm2) and the root enlargement ossified, making surgery unsuitable (Figures 1A and 1B). Further complicating matters, the true inner diameter of the 21-mm Mitroflow is 17.3 mm, strut height 13 mm, and left coronary artery height 2 mm above the annular plane (Figure 1A). Valve-in-valve TAVR was considered high risk, and effectiveness of BASILICA was not certain due to the heavy leaflet calcification. Therefore, the patient underwent OPEN-BASILICA (Video 1). The heavily calcified leaflets were surgically resected (Figures 1E and 1F), and a 23-mm Evolut R was implanted under direct vision in a pronounced supra-annular position (Figures 1G and 1H). Normal pressure postdilatation with a 20-mm balloon was performed subsequently under direct visualization to optimize expansion of the transcatheter heart valve (THV), but not to fracture the surgical ring. Postoperative hemodynamics were Pmax/mean 19/10 mm Hg on the sixth day in transthoracic echocardiography without any paravalvular leaks (Figures 1C and 1D).
Transcatheter mitral valve (MV) replacement (TMVR) has been explored for patients denied surgery and not suitable for interventional reconstruction (1). Early promising results of the Tendyne valve (Abbott Laboratories) implantation in very ill patients have been published (2). Here, a 69-year-old female patient with high surgical risk (STS [Society of Thoracic Surgeons] score of 7.1%) and cardiac decompensation was treated by TMVR: she had already received an 23-mm Perimount aortic bioprosthesis (Edwards Lifesciences) and later a valve-in-valve (ViV) procedure with a 26-mm Evolut R aortic valve (Medtronic) due to her porcelain aorta (Figure 1A). The MV insufficiency increased from stage II to stage IV 1 year after the transcatheter aortic ViV procedure. With respect to the severe symptomatic patient (New York Heart Association stage III-IV) and her sclerosed and thickened MV leaflets (Figure 1B), she was screened for a TMVR procedure
Objectives This study evaluated the association between elevated levels of lipoprotein(a) [Lp(a)] and risk of recurrent ischemic events in patients who underwent percutaneous coronary intervention (PCI).
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