A 75-year-old woman presented with progressive dyspnea on exertion. She had a history of bicuspid aortic valve stenosis status post-Ross procedure in 2001, and subsequent pulmonary homograft failure prompting a replacement in 2002, complicated by entry into the aorta that was adherent to the undersurface of the sternum with massive bleeding status post-repair. Pertinent comorbidities included chronic kidney disease, diabetes, and prior stroke. Echocardiography and computed tomography imaging revealed a thickened, severely calcified pulmonary homograft with severe pulmonic regurgitation (Figure 1).
An 83-year-old woman with hypertension, hyperlipidemia, coronary artery disease, and porcelain aorta presented with symptomatic severe aortic stenosis (mean gradient 45 mm Hg) and underwent a successful transcatheter aortic valve replacement using a 23-mm Edwards S3 Ultra (Edwards Lifesciences, Irvine, California) on December 14, 2020. She did well in the postoperative setting and was discharged on day 2 with no complications. A postoperative echocardiogram on days 1 and 30 showed a normal functioning aortic bioprosthetic valve with a mean gradient of 6 mm Hg. She presented with symptoms of breathlessness 3 months later and was noted to have continuous murmur on physical examination, and a transthoracic and transesophageal echocardiogram demonstrated a fistula between the right coronary cusp and the right ventricle consistent with a contained rupture (Figures 1 and 2, Video 1). She underwent a right heart catheterization, which showed a significant left-to-right shunt with a shunt fraction of 1.78:1 (Qp:Qs). She successfully underwent closure of the defect using a 4-mm Amplatzer Septal Occluder (Abbott, Plymouth, Minnesota) with a reduction in the shunt fraction to 1:1 (Qp:Qs). Subsequent transthoracic and transesophageal echocardiography showed a normal functioning bioprosthetic valve function (mean gradient 7 mm Hg) and trace leak.
A 59-year-old woman presented with fibrosing mediastinitis from prior coccidioidomycosis infection causing severe bilateral proximal branch pulmonary artery (PA) obstruction and right ventricular hypertension. Bilateral PA stents were placed 12 years ago. Ten years ago, the left PA stent was completely occluded and the right stent severely stenotic. A surgical right ventricle–PA homograft was placed to the right PA distal to the stent and the left PA “abandoned.” Cardiac computed tomography showed no flow through the left PA stent and minimal flow through the right stent (Figure 1). She required chronic supplemental oxygen and had dyspnea with walking for 10 years, which recently worsened, and was referred for left PA recanalization.
An 89-year-old man with aortic stenosis and an anomalous origin of the left coronary artery (Figures 1A and 1B, Videos 1 and 2) underwent transcatheter aortic valve replacement (TAVR). The left coronary artery originated near the commissure of the non and left coronary cusp. Because the right coronary leaflet was heavily calcified, we anticipated the transcatheter valve would be biased toward the left main trunk (LMT). We protected the left coronary artery with 2 wires during TAVR to mitigate the risk of coronary occlusion. After a 29-mm CoreValve Evolut PRO+ (Medtronic Inc., Galway, Ireland) crossed the aortic valve following balloon aortic valvuloplasty, his blood pressure immediately dropped and electrocardiogram showed ST-segment elevation in aVR. We rapidly expanded the Evolut PRO+ at the point of no recapture; however, his blood pressure did not recover. Maintaining his blood pressure with epinephrine, we performed coronary angiography and intravascular ultrasound (Figures 1C to 1E, Videos 3 and 4). Although LMT appeared hazy by coronary angiography, intravascular ultrasound clearly revealed the narrowed lumen of the proximal LMT, but not the ostium. Confirming LMT narrowing, which might be associated with extramural compression caused by the Evolut PRO+ and aortic valve leaflets, we implanted a 4.0-mm drug-eluting stent in LMT. Afterward, his blood pressure and ST-segment elevation improved. Finally, the Evolut PRO+ was uneventfully released (Figures 1F to 1H, Videos 5 and 6). Multidetector computed tomography after TAVR supported the speculation of extramural compression (Figure 1I).
A 65-year-old man with diabetes mellitus, hyperlipidemia, and previous coronary interventions was referred for coronary angiography, due to angina and ischemia in a nuclear scan. Multiple lesions and in-stent restenosis were found, and bypass surgery was recommended.
Coronary artery fistulas (CAFs) are rare coronary anomalies that are usually diagnosed incidentally with cardiac imaging. Small CAFs are generally asymptomatic and can close over time, while some untreated medium or large CAFs can enlarge, leading to clinical sequelae such as cardiac chamber enlargement or myocardial ischemia. With the advancement of transcatheter equipment and techniques, CAFs have been increasingly closed using a percutaneous approach. However, the procedure is not free of limitations given the risk for myocardial infarction, device embolization, and fistula recanalization. In this review, the authors illustrate the contemporary procedural considerations, techniques, and outcomes of transcatheter CAF closure.
Objectives The authors sought to evaluate the impact of ischemic burden reduction after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on long-term prognosis and cardiac symptom relief.
Objectives The aims of this study were to use a national percutaneous coronary intervention (PCI) registry to study temporal changes in procedure volumes of PCI using rotational atherectomy (ROTA-PCI), the patient and procedural factors associated with differing quartiles of operator ROTA-PCI volume, and the relationship between operator ROTA-PCI volumes and in-hospital patient outcomes.
Objectives The aim of this study was to assess the impact of age on the safety and efficacy of ticagrelor monotherapy after percutaneous coronary intervention (PCI).
Objectives The aim of the present study was to evaluate the safety and efficacy of thinner strut Firesorb (100/125 μm) sirolimus-eluting bioresorbable scaffolds (BRS) versus cobalt-chromium everolimus-eluting stents (CoCr-EES) in patients with coronary artery disease
Objectives This study aimed to compare incidence and impact of measured prosthesis-patient mismatch (PPMM) versus predicted PPM (PPMP) after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR).
Objectives The aim of this study was to assess the impact of aortic valve replacement (AVR) on survival in patients with each subclass of low-gradient (LG) aortic stenosis (AS) and to compare outcomes following surgical AVR (SAVR) and transcatheter AVR (TAVR).
Objectives The aim of this study was to assess the impact of aortic valve replacement (AVR) on survival in patients with each subclass of low-gradient (LG) aortic stenosis (AS) and to compare outcomes following surgical AVR (SAVR) and transcatheter AVR (TAVR).
Objectives This study investigated whether transcatheter aortic valve replacement (TAVR) with peri-procedural continuation of oral anticoagulation is equally safe and efficacious as TAVR with peri-procedural interruption of anticoagulation.
Transcatheter aortic valve replacement (TAVR) is a safe and feasible alternative to surgery in patients with symptomatic severe aortic stenosis regardless of the surgical risk. Conduction abnormalities requiring permanent pacemaker (PPM) implantation remain a common finding after TAVR due to the close proximity of the atrioventricular conduction system to the aortic root. High-grade atrioventricular block and new onset left bundle branch block (LBBB) are the most commonly reported conduction abnormalities after TAVR. The overall rate of PPM implantation after TAVR varies and is related to pre-procedural and intraprocedural factors. The available literature regarding the impact of conduction abnormalities and PPM requirement on morbidity and mortality is still conflicting. Pre-procedural conduction abnormalities such as right bundle branch block and LBBB have been linked with increased PPM implantation and mortality after TAVR. When screening patients for TAVR, heart teams should be aware of various anatomical and pathophysiological conditions that make patients more susceptible to increased risk of conduction abnormalities and PPM requirement after the procedure. This is particularly important as TAVR has been recently approved for patients with low surgical risk. The purpose of this review is to discuss the incidence, predictors, impact, and management of the various conduction abnormalities requiring PPM implantation in patients undergoing TAVR.
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