Surgery for delayed leaflet impingement after transcatheter closure of a paravalvular leak associated with an aortic pseudoaneurysm

Background: Paravalvular leak (PVL) is a recognized and challenging complication after surgical or transcatheter valve replacement. The transcatheter closure of PVL has become the first-line treatment in clinical practice when the procedure is not contraindicated. Transcatheter PVL closure rests on a complex procedure and complications still occur in approximately 9% of patients. Case Report: We describe the case of a delayed mechanical prosthetic leaflet impingement after transcatheter closure of a paravalvular leak associated with a Valsalva pseudoaneurysm that required an urgent surgery. Conclusion: Aorta-left ventricle communication could be a relative contraindication to be assessed on a case-by-case basis, but transcatheter closure does not preclude subsequent attempt for surgical repair and outcome.

A Complicated Case Report of Coronary Artery Fistula

Background

Coronary artery fistulas (CAFs), also, known as coronary arteriovenous malformation, are aberrant connections between coronary arteries and other structures, such as other artery branches or heart chambers. CAFs are infrequent and asymptomatic in young patients, but symptoms and complications become more frequent with age. CAFs can affect hemodynamic parameters and lead to complications, such as myocardial ischemia, heart failure, arrhythmia, and infective endocarditis.

Objective

The aim of this article was to present a typical CAF case with severe symptoms who underwent successful embolization to resolve their symptoms.

Case presentation

A 50-year-old Vietnamese male visited our cardiac outpatient clinic (S.I.S General Hospital, Can Tho, Vietnam) because of exertional dyspnea and chest pain. Signs of congestive heart failure and abnormal murmur were not presented on chest auscultation. Diagnostic digital subtraction angiography was performed to determine the detailed angioarchitecture of the CAF, revealing a fistulous connection between the left anterior descending artery (LAD) and the LV chamber through an aneurysm. In addition, the RCA measured 7 mm in diameter with a fistula (16 × 9 mm) draining into an aneurysm and then terminating into the LV chamber. The patient had an RCA aneurysm with a fistula into the LV. It was treated successfully by closing the fistula with a vascular plug. Access to the fistula was complex and difficult because of complications due to the CAF. After the procedure, the patient had no chest pain or shortness of breath and was discharged after three days. After six months, he was taking dual antiplatelet therapy and antihypertensive medications and felt better. We performed contrast computed tomography (CT) to examine the fistula after a year, which showed the successful closure of the fistula without any relevant alteration in the coronary artery.

Conclusion

CAF closure is indicated if patients have symptoms or secondary complications, and percutaneous closure is a safe and effective method to manage CAF. A CAF is rare and does not have specific symptoms, making it difficult to diagnose. Most patients are asymptomatic and have serious recent complications. Currently, the percutaneous transcatheter method is popular because it is noninvasive and successful in most patients.

Clinical Characteristics and Contemporary Prognosis of Ventricular Septal Rupture Complicating Acute Myocardial Infarction: A Single-Center Experience

Objectives: Ventricular septal rupture (VSR) is a rare but lethal complication of acute myocardial infarction (AMI). We conducted a retrospective analysis of the clinical characteristics of VSR patients and explored the risk factors for long-term mortality. Methods: In this single-center cohort study, 127 patients diagnosed with post-AMI VSR between May 2012 and April 2019 were included. Demographic, clinical, operative, and outcome data were collected. The 30-day and long-term mortality were outcomes of interest. Cox proportional hazard regression analysis was used to explore the predictors of long-term mortality. Results: The mean age of the VSR cohort was 66.6 ± 8.7 years, 67 (52.8%) were males. Among the 127 patients, 78 patients (61.4%) were medically managed, 31 (24.4%) patients underwent percutaneous transcatheter closure (TCC), and 18 (14.2%) patients received surgical repair. The median follow-up time was 1129 days [interquartile range: 802-2019 days]. The 30-day mortality of the medically managed group, percutaneous TCC group, and surgical management group was 93.6, 22.6, and 11.1%, respectively; and the long-term mortality was 96.2, 25.8, and 22.2%, respectively. VSR repair treatment including surgical management (HR 0.01, 95% CI 0.001-0.09, p < 0.001) and percutaneous TCC (HR 0.09, 95% CI 0.03-0.26, p < 0.001) was associated with a better prognosis, and cardiogenic shock (CS) (HR 9.30, 95% CI 3.38-25.62, p < 0.001) was an independent risk factor of long-term mortality. Conclusions: The prognosis of VSR patients without operative management remains poor, especially in those complicated with CS. Timely and improved surgery treatment is needed for better outcomes in VSR patients.

The immediate haemodynamic response and right and left cardiac remodelling after percutaneous transcatheter closure of secundum atrial septal defect in children: a longitudinal cohort study

OBJECTIVE

We aimed to assess the immediate haemodynamic response and the timing of cardiac remodelling in paediatric secundum atrial septal defect patients who underwent percutaneous transcatheter closure.

METHODS

In this longitudinal cohort study with 41 paediatric secundum ASD patients who underwent PTC with Amplatzer Occluder device were assessed for immediate post-interventional haemodynamic response measured by catheterisation and was evaluated for right and left cardiac remodelling during a follow-up period of 12 months by transthoracic echocardiography. SPSS 20.0 was used for statistical analyses of pre- and post-interventional invasive haemodynamic parameters of the patients, and pre- and post-interventional TTE data compared with the values of the control group consisted of 39 healthy children.

RESULTS

The mean diameter of ASD was 13.9 ± 4.7 mm. PTC intervention in all patients completed with 100% success and 0% complication rates. All invasive haemodynamic data, except the ratio of pulmonary resistance to systemic resistance, significantly reduced after PTC (p < 0.05). TTE and PW Doppler revealed that right and left cardiac remodelling started as soon as the post-interventional 24th hour and completed in the 12th month.

CONCLUSIONS

This study with a very high interventional success rate can be counted as the first example of research on the haemodynamic response and timing of cardiac remodelling after PTC of secundum ASD in children. We suggest that future multicentric studies with larger cohorts and a comprehensive methodology like ours with longer follow-up periods would better serve to further assess the cardiac remodelling in children after PTC of secundum ASD.

Transcatheter Closing Atrial Septal Defect in a Child With Hereditary Spherocytosis

A 3-year-old girl was admitted to our hospital for the correction of atrial septal defect (ASD). Open heart operation with cardiopulmonary bypass is dangerous because the patient also had hereditary spherocytosis, which put her at risk for hemolytic anemia. Therefore, percutaneous transcatheter closure for ASD was chosen and performed successfully, which avoided the erythrocyte damage caused by cardiopulmonary bypass. This is the first time such a case has been reported, and we present an alternative approach for ASD with hereditary spherocytosis.

Efficacy and Safety of Transthoracic Echocardiography Alone in Transcatheter Closure of Secundum-Type Atrial Septal Defects in Adults

BACKGROUND

On-site transthoracic echocardiography (TTE) to guide the transcutaneous closure of secundum-type atrial septal defects (ASDs) in the catheterization laboratory remains unclear, especially in adults.

METHODS

Between 2005 and 2012, a total of 82 adults underwent transcutaneous closure of ASDs. The initial 15 cases underwent the procedure with both on-site transesophageal echocardiography (TEE) and TTE monitoring. Since January 2008, a total of 67 patients underwent on-site TTE alone to guide the procedure.

RESULTS

Among the 82 adult patients who underwent a transcutaneous closure of the secundum-type ASD procedure, all had successful closure of the defects, and no periprocedural adverse complications occurred. No statistical significance was observed in the successful complete shunt closure rate between the TEE plus TTE and TTE groups during sequential follow-up (postprocedure 24 hour [87% vs. 92%],1 month [93% vs. 95%], 3 month [93% vs. 97%], and 12 month [93% vs. 97%], P > 0.05, respectively) nor was a significant difference observed between the two groups, including decreased right ventricular dimension (29.5 ± 3.3 vs. 32.0 ± 4.9 mm, 26.5 ± 3.0 vs. 28.7 ± 4.6 mm, 26.2 ± 3.1 vs. 28.2 ± 4.8 mm, and 25.6 ± 2.8 vs. 27.7 ± 4.7 mm, P > 0.05, respectively) or increased left ventricular end-diastolic dimension (41.1 ± 2.0 vs. 42.6 ± 3.0 mm, 44.3 ± 2.7 vs. 45.5 ± 3.1 mm, 44.2 ± 2.8 vs. 45.4 ± 3.1 mm, 44.9 ± 2.7 vs. 45.8 ± 2.6 mm, P > 0.05, respectively) before the procedure, and at the 3-, 6-, and 12-month follow-up evaluations.

CONCLUSION

This study showed that TTE guidance alone may be considered efficacious and safe as TEE during a transcutaneous ASD occlusion procedure in select adults.

How to Understand Patent Foramen Ovale Clinical Significance - Part II: Therapeutic Strategies in Cryptogenic Stroke

In the first part of this review, we reminded that patent foramen ovale (PFO) is a slit or tunnel-like passage in the interatrial septum occurring in approximately 25% of the population and that a number of conditions have been linked to its presence, the most important being cryptogenic stroke (CS) and migraine. We have also shown how, in the setting of neurological events, it is not often clear whether the PFO is pathogenically-related to the index event or an incidental finding, and therefore we thought to provide some useful key points for understanding PFO clinical significance in a case by case evaluation. The controversy about PFO pathogenicity has consequently prompted a paradigm shift of research interest from medical therapy with antiplatelets or anticoagulants to percutaneous transcatheter closure, in secondary prevention. Observational data and meta-analysis of observational studies previously suggested that PFO closure with a device was a safe procedure with a low recurrence rate of stroke, as compared to medical therapy. However, so far, published randomized controlled trials (CLOSURE I^®, RESPECT^® and PC Trial^®) have not shown the superiority of PFO closure over medical therapy. Thus, the optimal strategy for secondary prevention of paradoxical embolism in patients with a PFO remains unclear. Moreover, the latest guidelines for the prevention on stroke restricted indications for PFO closure to patients with deep vein thrombosis and high-risk of its recurrence. Given these recent data, in the second part of the present review, we aim to discuss today treatment options in patients with PFO and CS, providing an updating on patients’ management.