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Serious paravalvular leakage occurs in 1-5% of patients who have undergone surgical cardiac valve replacement procedures. Clinical manifestations include hemolysis, heart failure and arrhythmias. Presently, the gold standard treatment for severe paravalvular leakage is surgery; however, the outcomes remain far from optimum. In this Review we discuss the problem of paravalvular leak and focus on the role of percutaneous repair as a treatment option.

Saphenous vein graft aneurysms are an uncommon late complication of coronary artery bypass surgery (CABG). Management strategies include surgical revision, percutaneous closure using covered stent grafts, coil embolisation, vascular plug insertion and ethylene vinyl alcohol copolymer injection. We report a case of a very large saphenous vein graft aneurysm successfully treated with a covered stent graft.

Background This study evaluates the in-hospital, 30 day and long-term results of stenting for unprotected left main coronary artery disease in our institution. Methods Between April 2001 and October 2005 all unprotected left main cases were retrospectively reviewed. Outcomes were obtained by case note review and postal questionnaire; primary care physicians were contacted to complete missing data. Results We identified 100 consecutive patients who underwent unprotected left main procedures, 1.44% of the institution PCI volume. Indications for a percutaneous strategy were non-surgical candidates (47), emergency revascularisation (25) and patient/physician preference (28). Overall procedural success was 97%. The majority of cases ( n =78) were performed with a single-stent strategy. 55% received a drug-eluting stent. There were 7 in-hospital deaths, 5 in the emergency group (cardiogenic shock) and 2 non-CABG candidates. Post hospital discharge long-term clinical follow-up was 651±431 days (range 6–1741). There were 8 deaths post discharge. Patients presenting as an emergency had a 72% survival rate at long-term follow-up, non-surgical candidates 83%, and patient/physician preference group had a 100% long-term survival. Multivariate analysis revealed cardiogenic shock (HR=7.9, 95% CI 1.7–3.6, p =0.008), failed thrombolysis (HR=8.5, 95% CI 1.7–41.7, p =0.008) and use of a bare-metal stent (HR=4.4, 1.1–17.0, p =0.034) were independent predictors of mortality. Conclusions Our data suggest that in contemporary practice stenting for unprotected left main disease can be considered as an alternative treatment to surgery for selected patients. The results of randomised controlled trials are awaited.

Patients undergoing elective PCI are traditionally admitted overnight, however day case PCI cuts costs and has been proposed as a safe method for selected patients. We evaluated the success and long term clinical outcomes of day case percutaneous coronary intervention (PCI) for outpatients with stable angina. In total, 484 consecutive patients treated over a five year period with planned day case PCI were studied and followed up for 12 months. Successful PCI with same day discharge was performed in 463 patients (95.7%). There were 21 patients (4.3%) who required hospital admission. Reasons for failed discharge were hematoma formation (n=7, 1.4%), coronary dissection (n=4, 0.8%), post-procedural chest pain (n=3, 0.6%), prolonged procedure (n=2, 0.4%), and 1 each of acute stent thrombosis, coronary perforation, anaphylaxis, minor drug reaction and a functional study for untreated disease. One year follow up was complete for 439/484 (90.7%). At 12 months there were 6 hospitalizations for angina (1.2%, 95% CI 0.6-3.0%), 20 repeat revascularisations (4.1%, 95% CI 2.7-6.3%), 3 myocardial infarctions (0.6%, 95% CI 0.2-2.1%) and 2 deaths (0.4%, 95% CI 0.1-1.6%). Event free survival at 1 year follow up was 93.6% (95% CI 90.7-95.6%). Selecting patients for day case PCI is safe, and can achieve a high rate of success with excellent long term outcomes.

Objective: To review the procedures, results and follow-up of patients who underwent percutaneous device closure of a patent foramen ovale (PFO) during pregnancy. We report modifications made to the established technique that allowed absolute minimization of radiation exposure. Relevant management issues of this unusual presentation of cardiac disease in pregnancy are discussed. Background: Stroke during or immediately prior to pregnancy is a catastrophic event. Paradoxical embolism may be more frequent due to the hypercoagulable state and increased incidence of venous thromboembolism. Treatment strategies must take into account the competing risks to mother and fetus. Methods: Three patients, aged 34, 27, and 39, presented with ischemic neurological events during or immediately preceding pregnancy. Due to evidence of recurrent events or relative contraindication to anticoagulation they proceeded to percutaneous device closure during the second trimester. The Helex device (WL Gore and Associates) was used in all patients. Procedures were performed with local anesthesia under intra-cardiac echocardiography guidance. Results: Successful closure was achieved with the Helex device in all three patients. Radiation doses, as assessed by dose area product, were 260, 58, and 19 cGy/cm2, with estimated uterine (fetal) dose of

We report the successful percutaneous closure of an iatrogenic atrial septal defect in a 71-year-old woman. The patient had undergone mitral valve replacement and coronary artery bypass grafting, followed by redo surgery to repair a para-valvular mitral leak. Post-operatively she remained significantly limited by dyspnoea. Repeat transoesophageal echocardiography documented a large iatrogenic atrial septal defect. The patient underwent percutaneous, trans-femoral closure of the defect using the Helex septal occluder (W.L. Gore, Newark, Delaware, USA) with dramatic clinical improvement.

A 76-year-old man presented with successfully resuscitated cardiac arrest due to ventricular tachycardia. He was in florid pulmonary oedema, but maintaining a blood pressure and electrically stable. Past medical history included hypertension and a permanent pacemaker for syncope. Transthoracic echocardiography revealed a muscular ventricular septum rupture with gross left-to-right shunting (Panel A). Clinical progress was marked by refractory pulmonary oedema and recurrent gastrointestinal bleeding. Due to excessive surgical risk he underwent …