Search

Advances in surgical techniques in tetralogy of Fallot (TOF) patients have improved survival of these patients into adulthood. The procedure requires right ventricular outflow tract or trans-annular patch with resultant pulmonary stenosis and/or regurgitation. As such, adult patients seen with this condition may have increasing right ventricular hypertrophy and/or right ventricular dilation. Recently, the Sapien XT valve (Edwards Lifesciences, CA) was approved by the FDA for pulmonary implantation. In some cases, advancing the valve in right ventricular outflow tract is difficult. This is a case series of delivering Sapien XT valves in TOF patients with severe pulmonary regurgitation and/or stenosis, using the anchor balloon, buddy wire, and the novel, wire and sheath techniques. © 2017 Wiley Periodicals, Inc.

Introduction Current guidelines recommend continuation of dual anti-platelet therapy (DAPT) for 12 months after percutaneous coronary intervention (PCI). Recent studies have shown benefit in continuing DAPT beyond 12 months but at the risk of increase bleeding. To date, there has been little data on risk stratifying patients to determine who can continue DAPT beyond 12 months at minimal bleeding risk. Methods All patients who underwent drug-eluting stent (DES) placement from January 1, 2013 to September 30, 2014 were reviewed. Patients who had follow-up for at least 12 months, placement of 2nd generation everolimus-coated DES, and were on DAPT for at least 12 months were included. Patients with a history of atrial fibrillation, follow-up time less than 12 months, or were on concurrent oral anticoagulation therapy were excluded. Results Five hundred thirty-one patients were analyzed as described above. Two hundred two patients included in our study with 7 patients in the bleeding cohort and 195 patients in no-bleed cohort. The HAS-BLED score in patients who had a bleeding episode vs. those who did not was 3.29 vs. 2.24 (P value of 0.0009). Although not statistically significant, patients who had a bleeding episode were more likely to have renal dysfunction, alcohol use, be on prasugrel, and be on 325mg of aspirin. Conclusion The study shows that the HAS-BLED score can be of utility in risk stratifying patients in determining who can continue DAPT beyond 12 months. Furthermore, a HAS-BLED score of less than 2 may help guide extended DAPT beyond 12 months at minimal bleeding risk. © 2016 Wiley Periodicals, Inc.

Coarctation of the aorta (COA) is one of the more common congenital anomalies, occurring in four in ten thousand live births and accounting for five to eight percent of all congenital heart defects. COA lesions can be challenging to treat percutaneously, especially if complex vascular anatomy is a barrier to crossing the lesion. We present two cases of COA that utilized a trans-septal approach to cross the lesion in anterograde fashion, subsequently facilitating retrograde stenting of the lesions after snaring and externalizing the wire. In both cases, the trans-septal approach was employed because traditional femoral and radial approaches failed due to complex anatomy, and the trans-septal approach allowed for effective intervention without the need for surgery.

Actinomycotic endocarditis is a rare disease with only 18 documented cases to date. Most of these cases are sub-acute or chronic infections and usually lack the stigmata of classic endocarditis. This article reviews the details of previously published reports of endocarditis due to various species of actinomyces, along with consensus opinion on diagnosis and treatment. We also present our unique case of Actinomyces naeslundii infective endocarditis, the first case ever attributed to this organism in medical literature.

OBJECTIVES: The purpose of this study was to understand the reason for variation in the sensitivity of different methods of detecting right-to-left shunts (RLS). BACKGROUND: Patent foramen ovale (PFO) is implicated in the pathogenesis of cryptogenic stroke, decompression illness, and migraine headaches. Intravenous agitated saline injections with tomographic imaging (transthoracic, transesophageal, and intracardiac echocardiography) has been used for detecting intracardiac shunts. Some patients with a high clinical suspicion of PFO have inconclusive echocardiographic study results. Transcranial Doppler (TCD) is an alternative method for detecting RLS that is not dependent on tomographic imaging. METHODS: Thirty-eight consecutive patients who were undergoing PFO closure had simultaneous transcranial Doppler and intracardiac echocardiography performed. Agitated saline injections were performed at rest, with Valsalva maneuver, and with forced expiration into a manometer to 40 mm Hg before and after closure, as well as 3 or more months after closure. Right atrial pressures were measured in the periprocedural period, and RLS were graded according to standard methods during these maneuvers. RESULTS: Right atrial pressures were significantly higher with Valsalva maneuver compared with rest (before closure 21.6 +/- 11.9 mm Hg vs. 6.6 +/- 2.6 mm Hg, p < 0.001; after closure 28.4 +/- 13.9 mm Hg vs. 6.8 +/- 2.6 mm Hg, p < 0.001) and with manometer compared with Valsalva maneuver (before closure 38.7 +/- 6.6 mm Hg vs. 21.6 +/- 11.9 mm Hg, p < 0.001; after closure 44.0 +/- 9.5 mm Hg vs. 28.4 +/- 13.9 mm Hg, p < 0.001). Intracardiac echocardiography underestimated shunting in 34% of patients with Valsalva maneuver or manometer after closure compared with TCD. CONCLUSIONS: Transcranial Doppler with immediate feedback provided by forced expiration against a manometer to 40 mm Hg is more sensitive than echocardiographic imaging for the detection of RLS. These observations have significant implications for determining the incidence of RLS in patients with stroke or migraine.

Current guidelines recommend continuation of dual anti-platelet therapy (DAPT) for 12 months after percutaneous coronary intervention (PCI). Recent studies have shown benefit in continuing DAPT beyond 12 months but at the risk of increase bleeding. To date, there has been little data on risk stratifying patients to determine who can continue DAPT beyond 12 months at minimal bleeding risk.All patients who underwent drug-eluting stent (DES) placement from January 1, 2013 to September 30, 2014 were reviewed. Patients who had follow-up for at least 12 months, placement of 2nd generation everolimus-coated DES, and were on DAPT for at least 12 months were included. Patients with a history of atrial fibrillation, follow-up time less than 12 months, or were on concurrent oral anticoagulation therapy were excluded.Five hundred thirty-one patients were analyzed as described above. Two hundred two patients included in our study with 7 patients in the bleeding cohort and 195 patients in no-bleed cohort. The HAS-BLED score in patients who had a bleeding episode vs. those who did not was 3.29 vs. 2.24 (P value of 0.0009). Although not statistically significant, patients who had a bleeding episode were more likely to have renal dysfunction, alcohol use, be on prasugrel, and be on 325mg of aspirin.The study shows that the HAS-BLED score can be of utility in risk stratifying patients in determining who can continue DAPT beyond 12 months. Furthermore, a HAS-BLED score of less than 2 may help guide extended DAPT beyond 12 months at minimal bleeding risk. © 2016 Wiley Periodicals, Inc.

Coarctation of the aorta (COA) is one of the more common congenital anomalies, occurring in four in ten thousand live births and accounting for five to eight percent of all congenital heart defects. COA lesions can be challenging to treat percutaneously, especially if complex vascular anatomy is a barrier to crossing the lesion. We present two cases of COA that utilized a trans-septal approach to cross the lesion in anterograde fashion, subsequently facilitating retrograde stenting of the lesions after snaring and externalizing the wire. In both cases, the trans-septal approach was employed because traditional femoral and radial approaches failed due to complex anatomy, and the trans-septal approach allowed for effective intervention without the need for surgery.

Although performing a biopsy of the right ventricular septum is a routine procedure in many cardiac catheterization laboratories, the ability to direct a bioptome to a mass within the right or left side of the heart is extremely difficult with fluoroscopic or echocardiographic guidance. The first intracardiac echo (ICE) was performed in the early 1970s. Since that time, the use of ICE in the cardiac catheterization laboratory has aided in transseptal puncture, ablation of cardiac arrhythmias, mitral valvuloplasty, and the closure of atrial septal defects and patent foramen ovale. This case report describes the use of ICE to facilitate intracardiac biopsy of a right atrial mass.

Percutaneous coronary intervention (PCI) has traditionally not been an option for patients with end-stage liver disease (ESLD) and coronary artery disease (CAD). This retrospective study was designed to demonstrate the feasibility and safety of PCI in liver transplant candidates. Patients with ESLD and hemodynamically significant CAD who were otherwise deemed to be acceptable candidates for liver transplantation underwent PCI. The procedural success rates, mortality and myocardial infarction rates, and bleeding outcomes were examined. Sixteen patients with ESLD underwent PCI: 15 with bare-metal stents (1.3 stents per patient on average) and 1 with balloon angioplasty alone. The median diameter stenosis per lesion was 80%, the median platelet count was 68 × 10(9) /L, the median international normalized ratio was 1.3, and the median Model for End-Stage Liver Disease score was 13. PCI was successful in 94% of the patients. One patient had a suboptimal residual stenosis of 50% after stenting. There were no in-hospital or 30-day deaths or myocardial infarctions, and no patients developed hematomas. One patient required a 1-U platelet transfusion, and another required 1 U of packed red blood cells. All patients remained clinically stable 1 month after PCI. Nine of the 16 patients were listed for liver transplantation, and 3 patients underwent liver transplantation. In conclusion, we have demonstrated the safety and feasibility of PCI in a small cohort of patients with ESLD and hemodynamically significant CAD, the majority of whom had significant thrombocytopenia. Larger studies are required to determine whether PCI is an effective treatment strategy for patients with ESLD and hemodynamically significant CAD who otherwise would not be candidates for liver transplantation.

The HELEX device is approved for percutaneous closure of an atrial septal defect (ASD). It is also often used off-label to close patent foramen ovale (PFO). The device is well tolerated because it is very flexible, but this characteristic increases the likelihood of embolization of locked implants. While the company provides a mechanism to retrieve devices that do not lock correctly, retrieval of locked and released devices is much more difficult. A case of percutaneous retrieval of an embolized, locked HELEX device is reported. This device was successfully retrieved from the aorta by snaring the left atrial eyelet and unlocking the device. A variety of potential techniques for retrieval of these devices was explored on the bench top. Strategies which can be used to successfully retrieve embolized HELEX devices are described. © 2011 Wiley-Liss, Inc.