Permanent pacemaker (PPM) requirement is a recognized complication of transcatheter aortic valve implantation. We assessed the UK incidence of permanent pacing within 30 days of CoreValve ...implantation and formulated an anatomic and electrophysiological model.
Data from 270 patients at 10 centers in the United Kingdom were examined. Twenty-five patients (8%) had preexisting PPMs; 2 patients had incomplete data. The remaining 243 were 81.3±6.7 years of age; 50.6% were male. QRS duration increased from 105±23 to 135±29 milliseconds (P<0.01). Left bundle-branch block incidence was 13% at baseline and 61% after the procedure (P<0.001). Eighty-one patients (33.3%) required a PPM within 30 days. Rates of pacing according to preexisting ECG abnormalities were as follows: right bundle-branch block, 65.2%; left bundle-branch block, 43.75%; normal QRS, 27.6%. Among patients who required PPM implantation, the median time to insertion was 4.0 days (interquartile range, 2.0 to 7.75 days). Multivariable analysis revealed that periprocedural atrioventricular block (odds ratio, 6.29; 95% confidence interval, 3.55 to 11.15), balloon predilatation (odds ratio, 2.68; 95% confidence interval, 2.00 to 3.47), use of the larger (29 mm) CoreValve prosthesis (odds ratio, 2.50; 95% confidence interval, 1.22 to 5.11), interventricular septum diameter (odds ratio, 1.18; 95% confidence interval, 1.10 to 3.06), and prolonged QRS duration (odds ratio, 3.45; 95% confidence interval, 1.61 to 7.40) were independently associated with the need for PPM.
One third of patients undergoing a CoreValve transcatheter aortic valve implantation procedure require a PPM within 30 days. Periprocedural atrioventricular block, balloon predilatation, use of the larger CoreValve prosthesis, increased interventricular septum diameter and prolonged QRS duration were associated with the need for PPM.
Epithelioid angiomyolipoma is a recently described rare variant of renal angiomyolipoma. It can occur in patients with or without tuberous sclerosis, and may potentially be malignant. We report the ...imaging findings from two cases of epithelioid angiomyolipoma: the first in a patient with tuberous sclerosis complex, arising in a horse-shoe kidney and growing into the inferior vena cava and right atrium; the second in a 62-year-old hypertensive man.
Abstract Objectives We sought to investigate the role of balloon size during pre-implantation valvuloplasty in predicting AR and optimal Medtronic CoreValve (MCS) implantation depth. Background ...Paravalvular aortic regurgitation (AR) is common following MCS implantation. A number of anatomical and procedural variables have been proposed as determinants of AR including degree of valve calcification, valve undersizing and implantation depth. Methods We conducted a multicenter retrospective analysis of 282 patients who had undergone MCS implantation with prior cardiac CT annular sizing between 2007 and 2011. Native valve minimum (Dmin), maximum (Dmax) and arithmetic mean (Dmean) annulus diameters as well as agatston calcium score were recorded. Nominal and achieved balloon size was also recorded. AR was assessed using contrast angiography at the end of each procedure. Implant depth was measured as the mean distance from the nadir of the non- and left coronary sinuses to the distal valve frame angiographically. Results 29 mm and 26 mm MCS were implanted in 60% and 39% of patients respectively. The majority of patients (N = 165) developed AR < 2 following MCS implantation. AR ≥ 3 was observed in 16% of the study population. High agatston calcium score and Dmean were found to be independent predictors of AR ≥ 3 in multivariate analysis ( P < 0.0001). Nominal balloon diameter and the number of balloon inflations did not influence AR. However a small achieved balloon diameter-to-Dmean ratio (≤ 0.85) showed modest correlation with AR ≥ 3 ( P = 0.04). This observation was made irrespective of the degree of valve calcification. A small MCS size-to-Dmean ratio is also associated with AR ≥ 3 ( P = 0.001). A mean implantation depth of ≥ 8 + 2 mm was also associated with AR ≥ 3. Implantation depth of ≥ 12 mm was associated with small MCS diameter-to-Dmean ratio and increased 30-day mortality. Conclusion CT measured aortic annulus diameter and agatston calcium score remain important predictors of significant AR. Other procedural predictors include valve undersizing and low implantation depth. A small achieved balloon diameter-to-Dmean ratio might also predict AR ≥ 3. Our findings confirm that a small achieved balloon size during pre-implantation valvuloplasty predicts moderate–severe AR in addition to previously documented factors.
OBJECTIVE To examine patients' individual requirements for risk disclosure before surgery. DESIGN Structured interview and questionnaire. SETTING 50 patients interviewed following coronary artery ...bypass grafting or valve replacement or repair. MAIN OUTCOME MEASURES Patient assessment of the nature and probability of risks they would have wished to be informed of from a pool comprising death and 13 postoperative complications. RESULTS Out of 50 patients, 21 (42%) wanted no risk information at all, 25 (50%) did not want to be advised of the risk of death, and 27 (54%) did not want information about the risk of permanent stroke. This contrasts with standard practice of routinely informing patients of the risk of death and stroke. However, there were pronounced individual patient preferences. Three groups of patients emerged: those requiring little or no risk information, those requiring information about major risks, and those requiring full risk disclosure. Patients were not generally concerned about the specific probabilities of any risk. CONCLUSIONS Clinicians counselling patients before operation should routinely discuss patient preferences before risk disclosure, distinguishing among a preference for “no risk information”, “all potentially relevant risks”, and “those risks considered significant or likely to occur”. The fact of individual patient preferences may undermine the concept of the “reasonable patient” in determination of the legal requirements for risk disclosure. Future studies, in addition to replicating the present findings, should examine the reasons underlying individual patient preferences and the long term implications of degrees of risk disclosure, particularly when adverse outcomes occur.
Cardiopulmonary bypass-induced organ dysfunction remains a clinical problem in certain groups of patients. Although the pathogenesis is multifactorial, it is likely that a panendothelial injury ...consequent upon widespread humoral and cellular activation is a major contributor to this process. The biologically active products of complement activation are certainly capable of inducing many of the features of the post-perfusion syndrome. The complex interactions between complement and many of the other proposed mediators of this response also supports this contention. However, it is equally certain that many of the other proposed mediators have some role to play. Inhibition of one cell type or inflammatory cascade is therefore unlikely to abolish all the adverse effects of CPB but will, at least in experimental systems, permit a more precise determination of the pathogenesis of this problem. The temptation to simply measure elevated circulating levels of newly identified mediators must be resisted and more effort applied to examining the pathophysiological effects of specific inhibitors. This type of investigation should initially be effected in experimental models where reproducible conditions can be ensured. In conjunction with this, far more precise end-points are required in order to assess the effect of any potential therapeutic intervention in a clinical setting. In particular, new techniques of evaluating endothelial injury need to be developed. In clinical studies careful consideration must be given to the patient population studied. Whilst patients undergoing routine coronary artery surgery form a relatively homogeneous group, the magnitude of endothelial injury sustained is probably small and, especially in terms of lung function, the signal will be diluted by other non-bypass-related events. The study of high risk groups would seem more appropriate despite their heterogeneity. An important unanswered question is why certain sub-populations of patients are at increased risk of clinically relevant bypass-induced injury. The endothelium of these patients may be different: the neonatal pulmonary microcirculation is not the same as that of an adult (with increased fluid filtration pressure and a higher microvascular surface area per unit lung mass 5,6), children with pulmonary hypertension have histological evidence of an altered/damaged endothelium (S.G. Haworth, Personal Communication) whilst pre-existing sepsis could clearly induce a degree of endothelial dysfunction. A further possibility is that the inflammatory response in these patients is already "primed". Some patients with heart failure have been shown to have elevated circulating TNF.
Aims To critically review the available transcatheter aortic valve implantation techniques and their results, as well as propose recommendations for their use and development. Methods and results A ...committee of experts including European Association of Cardio-Thoracic Surgery and European Society of Cardiology representatives met to reach a consensus based on the analysis of the available data obtained with transcatheter aortic valve implantation and their own experience. The evidence suggests that this technique is feasible and provides haemodynamic and clinical improvement for up to 2 years in patients with severe symptomatic aortic stenosis at high risk or with contraindications for surgery. Questions remain mainly concerning safety and long-term durability, which have to be assessed. Surgeons and cardiologists working as a team should select candidates, perform the procedure, and assess the results. Today, the use of this technique should be restricted to high-risk patients or those with contraindications for surgery. However, this may be extended to lower risk patients if the initial promise holds to be true after careful evaluation. Conclusion Transcatheter aortic valve implantation is a promising technique, which may offer an alternative to conventional surgery for high-risk patients with aortic stenosis. Today, careful evaluation is needed to avoid the risk of uncontrolled diffusion.
Background: Assessment of right ventricular performance in the perioperative period is difficult because there is no generally accepted method of measuring right ventricular volume. We set out to ...determine whether conductance technology could provide a valuable technique for the investigation of intraoperative right ventricular function.
Methods and results: Three validating studies were performed in 25 patients undergoing routine coronary revascularization. Study 1: The influence of conductance catheter position in the right ventricle was examined in 10 patients. Insertion of the conductance catheter through the outflow tract was associated with a larger gain constant and a smaller parallel conductance compared with insertion through the tricuspid valve. Study 2: The reproducibility of contractility measurements with the use of a conductance catheter was examined in 7 additional patients. Removal and reinsertion of the conductance catheter was not associated with any significant difference in right ventricular volume or contractile function. Study 3: Right ventricular performance before and after cardiopulmonary bypass was compared in 8 additional patients. There was a fall in the slope of the right ventricular preload recruitable stroke work from 15.6 (3.8) to 11.0 (5.1) mm Hg (
P = .01) and an increase in the slope of the end-diastolic pressure-volume relations from 0.05 (0.02) to 0.11 (0.05) mm Hg/mL (
P = .001).
Conclusions: The conductance technique can be used to study perioperative changes in right ventricular performance. Insertion of the conductance catheter through the outflow tract provides stable and reproducible data. There is significant impairment of right ventricular contractility in the early postoperative period. (J Thorac Cardiovasc Surg 1998;116:468-76)
Objectives This study aimed to assess the clinical and echocardiographic results of MitraClip implantation in noncentral degenerative mitral regurgitation (dMR) compared with central dMR. Background ...It is unknown whether the use of MitraClip therapy in noncentral dMR is as safe and effective as in central dMR. Methods We analyzed a multicenter registry of 173 patients treated with the MitraClip and compared results of central and noncentral dMR. Results Seventy-nine patients (age 79.2 ± 8.0 years, 58.2% men) had dMR. Forty-nine patients (62%) had central dMR, with the remainder classified as noncentral dMR (n = 30, 38%). Patients with noncentral dMR had a wider pre-procedural vena contracta (8.5 ± 2.0 mm vs. 6.9 ± 2.2 mm, p = 0.039) and higher systolic pulmonary pressure (57.9 ± 18.0 vs. 47.3 ± 13.0 mm Hg, p = 0.019). Procedural success was the same in both groups (95.5% central vs. 96.7% noncentral, p = 0.866). Post-procedural MR and New York Heart Association (NYHA) functional class at 1 month (MR ≤2, 96.0% vs. 96.6%, p = 0.866, and NYHA functional class ≤II, 81.6% vs. 90.0%, p = 0.335) and 6 months (95.2% central vs. 91.7% noncentral, p = 0.679; and NYHA functional class >II, 21.1% vs. 0%, p = 0.128) did not differ between groups. There were also no differences in serious post-procedural adverse events: partial clip detachment (central n = 1 2.0% vs. noncentral n = 1 3.3%, p = 1.000), death (5.4% central vs. 13.0% noncentral, p = 0.298), or heart failure admission (10.8% central vs. 8.7% noncentral, p = 0.791). Conclusions In experienced centers, MitraClip treatment can be performed safely and effectively in both central and noncentral dMR.
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