Cerebral Protection against Left Ventricular Thrombus during Transcatheter Aortic Valve Replacement in a Patient with Critical Aortic Stenosis

Transcatheter aortic valve replacement is an increasingly common treatment of critical aortic stenosis. Many aortic stenosis patients have concomitant left ventricular dysfunction, which can instigate the formation of thrombus resistant to anticoagulation. Recent trials evaluating transcatheter aortic valve replacement have excluded patients with left ventricular thrombus. We present a case in which an 86-year-old man with known left ventricular thrombus underwent successful transcatheter aortic valve replacement under cerebral protection.Key words: Aortic valve stenosis/therapy, cerebral infarction/etiology, embolic protection devices, heart valve prosthesis implantation, intracranial embolism/prevention & control, stroke/etiology, thrombus, left ventricularTranscatheter aortic valve replacement (TAVR) has given hope to patients with surgically inoperable critical aortic stenosis.^1,2 However, the enthusiasm generated by this emerging technology has been tempered by the incidence of both silent and clinically apparent cerebral vascular accidents.^2–4 These events can be either atheroembolic (originating from manipulation of the TAVR sheath in a diseased ascending aorta) or thromboembolic (originating from intracardiac chambers or from the aortic valve itself). The presence of left ventricular (LV) thrombus has been shown to be responsible for up to 20% of cardioembolic events in a clinical setting.^5,6 According to professional societies, LV thrombus is a contraindication for TAVR; and such thrombus has been an exclusion criterion in clinical trials.^7–9 However, a minority of aortic stenosis patients in need of transcatheter valve therapy present with intraventricular thrombus that does not respond to anticoagulation and therefore poses a challenge to the clinician. Evidence to support the optimal treatment of these patients is lacking. We present a case of TAVR in which we used cerebral protection in treating a surgically inoperable patient who had an LV thrombus.     

Aortic Valve Regurgitation that Resolved after a Ruptured Coronary Sinus Aneurysm Was Patched

Sinus of Valsalva aneurysms appear to be rare. They occur most frequently in the right sinus of Valsalva (52%) and the noncoronary sinus (33%). More of these aneurysms originate from the right coronary cusp than from the noncoronary cusp. Surgical intervention is usually recommended when symptoms become evident.We report the case of a 34-year-old woman who presented with a congenital, ruptured sinus of Valsalva aneurysm that originated from the noncoronary cusp. Moderate aortic regurgitation was associated with this lesion. Simple, direct patch closure of the ruptured aneurysm resolved the patient''s left-to-right shunt and was associated with decreased aortic regurgitation to a degree that valve replacement was not necessary. Only trace residual aortic regurgitation was evident after 3 months, and the patient remained free of symptoms after 6 months.Our observations support the idea that substantial runoff blood flow in the immediate supra-annular region can be responsible for aortic regurgitation in the absence of a notable structural defect in the aortic valve, and that restoring physiologic flow in this region and equalizing aortic-cusp closure pressure can largely or completely resolve aortic insufficiency. Accordingly, valve replacement may not be necessary in all cases of ruptured sinus of Valsalva aneurysms with associated aortic valve regurgitation.Key words: Aortic aneurysm/congenital/etiology/radiography/surgery, aortic valve insufficiency, cardiac surgical procedures/methods, differential diagnosis, sinus of Valsalva/pathology/radiography/surgery, treatment outcomeSinus of Valsalva aneurysm (SVA) was first described in 1839.¹ This lesion is encountered during 0.14% to 0.96% of all open-heart procedures and in 0.09% of postmortem studies.² Right coronary cusp aneurysms are the most frequent form of SVA (52% of all SVA cases), and noncoronary cusp aneurysms are diagnosed in 33% of SVA cases.³ We present the case of a woman who had a congenital, ruptured SVA of the noncoronary cusp and moderate aortic regurgitation (AR). We discuss our simple, direct patch closure of the aneurysm, and we present our reasoning as to how this treatment eliminated the patient''s AR without the need to replace the aortic valve.     

Does Minimal-Access Aortic Valve Replacement Reduce the Incidence of Postoperative Atrial Fibrillation?

As the most common sequela of cardiac valvular surgery, atrial fibrillation (AF) has an important impact on postoperative morbidity. Minimal-access aortic valve replacement (AVR), with purported benefits on operative outcomes, has emerged as an alternative to conventional AVR. We used meta-analysis to determine whether minimal access influences the incidence of postoperative AF after AVR. Further, we sought first to evaluate via sensitivity analysis the impact of any differences and to identify the sources of possible heterogeneity between studies; second, we sought to evaluate any indirect effect of minimal-access AVR on other surrogate outcomes related to postoperative AF. We identified 10 studies from 26 comparative randomized and nonrandomized reports that documented the primary outcome of interest: new-onset AF. Overall meta-analysis showed no significant difference between minimal-access and conventional AVR in the incidence of postoperative AF (odds ratio, 0.85; 2,262 patients; P=0.24; 95% confidence interval, 0.66–1.11). Nor were there any apparent differences in surrogate outcome measures of intensive care unit stay, total length of stay, or stroke among studies that displayed a notable difference in AF incidence between groups. Sensitivity analysis that included only high-quality studies similarly showed no significant difference in the incidence of AF and further showed several intraoperative variables as potential sources of heterogeneity between studies. Therefore, minimal access may not have a significant effect on postoperative AF. Future randomized studies must take into account the potential sources of heterogeneity identified here to better demonstrate any differences between the 2 approaches in the onset of AF.Key words: Aortic valve/surgery, aortic valve stenosis/surgery, atrial fibrillation/etiology/prevention & control, postoperative complications, surgical procedures, minimally invasiveAtrial fibrillation (AF) is an important complication of valvular heart surgery: the reported incidence is as high as 60%.^1–3 Postoperative AF can result in hemodynamic compromise, thromboembolic phenomena, and anxiety. Other sequelae include prolonged length of stay (LoS) and increased cost. Controversy exists concerning the benefits of a minimal-access approach for aortic valve replacement (AVR); it is important, therefore, to evaluate whether the minimal-access approach carries a different incidence of AF than does the conventional approach.Preoperative, intraoperative, and postoperative variables all affect the incidence of postoperative AF.^1,3–7 Therefore, the array of contributory pathophysiologic factors implicated in postoperative AF is diverse. It includes age- and hypertension-related structural changes in the atria, the effects of surgical manipulation of the heart or pericardium, the duration of myocardial ischemia, and the effects of systemic influences such as electrolyte imbalance, drug administration, and cardiopulmonary bypass (CPB)-related inflammatory effects.^8,9Minimal-access AVR (mAVR) offers apparent benefits in terms of postoperative morbidity, such as fewer respiratory complications and fewer patients transfused.^10–16 On the other hand, mAVR has been associated with longer CPB and aortic cross-clamp (CC) times and with a greater propensity for pleural and pericardial effusions.^14,15,17 We hypothesized that the incidence of AF after mAVR would relate to factors other than the technique of surgical access itself. To investigate this, we analyzed all studies in the surgical literature published in English that compared mAVR and conventional AVR (cAVR) with regard to the incidence of postoperative AF. We used a meta-analytical synthesis of data to examine the effects of minimal access on the incidence of AF, and we focused on the variables associated with AF, including the established preoperative predictors of postoperative AF and predictors that are related to intraoperative manipulation of the heart.     

Reconstruction of the Fibrous Trigone

A 48-year-old man with a history of infective endocarditis and severe aortic regurgitation had undergone prosthetic aortic valve replacement at another institution. Two months later, the patient developed prosthetic valve endocarditis with an aortic root abscess and an aorto–left atrial periprosthetic valvular fistula through the detached posterior annulus of the mitral valve. We repaired the fistula by constructing a fibrous trigone made of bovine pericardium. We also replaced the prosthetic aortic valve with another prosthetic valve, while protecting the native mitral valve.Key words: Aortic valve replacement, endocarditis/complications/surgery, fistula/etiology/surgery, heart valve prosthesis/adverse effects, mitral valve repair, prosthesis-related infections, reoperationThe incidence of prosthetic valve endocarditis (PVE) within 12 months after heart valve replacement is between 1% and 3.1%.^1,2 In the largest PVE case series to date, 20.1% of the cases of infective endocarditis were due to PVE³—a severe and life-threatening infection, particularly when accompanied by a paraprosthetic abscess and progression of fistulous communication.Aorto–left atrial fistula, a rare complication of PVE, is surgically challenging. We report the successful surgical repair of an aorto–left atrial periprosthetic valvular fistula in concordance with re-replacement of the aortic valve, while protecting the native mitral valve.     

Coronary Revascularization Alone or with Mitral Valve Repair: Outcomes in Patients with Moderate Ischemic Mitral Regurgitation

We sought to evaluate retrospectively the outcomes of patients at our hospital who had moderate ischemic mitral regurgitation and who underwent coronary artery bypass grafting (CABG) alone or with concomitant mitral valve repair (CABG+MVr).A total of 83 patients had a reduced left ventricular ejection fraction and moderate mitral regurgitation: 28 patients underwent CABG+MVr, and 55 underwent CABG alone. Changes in mitral regurgitation, functional class, and left ventricular ejection fraction were compared in both groups.The mean follow-up was 5.1 ± 3.6 years (range, 0.1–15.1 yr). Reduction of 2 mitral-regurgitation grades was found in 85% of CABG+MVr patients versus 14% of CABG-only patients (P < 0.0001) at 1 year, and in 56% versus 14% at 5 years, respectively (P = 0.1), as well as improvements in left ventricular ejection fraction and functional class. One- and 5-year survival rates were similar in the CABG+MVr and CABG-only groups: 96% ± 3% versus 96% ± 4%, and 87% ± 5% versus 81% ± 8%, respectively (P = NS). Propensity analysis showed similar results. Recurrent (3+ or 4+) mitral regurgitation was found in 22% and 47% at late follow-up, respectively.In patients with moderate ischemic mitral regurgitation, either surgical approach led to an improvement in functional class. Early and intermediate-term mortality rates were low with either CABG or CABG+MVr. However, an increased rate of late recurrent mitral regurgitation in the CABG+MVr group was observed.Key words: Cardiac surgical procedures, coronary artery bypass, coronary disease/complications/surgery, disease-free survival/trends, matched-pair analysis, mitral valve insufficiency/physiopathology/surgery, multivariate analysis, myocardial ischemia/complications/surgery, myocardial revascularization/methods/statistics & numerical data, postoperative period, recurrence, risk assessmentCoronary artery disease (CAD) can lead to ischemic mitral regurgitation (MR) due to myocardial ischemia or infarction in the absence of any intrinsic organic disease of the mitral valve. Uncorrected chronic MR is associated with a poor prognosis in patients after coronary revascularization by means of coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty.^1–5 Many investigators have evaluated the pathogenesis of ischemic MR and have been able to show the crucial role of changes in the geometry of the left ventricle (LV) and papillary muscle due to the myocardial scarring that results in annular dilation and leaflet tethering.^6–8 Because of higher morbidity and operative mortality rates associated with combined revascularization and mitral valve surgery,^3,4,9,10 some surgeons have advocated revascularization alone,^11,12 while others have recommended concomitant mitral valve surgery^{3,4,9,10,13–15} in order to optimize patients'' cardiac function and long-term prognosis.The clinical usefulness of combined surgery remains unclear due to the prolongation of cardiopulmonary bypass time and the additional technical complexity of such surgery in these patients. Although most surgeons would agree that mild MR can be treated by CABG alone and that severe MR should be corrected at the time of CABG, the optimal approach toward the management of moderate ischemic MR remains controversial. It has been shown that patients with moderate MR have lower survival rates after undergoing CABG alone than do patients who have no MR or mild MR,¹⁶ and that CABG alone leaves many patients with substantial residual MR.¹³ Although many studies have been undertaken in order to define the risk factors for high mortality rates and the appropriate approach, there is no clear consensus regarding the optimal treatment of these high-risk patients.Most published studies that have focused on differences in outcomes between CABG alone and with concomitant mitral valve repair (MVr) were not limited to a single MR grade, and various mitral valve surgical procedures were used. In this study, we reviewed the outcomes of the most problematic subgroup of patients in terms of surgical approach—patients with moderate MR. We evaluated the effectiveness of CABG alone and CABG with MVr with regard to changes in functional class, postoperative MR, LV function, and survival.     

Assessment of coronary artery disease using coronary computed tomography angiography in patients with aortic valve stenosis referred for surgical aortic valve replacement

Background

In patients referred for aortic valve replacement (AVR) a pre-surgical assessment of coronary artery disease is mandatory to determine the possible need for additional coronary artery bypass grafting. The diagnostic accuracy of coronary computed tomography angiography (coronary CTA) was evaluated in patients with aortic valve stenosis referred for surgical AVR.

Methods

Between March 2008 and March 2010 a total of 181 consecutive patients were included. All patients underwent pre-surgical coronary CTA (64- or 320-detector CT scanner) and invasive coronary angiography (ICA). The analyses were performed blinded to each other.

Results

The mean ± SD age of the included patients was 71 ± 9 years and 59% were male. The prevalence of significant coronary artery stenosis > 70% by ICA was 36%. Average heart rate during coronary CTA was 65 ± 16 bpm. In a patient based analysis 94% of the patients (171/181) were considered fully evaluable. Coronary CTA had a sensitivity of 68%, a specificity of 91%, a positive predictive value of 81%, and a negative predictive value of 83%. Advanced age, obstructive lung disease, NYHA function class III/IV, and high Agatston score were found to be significantly associated with disagreement between ICA and coronary CTA in univariate analysis.

Conclusion

In patients with aortic valve stenosis referred for surgical AVR the diagnostic accuracy of coronary CTA to identify significant coronary artery disease is moderate. Coronary CTA may be used successfully in a subset of patients with low age, no chronic obstructive lung disease, NYHA function class < III and low coronary Agatston score.     

Coronary Artery Diameter Related to Calcium Scores and Coronary Risk Factors as Measured with Multidetector Computed Tomography: A Substudy of the Accuracy Trial

Arterial remodeling, an early change of atherosclerosis, can cause dilated arterial diameter. We measured coronary artery diameter with use of noncontrast 64-slice multidetector computed tomography (MDCT), and studied its association with coronary artery calcium levels and traditional coronary risk factors.We included 140 patients from the ACCURACY trial whose noncontrast MDCT images showed measurable coronary arteries. Using 3 measurements of left main coronary artery (LMCA) and right coronary artery (RCA) diameters within 3 mm of the ostium, we associated the results with traditional coronary risk factors and calcium scores.The prevalence of LMCA and RCA calcium was 22% and 51%, respectively. Mean arterial diameters were 5.67 ± 1.18 mm (LMCA) and 4.66 ± 1.08 mm (RCA). Correlations for LMCA and RCA diameters in 50 randomly chosen patients were 0.91 and 0.93 (interobserver) and 0.98 and 0.93 (intraobserver). Adjusted odds ratios for the relationship of LMCA and RCA diameters to calcium in male versus female patients were 5.65 (95% confidence interval [CI], 2.78–11.5) and 4.35 (95% CI, 2.24–8.47), respectively. Adjusted ratios and 95% CIs for the association of larger RCA diameter with age, hypertension, and body mass index were 1.36 (1.00–1.86), 3.13 (1.26–7.78), and 1.60 (1.16–2.22), respectively.Arterial diameters were larger in women and patients with higher calcium levels, and body mass index and hypertension were predictors of larger RCA diameters. These findings suggest a link between arterial remodeling and the severity of atherosclerosis.Key words: Arteriosclerosis/complications/pathology, calcinosis/complications, coronary artery disease/etiology/pathology, coronary vessels/pathology/physiology, dilatation, pathologic/pathology, disease progression, models, cardiovascular, regression analysis, risk assessment, tomography, x-ray computed/methodsAn early change of atherosclerosis is arterial remodeling, which can result in dilated arterial diameter. In positive (expansive) arterial remodeling, luminal size is often preserved.^1–4 Conventional coronary angiography and myocardial perfusion imaging detect anatomically significant and hemodynamically relevant luminal stenosis, respectively, but perform less well in depicting atherosclerotic disease in its earlier stages when luminal integrity has not yet been compromised by positive vascular remodeling. Imaging studies of early culprit lesions in patients with acute coronary syndrome have revealed an association of echolucent plaque and positive remodeling with unstable clinical presentation.^5–7 Many studies of normal human coronary artery size have been conducted during postmortem examinations of the heart.^8–17 Investigators using intravascular ultrasonography, cardiac magnetic resonance, and cardiovascular computed tomography (CT) have suggested that coronary plaque rupture could occur in positively remodeled lesions.^18,19 Large positively remodeled lesions as predictors of plaque rupture are the subject of active research. Intravascular ultrasonography yields good views of coronary artery lumina and arterial walls and can help to reveal disease that is not angiographically evident; however, it is an invasive technique that is unsuitable as a screening procedure.^20–22 Coronary artery calcium (CAC), as evaluated by means of cardiovascular CT, is currently used as a surrogate marker of atherosclerosis.^23,24 In this study, we used noncontrast 64-slice multidetector computed tomography (MDCT) to measure coronary artery diameters in patients who had been referred for CAC scoring. We then used these measurements to study the relationship of increased coronary artery diameter to CAC and to traditional cardiovascular (CV) risk factors.     

Transcatheter Aortic Valve Implantation through a Left Aortoiliac Graft

The indications for transcatheter aortic valve implantation have been increasing with the development of new-generation valves and delivery systems. Our patient, an 81-year-old man with aortic stenosis, had an existing coronary artery bypass graft and bilateral aortoiliac bypass grafts. We used the transfemoral approach through the left femoral artery and the left aortoiliac graft to successfully deploy a new-generation Edwards SAPIEN valve.Key words: Aortic stenosis, arterial disease, peripheral, heart valve prosthesis implantation/methods, transcatheter aortic valve implantationTranscatheter aortic valve implantation (TAVI) has emerged as a promising alternative to conventional aortic valve replacement for patients whose severe, symptomatic aortic stenosis is otherwise left untreated due to comorbidities and to the high operative mortality rates associated with open-heart surgery under those circumstances.¹ The first application of this method in human beings was performed in 2002 by Cribier and colleagues.² Today, there are 2 widely used valve types. These are the balloon-expandable Edwards SAPIEN transcatheter valves (Edwards Lifesciences LLC; Irvine, Calif) and the self-expanding CoreValve® valves (Medtronic CV Luxembourg S.a.r.l.; Luxembourg). The first-generation Edwards SAPIEN valve is approved for use in the United States, but the latest generations of both valves are awaiting approval.     

Impact of Bicuspid Aortic Valve on Complications and Death in Infective Endocarditis of Native Aortic Valves

We retrospectively investigated the impact of bicuspid aortic valve on the prognosis of patients who had definite infective endocarditis of the native aortic valve.Of 51 patients, a bicuspid aortic valve was present in 22 (43%); the other 29 had tricuspid aortic valves. On average, the patients who had bicuspid valves were younger than those who had tricuspid valves. Patients with a tricuspid valve had larger left atrial diameters and were more likely to have severe mitral regurgitation.Periannular complications, which we detected in 19 patients (37%), were much more common in the patients who had a bicuspid valve (64% vs 17%, P = 0.001). The presence of a bicuspid valve was the only significant independent predictor of periannular complications. The in-hospital mortality rate in the bicuspid group was lower than that in the tricuspid group; however, this figure did not reach statistical significance (9% vs 24%, P = 0.15). In multivariate analysis, left atrial diameter was the only independent predictor associated with an increased risk of death (hazard ratio, 2.19; 95% confidence interval, 1.1–4.5; P = 0.031).In our study, patients with infective endocarditis in a bicuspid aortic valve were younger and had a higher incidence of periannular complications. Although a worse prognosis has been reported previously, we found that infective endocarditis in a native bicuspid aortic valve is not likely to increase the risk of death in comparison with infective endocarditis in native tricuspid aortic valves.Key words: Aortic valve/abnormalities/pathology/ultrasonography, aortic valve insufficiency/classification/diagnosis, echocardiography/methods, endocarditis, bacterial/complications/mortality/pathology/ultrasonography, heart defects/congenital, heart diseases/complications, heart valve diseases/classification/complications/congenital/pathology, hospital mortality, retrospective studies, risk factorsBicuspid aortic valve is the most common congenital cardiac malformation, affecting 1% to 2% of the population.¹ The incidence of infective endocarditis (IE) in the bicuspid aortic valve population ranges from 10% to 30%. Twenty-five percent of IE cases occur in a bicuspid aortic valve.^2,3Few data exist about IE in persons who have a bicuspid aortic valve, in contrast with the large amount of data involving other IE populations. Risk stratification is an important objective in the evaluation of patients who have IE, especially IE of the aortic valve. In patients with IE of the native valve, acute heart failure occurs more frequently in association with aortic valve infection (29%) than mitral valve infection (20%).⁴ In view of these factors, we sought to evaluate the impact of bicuspid aortic valve on complications and death related to IE that occurs in a native aortic valve.     

Valve-Sparing Aortic Root Replacement and Tricuspidization in a Patient with an Asymmetric Bicuspid Aortic Valve

Aortic valve replacement is the standard surgical procedure for severe aortic regurgitation. Due to advances over the past decade, there have been substantial improvements in aortic root graft design, in aortic valve repair techniques, and in the understanding of valvular function in the remodeled aortic root. Herein, we describe the case of a dyspneic patient with an asymmetric bicuspid aortic valve who underwent valve-sparing aortic root replacement and tricuspidization. The patient subsequently resumed strenuous physical activity and was asymptomatic 2 years after the operation.Key words: Aortic diseases/pathology/surgery/ultrasonography, aortic valve/abnormalities, aortic valve insufficiency/complications/surgery/ultrasonography, cardiac surgical procedures/methods, suture techniques, treatment outcomeThe conventional surgery for severe aortic regurgitation has been aortic valve replacement. This procedure, however, may soon become obsolete due to advances in aortic valve repair. Over the past decade, there have been substantial improvements in aortic root graft design, in aortic valve repair technique, and in the understanding of valvular function in the remodeled aortic root.^1–7 Herein, we describe the case of a patient with complex aortic root disease who underwent surgical repair.     

Late Stent Thrombosis Associated with Heavy Exercise

Bare-metal stents are commonly used in the treatment of coronary artery disease. Stent thrombosis usually occurs within the first 48 hours after stent deployment. After a week, the incidence of thrombosis is low. Late stent thrombosis (after 30 days) is rarely seen; however, its clinical outcomes are severe 30-day mortality rates of 20% to 48% and myocardial infarction rates of 60% to 70%. Herein, we present the case and discuss the treatment of a patient who, after heavy exercise, experienced acute myocardial infarction due to late thrombosis in a bare-metal stent.A 54-year-old man presented with unstable angina pectoris. Coronary angiography revealed critical occlusion of the middle right coronary artery. A bare-metal stent was implanted, and he was discharged from the hospital on a medical regimen. Eleven months later, he presented with acute myocardial infarction, which had developed after heavy exercise. Coronary angiography revealed occlusion of the stent in the right coronary artery. After the occlusion was crossed with a guidewire, balloon angioplasty was applied, and Thrombosis-in-Myocardial-Infarction (TIMI)-3 flow was restored. The patient was asymptomatic during his 5-day hospitalization and was discharged on dual antiplatelet therapy.In addition to presenting this patient''s case, we discuss mechanisms that may contribute to late stent thrombosis, implications of the condition, and preventive therapy.Key words: Aspirin/administration & dosage/therapeutic use, blood vessel prosthesis implantation/adverse effects, coronary disease/therapy, coronary restenosis/etiology/pathology/prevention & control/therapy, coronary thrombosis/etiology/therapy, exercise/physiology, myocardial revascularization, platelet aggregation inhibitors/administration & dosage, postoperative complications/etiology, stents/adverse effects, treatment outcomeBare-metal stents are commonly used in the treatment of coronary artery disease. When stent thrombosis occurs, it is usually within the first 48 hours after deployment of the stent; after a week, the incidence of thrombosis is very low.¹ Late stent thrombosis (after 30 days) is rarely seen; however, its concomitant clinical outcomes are severe 30-day mortality rates of 20% to 48% and myocardial infarction rates of 60% to 70%.^2,3 Here, we discuss the case and treatment of a 54-year-old man who, after heavy exercise, experienced acute myocardial infarction consequent to late stent thrombosis. We present implications of the condition, possible contributory mechanisms, and preventive measures.     

Concurrent Primary Cardiac Tumors of Differing Histology and Origin: Case Report with Literature Review

Primary cardiac tumors are rare and are diverse in histology and anatomic origin. Approximately 75% are benign, and nearly 50% of these are myxomas. Herein, we report concurrent myxoma and papillary fibroelastoma, which tumors were found attached to the left atrial septum and aortic valve, respectively. Concurrent primary cardiac tumors of differing histology and origin are rare, and, to our knowledge, this is one of the few such cases reported in the medical literature.Key words: Echocardiography, fibroma, heart neoplasms/primary/diagnosis/surgery, myxoma, neoplasms, multiple primary/diagnosis/surgeryPrimary cardiac tumors are rare, with an incidence ranging from 0.0017% to 0.19% in autopsy series in unselected patients.^1–3 Myxomas are the most common cardiac neoplasm, accounting for as many as 50% of all benign tumors.⁴ Papillary fibroelastoma, the 3rd most common cardiac neoplasm, occurs in adults and is frequently diagnosed postmortem.⁵ Concurrent primary cardiac tumors of differing histology and origin are rare, and few cases have been reported in the medical literature. We are reporting a case of concurrent intracardiac myxoma and papillary fibroelastoma.     

Dual-Source Computed Tomographic Coronary Angiography: Image Quality and Stenosis Diagnosis in Patients with High Heart Rates

We sought to evaluate prospectively the effects of heart rate and heart-rate variability on dual-source computed tomographic coronary image quality in patients whose heart rates were high, and to determine retrospectively the accuracy of dual-source computed tomographic diagnosis of coronary artery stenosis in the same patients.We compared image quality and diagnostic accuracy in 40 patients whose heart rates exceeded 70 beats/min with the same data in 40 patients whose heart rates were 70 beats/min or slower. In both groups, we analyzed 1,133 coronary arterial segments. Five hundred forty-five segments (97.7%) in low-heart-rate patients and 539 segments (93.7%) in high-heart-rate patients were of diagnostic image quality. We considered P < 0.05 to be statistically significant. No statistically significant differences between the groups were found in diagnostic-image quality scores of total segments or of any coronary artery, nor were any significant differences found between the groups in the accurate diagnosis of angiographically significant stenosis.Calcification was the chief factor that affected diagnostic accuracy. In high-heart-rate patients, heart-rate variability was significantly related to the diagnostic image quality of all segments (P = 0.001) and of the left circumflex coronary artery (P = 0.016). Heart-rate variability of more than 5 beats/min most strongly contributed to an inability to evaluate segments in both groups. When heart rates rose, the optimal reconstruction window shifted from diastole to systole.The image quality of dual-source computed tomographic coronary angiography at high heart rates enables sufficient diagnosis of stenosis, although variability of heart rates significantly deteriorates image quality.Key words: Artifacts, coronary angiography/methods, coronary stenosis/diagnosis/radiography, diastole/physiology, heart rate/physiology, image processing, computer-assisted, prospective studies, radiographic image interpretation, computer-assisted, sensitivity and specificity, systole/physiology, technology assessment, biomedical, tomography, spiral computed/instrumentation/methods/standardsDuring the past few years, noninvasive coronary angiography upon multidetector-row computed tomography (MDCT) has rapidly progressed and has shown promise with regard to the detection and quantification of coronary artery stenosis.^1–4 However, despite the increase in temporal resolution from 16- to 64-detector-row computed tomography (CT), coronary CT angiography remains sensitive to motion artifacts, which occur especially at higher heart rates.^2,5–7 Results of a study³ of 64-detector-row CT coronary angiography showed a nonsignificant tendency toward lower image quality at higher mean heart rates, and a significant negative relation between image quality and heart-rate variability. In order to reduce motion artifacts, it has been proposed that patients be administered oral β-blocker medication for heart-rate control, even when 64-detector-row CT is to be used.^8–11 In most studies that have involved 16- or 64-detector-row CT, the target for scanning has been maintained at heart rates slower than 70 or even 60 beats/min, so that good-quality images of coronary arteries could be obtained. The requirement to premedicate patients with β-blocker drugs in order to achieve a sufficiently low heart rate for scanning has been considered a major limitation surrounding the clinical use of MDCT coronary angiography.Dual-source CT (DSCT) coronary angiography incorporates 2 X-ray tubes and 2 detectors that are mounted onto a rotating gantry, with an angular offset of 90°.¹² The DSCT system affords a high temporal resolution of 83 ms in monosegment reconstruction mode. In contrast with single-source CT systems that rely on multisegment reconstruction techniques, temporal resolution upon DSCT is independent of heart rate. Initial studies have shown that DSCT enables the study of coronary arteries with excellent diagnostic quality in all patients, independent of heart rate—thus obviating the need to premedicate patients with β-blockers.^12–15 We believed that the effects of heart rate and heart-rate variability on image quality, diagnostic accuracy, and optimal reconstruction windows merited further evaluation in patients whose heart rates exceeded 70 beats/min.The aim of this study was to evaluate prospectively the effect of heart rate and heart-rate variability on DSCT image quality in patients who had high heart rates, and to determine retrospectively the accuracy of DSCT in the diagnosis of coronary artery stenosis, using invasive coronary angiography as the reference standard.     

Surgical Repair of Supravalvular Aortic Stenosis with Use of Brom's Technique: Short-Term Results in 9 Children

There are few published reports of the results of supravalvular aortic stenosis correction with the use of Brom''s 3-patch technique. Herein, we report our use of this procedure and the short-term results therefrom.From 2002 through 2007, 9 children underwent surgical correction of localized supravalvular aortic stenosis at our hospital. The patients ranged in age from 5 to 14 years, and 8 had Williams syndrome. All operations were performed by the same surgical team.No clinically significant associated cardiac anomalies were encountered. Each aortic repair involved the use of pericardium, Dacron, or both. One patient had an uncorrected right coronary artery obstruction and died postoperatively of refractory supraventricular tachycardia. In all 8 patients who survived, postoperative transaortic blood pressure gradients were improved (range, 0–16 mmHg), and no repeat operations were needed after 6 to 55 months'' follow-up.We consider Brom''s technique to be safe in the repair of supravalvular aortic stenosis. In our limited series, it produced effective anatomic restoration, with good short-term and potentially good long-term results.Key words: Aortic stenosis, supravalvular/complications/mortality/surgery; aortic valve stenosis/physiopathology/surgery; cardiac surgical procedures/methods; child; disease-free survival; heart defects, congenital/complications; survival analysis; treatment outcome; vascular surgical procedures/methods; Williams syndrome/physiopathologySupravalvular aortic stenosis (SVAS) is an uncommon but well-characterized congenital narrowing of the ascending aorta above the level of the aortic valve (Fig. 1).¹ Most often, the narrowing is localized just above or at the most superior level of the attachments of the valve commissures, in association with some dilation of the sinuses of Valsalva and absence of poststenotic dilation. The aorta then looks like an hourglass. Less often, the narrowing extends diffusely throughout the ascending aorta and sometimes extends into the arch and the origins of the brachiocephalic artery. Supravalvular aortic stenosis occurs in 3 forms: sporadic; as part of Williams syndrome; or in a familial form that is transmitted as an autosomal dominant trait.^2–4 The origin of SVAS is strongly suspected to depend on a quantitative reduction in elastin during development.^2,5–6Open in a separate windowFig. 1 A) Preoperative catheterization image of a patient with supravalvular aortic stenosis shows a narrowed supravalvular diameter with minimal aortic regurgitation. B) Postoperative image in the same patient shows a regular supravalvular diameter and a competent aortic valve.Since the 1st successful repair in 1956, various surgical techniques for the relief of SVAS have been developed.⁴ Extended aortoplasty that enlarges the affected structures, as reported by Doty and colleagues,⁷ is most commonly used to treat the anomaly. Because this technique reconstructs only the right and noncoronary sinuses, the left sinus might still exhibit substantially distorted anatomy, with the risk of ischemia secondary to limited inflow into the left coronary artery.^3,8 Steinberg and associates⁹ reported the cases of 3 patients in whom a double patch was used in order to improve the geometry of the aortic sinuses. Subsequently, Brom introduced symmetric aortoplasty that enabled the enlargement of all 3 sinuses with the use of a 3-patch technique.^3,8Supravalvular aortic stenosis is a rare disease, and most of the reported surgical series have been small. In view of the few reports on the use of Brom''s technique for SVAS repair, we report here our experience with the first 9 such corrections that were performed at the Hospital de Pediatría, CMNO IMSS, Guadalajara, Jalisco, México.     

Obesity: An Independent Predictor of In-Hospital Postoperative Renal Insufficiency among Patients Undergoing Cardiac Surgery?

We sought to determine, retrospectively, whether obesity was associated with adverse renal outcomes in 17,630 patients who underwent cardiac surgery from January 1995 through December 2006. Obesity was defined as a body mass index ≥30 kg/m². The primary outcome was any episode of postoperative renal insufficiency (requiring or not requiring dialysis) before hospital discharge. Outcomes were evaluated in the entire cohort and in subgroups undergoing isolated coronary artery bypass grafting (CABG), isolated valve surgery, and combined CABG and valve surgery.The final analysis included 16,429 patients, 5,124 (31%) of whom were obese. In the entire cohort, obesity was associated both with increased risk of any postoperative renal insufficiency (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.21–1.55) and with increased risk of renal insufficiency not requiring dialysis (OR, 1.41; 95% CI, 1.23–1.62). Obesity was associated with an increased risk of postoperative renal insufficiency in patients undergoing isolated CABG (OR, 1.38; 95% CI, 1.18–1.61), isolated valve surgeries (OR, 1.39; 95% CI, 1.05–1.85), and combined CABG and valve surgeries (OR, 1.35; 95% CI, 0.99–1.83; statistically nonsignificant). Development of postoperative renal insufficiency was associated with a significantly higher mortality rate (P <0.0001) and with a significantly longer hospital stay (23 vs 10.5 days; P <0.0001).We conclude that obesity is associated with a significant increase in postoperative renal insufficiency in cardiac surgery patients, an effect that we attribute to an increase in postoperative renal failure that does not require dialysis.Key words: Body mass index, cardiac surgical procedures/adverse effects, cardiopulmonary bypass/adverse effects, inflammation/complications, kidney failure/etiology, obesity/complications, oxidative stress, postoperative complications, retrospective studies, risk factors, systemic inflammatory response syndrome, treatment outcomeObesity is associated with the development of chronic kidney disease.^1–6 It has also been shown to be associated, in patients who have chronic kidney disease, with increased oxidative stress and inflammation,¹ impairment of renal endothelial function,^2,3 and proteinuria.^4,5 Inflammation appears to be an important mediator in the development of postoperative renal failure.^6,7 Although epidemiologic data indicate that obesity might be associated with the development of chronic kidney disease in the general population,^8–10 there are very few studies pertaining to obesity as an independent predictor of poor renal outcomes in patients undergoing cardiac surgeries. In most of these studies,^6,7,11–15 the occurrence of postoperative renal insufficiency has not been the primary outcome; moreover, the results have been inconsistent. We lack firm data on whether obesity is associated with an increase in the severity of postoperative renal failure.The aim of this study was to determine whether obesity is an independent predictor of postoperative renal insufficiency in patients undergoing cardiac surgeries, including patients undergoing isolated coronary artery bypass grafting (CABG), isolated valve surgeries, and combined CABG and valve surgeries. We also investigated the possible association between obesity and increased severity of postoperative renal failure (that is, postoperative renal failure requiring in-hospital dialysis).     

Left Main Coronary Artery Embolus: Unusual Presentation of Papillary Fibroelastoma of the Aortic Valve

The usual cause of left main coronary artery obstruction is atherosclerotic occlusion resulting from plaque rupture and subsequent thrombus formation. In previously reported cases, tumor embolization into the coronary arteries caused sudden death and was detected only at autopsy. Herein, we report an unusual presentation of cardiac papillary fibroelastoma of the aortic valve in a 62-year-old man. The fibroelastoma caused a left main coronary artery embolus and symptoms of acute coronary syndrome. The fibroelastoma was successfully excised during a valve-sparing surgical procedure. We believe that this is the 1st report of tumor embolization to the left main coronary artery—and in a living patient.Key words: Aortic valve/pathology/surgery, coronary disease/etiology, fibroma/complications/diagnosis/pathology/surgery/ultrasonography, heart neoplasms/physiopathology/surgery, heart valve diseases/pathology, incidental findings, papilloma/pathology, treatment outcomePapillary fibroelastomas are histologically benign neoplasms. These avascular tumors are small (mean diameter, 3–10 mm) and almost always occur singly. Often, they are mobile and have a thin stalk.¹ They have multiple papillary fronds, so that they resemble sea anemones. Papillary fibroelastomas consist of a core of dense connective tissue, an intermediate layer of loose connective tissue, and a covering of hyperplastic endothelial cells. Although cardiac papillary fibroelastoma is rare, it is the 2nd most common primary benign cardiac tumor (myxoma has been reported more often),² and it is the most common primary tumor of the heart valves. As with myxoma, its origin is not clear. Papillary fibroelastomas can develop on any cardiac valve or cardiac endothelial surface.³ Most are diagnosed incidentally.Clinical manifestations of cardiac papillary fibroelastomas include syncope, angina pectoris, transient ischemic attack, stroke, myocardial infarction, pulmonary embolism, congestive heart failure, and sudden death. Coronary ischemia has been caused by the prolapse of pedunculated coronary cusp tumors into the coronary ostia,⁴ and, alternatively, by the direct embolization of organized thrombus from a cusp lesion to a coronary artery.^3,5 In previously reported cases,^5-7 tumor embolization into the coronary arteries caused sudden death and was detected only at autopsy. Here, we present the case of a patient who presented with symptoms of acute coronary syndrome. The diagnosis was a left main coronary artery (LMCA) embolus from a cardiac papillary fibroelastoma.     

Quadricuspid Aortic Valve without Severe Dysfunction despite Advanced Age

We report the case of a 75-year-old woman who presented with stable angina and with a quadricuspid aortic valve, which consisted of 4 equal-sized leaflets that were diagnosed incidentally upon coronary angiography. Despite the patient''s advanced age, the abnormal valve was functioning almost normally.Key words: Aged, aortic valve/anomalies, coronary angiography, heart defects, congenital/diagnosis, heart valve diseasesSince the 1st case of quadricuspid aortic valve was published in 1969,¹ the total number of reported cases has reached approximately 200.² The diagnosis—more frequent in men—is commonly made between the 5th and 6th decades of life.^1,2 If valve replacement is needed (due mostly to severe aortic insufficiency), that too occurs most often in the 5th or 6th decade.³ However, we report a case in which a woman''s quadricuspid aortic valve was diagnosed in her 8th decade and did not result in significant valvular dysfunction, despite her advanced age.     

Percutaneous Balloon Mitral Valvulotomy and Coexisting Left Atrial Hemangioma: Case Report and Long-Term Follow-Up

Hemangiomas of the heart are extremely rare. The prognosis is quite variable, because this benign tumor may grow, involute, or stop growing; therefore, resection is usually the treatment of choice. In patients with tumors of the left atrium, percutaneous balloon mitral valvulotomy is generally contraindicated. Yet for patients with moderate-to-severe mitral valve stenosis, balloon valvulotomy is an established therapy.Herein, we present the case of a 73-year-old woman who was referred to our department in 1995 with severe mitral valve stenosis. Echocardiography showed a valve orifice area of 0.9 cm², according to Gorlin''s formula, and a mean pressure gradient of 11 mmHg. Surgical therapy was declined by the patient. There were no signs of coronary artery disease. The injection of contrast medium into the left coronary artery showed a hemangioma at the posterior wall of the left atrium. Magnetic resonance imaging and transesophageal echocardiography confirmed the diagnosis. Despite the increased risk posed by the hemangioma, we performed successful percutaneous balloon mitral valvulotomy with an Inoue balloon.We saw the patient in 2001, and again in 2008 when she was 86 years of age. She was in excellent condition, with no signs of relevant dyspnea. Magnetic resonance imaging showed the size of the hemangioma to be stable. By use of echocardiography, we were able to confirm a good long-term result of the balloon valvulotomy. In this patient, a nonsurgical approach was adequate because of the lack of growth of the hemangioma in the left atrium.Key words: Balloon dilatation/methods, echocardiography, heart neoplasms, hemangioma, left atrial/diagnosis, long-term outcome, magnetic resonance imaging, mitral valve stenosis/complications/treatment, percutaneous balloon mitral valvulotomyHemangiomas of the heart are benign proliferations of endothelial cells. Extremely rare, hemangiomas account for 2% to 3% of all benign cardiac tumors.¹ Cardiac hemangiomas can occur in any part of the heart but are more commonly found in intramural locations of the myocardium.² Subendocardial hemangiomas are seen in the right atrium and the right ventricle.³A case of coexisting cardiac hemangioma and mitral valve stenosis has not been described previously in the medical literature. Percutaneous balloon mitral valvulotomy is an established therapy in patients with moderate-to-severe mitral valve stenosis and is a proven alternative to a surgical approach⁴ in carefully selected patients. We present the case of a patient who underwent balloon mitral valvulotomy after refusing surgical therapy, and we describe the results of follow-up 12 years later.     

Coronary Artery Diseasein Association withDepression or Anxiety among Patients Undergoing Angiography to Investigate Chest Pain

In search of associations between coronary artery disease and symptoms of depression and anxiety, we conducted a prospective cross-sectional study of 314 patients (age range, 19–79 yr) who had presented with chest pain. Coronary angiographic findings were classified into 5 categories (0–4), in which higher numbers indicated more severe disease. Symptoms of depression and anxiety were evaluated by the Beck depression and anxiety inventories, in which higher scores indicated more severe symptoms.Older age, male sex, diabetes mellitus, hypercholesterolemia, and high income were found in association with coronary artery disease. Woman patients exhibited significantly higher depression and anxiety scores (P < 0.001), even though they had coronary artery disease infrequently (P = 0.003). At first, no significant correlation was found between coronary artery disease levels 0, 1, 2, 3, or 4 and scores of depression or anxiety.After controlling for sex differences and other confounding variables, however, we found that every 1-point increase in the depression score was associated with an average 5% to 6% increase in abnormal coronary angiographic findings or definitive coronary artery disease, respectively (P = 0.01 and P = 0.002). Although there was no such association between anxiety score and coronary artery disease, the highest anxiety scores were encountered in patients with slow coronary flow.Key words: Angina pectoris, anxiety disorders, chest pain, confounding factors, coronary angiography, coronary disease/epidemiology/etiology, depression/complications, depressive disorder, interview, psychological, psychiatric status rating scales, sex factors, social environment, somatoform disorders, stress, psychological, Turkey/epidemiologyEpidemiologic studies have shown that depression or anxiety disorder can predict the incidence of coronary artery disease (CAD) in healthy populations.¹ Moreover, depression or anxiety disorder can also influence the course and prognosis of known CAD.^2–4 Although one study reported similar psychological variables in groups of patients with chest pain who had angiographically normal or abnormal coronary arteries,⁵ several other studies^6–9 reported that patients who had chest pain and normal coronary arteries exhibited more psychiatric illnesses than did patients with definitive CAD.Because we expected that symptoms of depression and anxiety would be associated with CAD in a consecutive population that had been referred for selective coronary angiography, we compared coronary angiographic findings with depression and anxiety scores that had been estimated in accordance with symptom scales. Our findings are discussed herein.