Transcatheter closure of patent foramen ovale after presumed paradoxical embolism.

BACKGROUND. Many have proposed a relation between presence of a patent foramen ovale, with or without atrial septal aneurysm, and cryptogenic stroke. The effect of foramen ovale closure on the risk for subsequent strokes is unknown. METHODS AND RESULTS. Transcatheter closure of a patent foramen ovale was undertaken in 36 patients with known right-to-left atrial shunting and presumed paradoxical emboli (31 strokes, 25 transient neurological events, four systemic arterial emboli, and two brain abscesses). Individual patients had between one and four such events. None had a left heart or carotid source of embolism; 31 of 35 had no known risk factors for stroke. Events occurred in 12 patients while they were taking warfarin. At cardiac catheterization, patent foramina ovalia were significantly larger than predicted for age in 67% of the patients. Implantation of a double-umbrella device in the patent foramen ovale was achieved in all without serious procedural complications. Of 34 who have returned for follow-up, one has a residual atrial communication that may be clinically important, five had trivial leaks, and 28 have complete closure. There have been no strokes during a mean follow-up of 8.4 months. CONCLUSIONS. Transcatheter closure of a patent foramen ovale can be accomplished with little morbidity and may reduce the risk of recurrence. Further investigations directed toward identifying the population at risk and assessing the effect of intervention are warranted.     

Interventional closure with Amplatzer PFO occluder of patent foramen ovale in patients with paradoxical cerebral embolism

Percutaneous transcatheter closure has been proposed as an alternative to surgical closure or long-term anticoagulation in patients with presumed paradoxical embolism and patent foramen ovale (PFO). We report our mid-term results of 55 consecutive symptomatic patients (mean age: 47 years, range: 20-79) who underwent percutaneous transcatheter closure of PFO after at least one event of cerebral ischemia; 16 (29%) patients had at least one transient ischemic attack and 39 (71%) patients at least one embolic stroke. Multiple embolic events had occurred in 6 (11%) patients. Percutaneous transcatheter closure was technically successful in all 55 patients (100%). For the majority of patients, an Amplatzer PFO occluder measuring 25 mm in diameter (n=49) or an Amplatzer PFO occluder measuring 35 mm in diameter (n=6) was used. Complete occlusion by color Doppler and transesophageal contrast echocardiography investigation was achieved in 96% at follow-up 3-6 months after implantation; only 2 patients had a trivial residual shunt at follow-up. Mean fluoroscopy time was 6.7 minutes (range: 1.7-47.1), and in-hospital follow-up was uneventful except for 1 patient who developed a cardiac tamponade requiring uneventful and successful needle pericardiocentesis. At a mean follow-up of 19 months (range: 3-32) no recurrent embolic neurological events was observed. Transcatheter closure of PFO with Amplatzer PFO occluder devices is a safe and effective therapy for patients with previous paradoxical embolism and aneurysmatic or nonaneurysmatic PFO. Percutaneous closure is associated with a high success rate, low incidence of hospital complications, and freedom of cerebral ischemia events.     

Recurrent events following patent foramen ovale closure in patients above 55 years of age with presumed paradoxical embolism

Objectives: The aim of this article is to summarize our experience of patent foramen ovale (PFO) closure in patients above the age of 55 years. Background: PFO is associated with cryptogenic thromboembolic events (TEs) in patients younger than 55 years. Little is known about the recurrence rate of TE in patients above the age of 55 years undergoing PFO closure for presumed paradoxical embolism. Methods: PFO closure was performed in 1,055 patients, 423 of whom were above 55 years of age. Implantation of the device was guided by fluoroscopy and transesophageal or intracardiac echocardiography. Results: A PFO occluding device was implanted successfully in all patients. Residual shunt was documented in 10% of patients above 55 years of age and in 8.4% of patients aged 55 years or younger (P = 0.325). During a median follow‐up period of 18 months (range, 0–162 months) the annual incidence of recurrent TE in patients above 55 years was 1.8% while patients aged 55 or below had an annual incidence of recurrent TE of 1.3%. TE‐free survival was similar in patients above 55 years of age compared with those aged 55 years and below. Conclusions: PFO closure in older patients is as efficient and seems comparable to those under the age of 55. Although traditional cardiovascular risk factors may be more frequent in the older age group compared with those younger than 55 years, PFO closure should not be withheld as a possible therapeutic option in this age group. © 2008 Wiley‐Liss, Inc.     

Rescue of CardioSEAL PFO closure device malposition with Amplatzer PFO closure device at time of initial implantation.

This case report describes a patient undergoing patent foramen ovale (PFO) closure for recurrent transient ischemic attacks. A CardioSEAL device was placed, but immediately prolapsed into the left atrium in an unstable position. We describe a novel percutaneous technique that allowed capture of the CardioSEAL device and closure of the PFO.     

Outcomes after transcatheter closure of patent foramen ovale in patients with paradoxical embolism

The purpose of the present study was to assess clinical outcomes and closure status after the transcatheter closure of patent foramen ovale. Two hundred thirty-seven consecutive patients (mean age 53 +/- 15 years; 48% men) who underwent patent foramen ovale closure for the prevention of recurrent stroke were evaluated. Primary end points were death, recurrent stroke, and residual right-to-left shunt (RLS). Closure status was monitored at 1, 6, 12, 24, 36, and 48 months after the index procedure by power M-mode transcranial Doppler and was defined by the number of embolic tracks detected after the release of a sustained, calibrated Valsalva maneuver. During a mean follow-up period of 568 +/- 364 days, the cumulative event rate for recurrent stroke (n = 8) was 3.4%, for an estimated event-free survival of 0.94 (SE 0.03). There was a significant difference in the estimated probability of recurrent stroke for patients grouped by age (< or =55 years 1.4% vs >55 years 6.6%, p = 0.03). There were 7 deaths (3.0%), 1 secondary to and 6 unrelated to recurrent strokes, and 3 surgical explantations (1.3%). Event-free survival, defined as freedom from death, stroke, or explantation, was 0.92 (SE 0.02). The magnitude of RLS was significantly less at late follow-up compared with baseline (grade 4.6 +/- 0.7 vs 1.8 +/- 1.6, p <0.001). Complete closure or minimal residual RLS (grade 0 to II) was achieved in 66% of patients. Device type (CardioSEAL or Amplatzer) did not affect the risk for adverse events or the presence of large residual RLS. In conclusion, transcatheter patent foramen ovale closure is associated with a low recurrent stroke rate in long-term follow-up.     

重复消融对阵发性心房颤动复发患者远期获益的评估

目的:评估重复消融对阵发性心房颤动复发患者的远期获益.方法:入选2000-01-2004-12期间经导管消融(肺静脉电隔离)的阵发性心房颤动患者106例.所有患者心房颤动的症状明显,超过2种抗心律失常药物治疗无效.结果:106例中,失访9例(8.5％),非心源性死亡3例,2次消融时出现一过性脑梗死未完成完整术式1例,其余93例均纳入随访,平均随访5年.1次消融远期维持窦性心律39例,成功率为41.9％.复发者54例中39例(72.2％)进行2次消融,其中27例(69.2％)远期维持窦性心律,消融远期成功率提高了29.0％;复发者12例中5例(41.7％)进行3次消融,其中2例(40.0％)远期维持窦性心律,使远期成功率再提高2.2％;复发者3例中2例(66.7％)再行4次消融,术后均再次复发心房颤动.重复消融累计远期成功率较1次消融明显提高(73.1％:41.9％,P＜0.01).包括重复消融在内,12个月内的总成功率为81.7％,平均远期复发时间是术后(28.4±8.3)个月.1次消融因电隔离肺静脉电传导恢复导致心房颤动远期复发(6例),经重复消融均可实现远期维持窦性心律.结论:远期复发心房颤动的主要机制是电隔离肺静脉的电传导恢复,重复消融有望实现和维持远期窦性心律.     

动脉硬化闭塞症膝下动脉血管腔内治疗的近远期疗效观察

目的:观察动脉硬化闭塞症膝下动脉病变经皮血管腔内治疗的疗效。方法:选取我科2006年10月至2009年10月期间,动脉硬化闭塞症膝下动脉病变经皮血管腔内治疗的117例患者,回顾性分析腔内治疗开通血管的成功率及术后随访资料。结果:117例患者(132条患肢)初次腔内治疗成功率为90.15%(119/132)。术后平均随访18个月(4～36个月)。血管再狭窄发生率分别为:6个月8.5%(10/117),12个月19.0%(22/116),18个月25.9%(30/116)。21例临床症状复发,再次腔内治疗成功率85.7%(18/21)。患者手术后间歇性跛行、静息痛、缺血性溃疡等临床症状均明显改善。结论:动脉硬化闭塞症膝下动脉腔内治疗手术成功率较高,临床效果满意,远期有一定的复发率,但可再次治疗。     

Endobronchial closure of bronchopleural fistula with Amplatzer PFO device

Bronchopleural fistula (BPF) is a feared postoperative complication of pneumonectomy that carries significant morbidity and mortality. BPF can be treated by various surgical and medical techniques. Endobronchial techniques have been used for the delivery of biological glue, sealants, coils, and covered stents with variable degrees of success, depending on the size of the fistula. A recent case report described the endobronchial closure of a BPF through the implantation of an Amplatzer ASD device, commonly used for transcatheter closure of atrial septal defects. In this case report, we describe closure of a BFP using the Amplatzer PFO device.     

Hemodynamics of patients developing pulmonary arterial hypertension after shunt closure

Background

Pulmonary arterial hypertension (PAH) after shunt closure is associated with a poor prognosis. The aim of this study was to assess retrospectively the hemodynamics of patients developing PAH after shunt closure.

Methods

Hemodynamic data obtained by right heart catheterization (RHC) performed at baseline and after shunt closure were analyzed.

Results

Twenty-two patients, 13 with atrial septal defect (ASD), 6 with ventricular septal defect (VSD), 1 with patent ductus arteriosus, 1 with both ASD and VSD, and 1 with complete atrio-ventricular canal have been considered. The mean age at closure was 25.3 ± 20.1 years (range of 3 months to 56.7 years), and the mean age at PAH diagnosis was 37.0 ± 20.8 years (range of 5 to 61.2 years). The time delay between shunt closure and PAH diagnosis was 140.2 ± 100.2 months. At baseline RHC, hemodynamic data were as follows: pulmonary vascular resistance (PVR) of 8.6 ± 2.6 Wood units, PVR index (PVRi) of 10.1 ± 2.7 Wood units ∗ m², mean pulmonary arterial pressure of 43.7 ± 9.7 mm Hg, PVR to systemic vascular resistance ratio (PVR/SVR) of 0.70 ± 0.23, and Qp/Qs of 1.6 ± 0.4. In particular, 18/22 (81%) had PVR ≥ 5 Wood units, 21/22 (95%) PVRi ≥ 6 Wood units ∗ m², 21/22 (95%) PVR/SVR ≥ 0.33, and 11/22 (50%) Qp/Qs ≤ 1.5. During the follow-up, 5/22 (22%) patients died and one patient underwent successful double lung transplantation.

Conclusions

High baseline values of PVR (≥ 5 Wood units), PVRi (≥ 6 Wood units ∗ m²) and PVR/SVR (≥ 0.33) are common findings in patients who develop PAH late after shunt closure. Large prospective clinical trials are needed to establish the safe limits for shunt closure.     

心房颤动患者单次射频消融术后的远期效果及影响因素的观察

目的观察心房颤动(简称房颤)患者射频消融术后的疗效,探索房颤射频消融术后复发的危险因素。方法选取2010年8月至2013年9月首次行房颤射频消融治疗的63例患者,收集临床资料,分析术后长期有效性、探讨影响远期复发的因素。结果 63例房颤患者中,单次消融后第一年随访时23.8%的房颤患者复发,其中阵发性房颤20.8%复发,持续性房颤40%复发。平均随访46.7个月时40.7%的房颤患者复发,其中阵发性房颤38%复发,持续性房颤55.6%复发。年龄为房颤单次射频消融术后复发的独立危险因素(OR=3.8,95%CI:1.264~11.426,P=0.017)。结论射频消融治疗房颤远期观察具有较高的复发率,且年龄大的患者存在更高的复发率。     

High recurrence rate of Barrett's epithelium during long-term follow-up after argon plasma coagulation

OBJECTIVE: Several studies have shown that argon plasma coagulation (APC) combined with proton-pump inhibitor (PPI) therapy is a suitable procedure to eradicate Barrett's epithelium for a short-term follow-up. The real impact of this kind of management with respect to cancer risk and durability of squamous regeneration remains unclear. We present the follow-up data for up to 51 months after eradication of Barrett's mucosa. MATERIAL AND METHODS: In 1998-2001, 25 patients with Barrett's esophagus were included in a prospective study. After baseline documentation, Barrett's epithelium was treated with repeated APC until complete squamous restoration was reached. Thereafter, all patients were continuously treated with high-dose PPIs. RESULTS: Each patient underwent a median of four APC sessions. Twenty-one (84%) of the patients had complete squamous regeneration at the end of treatment. During a follow-up of up to 51 months, Barrett's epithelium was found to have recurred in 14/21 (66%) patients. Including the patients with initially incomplete squamous restoration, a long-lasting and complete effect was achieved in only 7 patients (28%) after a mean follow-up period of 30 months. CONCLUSIONS: So far, it is still not proven whether coagulation-induced squamous regeneration reduces the risk of Barrett's carcinoma. Furthermore, the high relapse rate, the procedure-related risk, and the high costs incurred preclude the routine use of APC for the treatment of non-dysplastic Barrett's esophagus. The different recurrence rates between published studies may be due to technical differences and PPI schedule. We suggest that optimal conditions for the procedure must be defined before further studies are undertaken.     

Single centre experience with GORE-HELEX septal occluder for closure of PFO

Several devices are available for percutaneous patent foramen ovale (PFO) closure. Over the past 3 years our planned treatment strategy of PFO closure has been routine use of the GORE-HELEX septal occluder device, followed by 6 months of aspirin therapy. We present the safety and feasibility of routinely using this device for all patients undergoing percutaneous PFO closure, with 3-month transthoracic echocardiogram (TTE) follow up. In total, 75 adult patients (44.0+/-11.7 years; 45.3% male) were referred for PFO closure during the study period. All patients underwent echocardiography prior to PFO closure. In 5 patients no PFO was found, and 1 patient had an atrial secundum defect closed using the Amplatzer septal occluder. Of the 69 remaining patients with PFO, 68/69 (98.6%) underwent closure with the GORE-HELEX device. Six of 69 cases required device retrieval and 5 of 6 were replaced successfully with a second GORE-HELEX device. One of the 6, a large PFO associated with atrial septal aneurysm, was replaced using the Amplatzer septal occluder. There were no major complications. At 3-month follow up, 65/68 (95.6%) had no residual shunt on TTE, and 3 patients had small residual shunts thought to be related to incomplete endothelialisation at 3 months. In conclusion, percutaneous PFO closure using the GORE-HELEX septal occluder device is safe and feasible, with no major peri-procedural complications and excellent short-term results at 3-month follow up.     

Amplatzer PFO Occluder for treatment of incomplete LAA closure with AtriClip

Herein, we describe the use of an Amplatzer PFO Occluder to treat incomplete LAA closure due to a malpositioned AtriClip.     

肺栓塞的抗凝疗程和复发率分析

目的 探讨肺栓塞患者抗凝疗程和肺栓塞复发率的关系.方法 对2002-2009年我院诊治并好转出院的167例肺栓塞患者进行随访,分别观察存在临时危险因素的肺栓塞患者、特发性肺栓塞患者和持续存在危险因素的肺栓塞患者序贯口服华法林抗凝治疗的疗程、复发率和出血发生率,并分析复发率与年龄、性别的关系.结果 特发性肺栓塞患者的复发率高于存在临时危险因素的肺栓塞患者(P＜0.05).持续存在危险因素的肺栓塞患者口服抗凝疗程较其余两组长,但出血发生率也高于其余两组(P值均＜0.05).特发性肺栓塞患者男性复发率高于女性(P＜0.05).结论 肺栓塞患者序贯口服华法林抗凝疗程应采取个体化方案,在综合评价复发风险和出血风险后决定,使患者取得最佳的长期获益.

Abstract：

Objective To investigate the relationship between duration of anticoagulant therapy and recurrence rate in pulmonary embolism. Methods 167 patients with pulmonary embolism who were treated and improved in our hospital from 2002 to 2009 were followed up. The duration of anticoagulant therapy, recurrence rate and bleeding incidence were observed in patients with pulmonary embolism associated with temporary risk factors, patients with idiopathic pulmonary embolism and patients with pulmonary embolism associated with permanent risk factors. The relationship between recurrence rate and age, gender was analyzed. Results The recurrence rate in patients with idiopathic pulmonary embolism was higher than that in patients with pulmonary embolism associated with temporary risk factors ( P ＜0. 05). The duration of anticoagulant therapy in patients with pulmonary embolism associated with permanent risk factors was longer than that in other groups, but the risk of bleeding was also higher than that in other groups (all P ＜ 0. 05). The recurrence rate in male patients with idiopathic pulmonary embolism was higher than that in female patients ( P ＜0. 05). Conclusions For patients with pulmonary embolism,the duration of anticoagulant therapy must be individualized, is decided after the comprehensive evaluation of recurrence risk and bleeding risk,so that patients get the best long-term benefit.     

围手术期输血对老年胃癌术后近期影响及远期复发率的影响

目的 探讨围手术期输血对老年胃癌术后近期影响及远期复发率的影响.方法 将80例老年胃癌手术患者按照有无输血分为输血组和无输血组,并对患者的临床资料进行回顾性分析.结果 （1）输血组患者肿瘤大小、侵袭度、淋巴结转移度、TNM分期、术前贫血高于无输血组患者,差异具有统计学意义（P＜0.05）;（2）随访显示29例患者复发,其中输血组有21例（52.5％）患者复发,无输血组有8例（20.0％）复发,输血组患者术后复发率显著高于无输血组,差异具有统计学意义（P＜0.05）,多元回归分析显示,侵袭度、淋巴结转移、TNM分期、围手术期输血、有无术前贫血均为影响患者预后的独立危险因素.结论 围手术期输血与胃癌患者术后复发发生率及预后不良之间存在密切的关系,围手术期输血可作为判断胃癌预后的独立因素.