Percutaneous alcohol septal ablation for hypertrophic obstructive cardiomyopathy: technical review and long-term clinical and echocardiographic outcomes

BackgroundPercutaneous septal ablation by alcohol-induced septal branch occlusion was introduced as a new treatment option in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Our aim was to evaluate procedural and long-term clinical and echocardiographic outcomes in patients with HOCM treated by alcohol septal ablation (ASA) at our center.MethodsThis single-center retrospective study included 14 consecutive HOCM patients undergoing percutaneous ASA (66.4 ± 12.1 years, 71.4% female). At baseline all patients presented persistent symptoms despite optimized medical treatment, left ventricular outflow tract (LVOT) obstruction with a peak gradient >50 mmHg, systolic anterior motion of the mitral valve, and ventricular septal thickness ≥15 mm. ASA was considered successful when the LVOT pressure gradient fell to less than 50% of baseline value. All patients had echocardiographic evaluation at baseline, intraprocedure and at follow-up, and a long-term clinical follow-up (25 ± 38 months) with evaluation of functional class and occurrence of symptoms or cardiovascular events.ResultsPercutaneous ASA achieved a 71.4% acute and 85.7% long-term success rate. Peak LVOT gradient decreased from 104 ± 40 mmHg at baseline to 58 ± 30 mmHg intraprocedure (p = 0.03) and 35 ± 26 mmHg at follow-up (p = 0.001); total gradient decrease was 75 ± 43 mmHg. Ventricular septal thickness and mitral regurgitation also presented significant decreases during follow-up (from 24 ± 5 mm to 18 ± 4 mm, p = 0.02, and from grade 2.4 ± 0.6 to 1.4 ± 0.5, p < 0.001, respectively). A tendency for long-term improvement in NYHA functional class (from 2.6 ± 1.1 to 1.8 ± 1.4, p = 0.09) was observed. Procedural complications occurred in 6.7% of patients; two deaths and one transient ischemic attack occurred in-hospital, but no long-term clinical events were recorded.ConclusionsPercutaneous ASA is an effective treatment for symptomatic patients with HOCM, obtaining a marked decrease in LVOT pressure gradient and symptomatic improvement. Despite the occurrence of a significant number of procedural complications, the favorable long-term outcomes underline the potential of ASA as a percutaneous alternative to surgical myectomy.     

Major determinants and possible mechanism of dobutamine-induced left ventricular outflow tract obstruction in patients with a sigmoid ventricular septum

BackgroundA sigmoid ventricular septum (SVS) may be related to normal aging, but some people with an SVS develop a left ventricular outflow tract (LVOT) obstruction (defined as a gradient of >30 mmHg). Therefore, we investigated the association of LVOT obstructions with an SVS by dobutamine stress echocardiography (DSE) and assessed the possible mechanism of the latent LVOT obstruction.Methods and resultsDSE was performed in 64 subjects with SVS (mean age: 73.3 ± 7.7 years; 36 women) without an LVOT obstruction. In 40 of the 64 subjects, an LVOT obstruction occurred during the DSE (defined as latent obstruction). At rest, the subjects with a latent obstruction had a shorter end-systolic mitral leaflet tethering distance (“α” distance, i.e. the distance between the tip of the posterior papillary muscle and the contralateral anterior mitral annulus) than those without one (29.9 ± 4.2 mm versus 35.2 ± 4.6 mm), as well as a smaller end-systolic LVOT diameter (13.4 ± 2.7 mm versus 16.1 ± 3.4 mm) and larger ejection fraction (72.0 ± 5.0% versus 67.8 ± 5.9%) (all p < 0.05). They also had a higher LV outflow velocity at rest (1.23 ± 0.24 m/s versus 1.03 ± 0.24 m/s) and during the Valsalva maneuver (1.31 ± 0.27 m/s versus 1.03 ± 0.27 m/s) (both p < 0.05). After adjusting for these parameters, the resting end-systolic “α” distance and LV outflow velocity at rest remained independent predictors of a latent obstruction.ConclusionA short leaflet tethering distance (“α”) was the major determinant of a latent obstruction, suggesting that a mitral leaflet displacement/redundancy caused by a short “α” distance contributes to the LVOT obstruction.     

Alcohol septal ablation for hypertrophic obstructive cardiomyopathy – 8 years follow up

BackgroundAlcohol septal ablation is emerging as an alternative to surgical myectomy in the management of symptomatic cases of Hypertrophic obstructive cardiomyopathy (HOCM). This involves injection of absolute alcohol into 1st septal perforator thereby producing myocardial necrosis with resultant septal remodelling within 3–6 months. This results in reduction of septal thickness and LV outflow gradients with improvement in symptoms.MethodsFifty three patients had undergone alcohol septal ablation, there were 2 early and 2 late deaths and 4 patients lost to follow up. Forty-five (85%) of them were followed up to a mean period of 96 ± 9.2 months. Clinical, ECG, and Echocardiographic parameters were evaluated during follow up.ResultsOnly 4 out of 51 patients remained in NYHA class III or IV at the end of 6 months. Significant reduction of LV outflow gradients (79 ± 35 to 34 ± 23 mmHg) and septal thickness (23 ± 4.7 mm to 19 ± 3 mm) were observed during 6 months follow up. Beyond 6 months there was no further decrease in either septal thickness or LVOT gradients noted. Ten percent of patients needed pacemaker implantation. There was 92% survival at the end of 8 years.ConclusionAlcohol septal ablation is a safe and effective nonsurgical procedure for the treatment of HOCM. By minimizing the amount of alcohol to ≤2 ml, one can reduce complications and mortality. The long-term survival is gratifying.     

Assessment of clinical factors associated with a successful catheter ablation outcome in younger patients with atrial fibrillation

BackgroundCatheter ablation is now an alternative approach to antiarrhythmic drug therapy for patients with symptomatic atrial fibrillation (AF). We focused on younger patients in whom the prevalence of AF is low, and we sought clinical factors associated with unsuccessful ablation outcomes.Methods and resultsAmong 1983 consecutive symptomatic patients who underwent AF ablation procedures, 95 patients (4.8%), age ≤ 40 years, were prospectively included. Of them, 64 had paroxysmal AF, and the remaining 31 had persistent AF. All patients underwent pulmonary vein isolation and cavotricuspid isthmus ablation. When AF recurred, redo ablations were performed if the patients desired. The mean number of ablation procedures was 1.3 ± 0.6 times per patient. During the follow-up of 40 [27.8–49.6] months, sinus rhythm was maintained in 86 patients (90.5%) without any antiarrhythmic drugs, but not in the remaining 9 patients (9.5%). Low body mass index (BMI) and persistent AF were associated with unsuccessful ablation procedures. In multivariate logistic regression analysis, a low BMI had the most significant value, with an odds ratio of 7.33 (p = 0.022). The receiver operating characteristic curve demonstrated a BMI cut point of 22.1 kg/m², with an area under the curve of 0.773.ConclusionIn symptomatic younger AF patients, a low BMI was an independent clinical factor for unsuccessful AF ablation outcomes.     

Right bundle branch block and ventricular septal fibrosis in patients with hypertrophic cardiomyopathy

BackgroundRight bundle branch block (RBBB) is associated with ventricular septal fibrosis in patients with hypertrophic cardiomyopathy (HCM) after alcohol septal ablation, but little data are available in HCM patients without a history of septal ablation.MethodsMagnetic resonance late gadolinium enhancement (LGE) was performed in 59 HCM patients with no history of alcohol septal ablation. The location and extent of LGE were examined in relation to electrocardiographic features including RBBB.ResultsLGE volume was higher in 7 HCM patients with RBBB (7.3 ± 7.4 g/cm) than in patients without RBBB (2.9 ± 7.4 g/cm, p = 0.016). LGE volume was positively correlated to QRS duration of RBBB (correlation coefficient = 0.93, p = 0.023). The diagnostic value of RBBB was highly specific for the detection of LGE in the ventricular septum, with sensitivity 21% and specificity 94%.ConclusionsThe presence of RBBB may be a simple marker for detecting ventricular septal fibrosis in HCM patients who had no history of alcohol septal ablation. Further studies are necessary to confirm our findings.     

Radiofrequency catheter ablation of premature ventricular complexes from right ventricular outflow tract in patients with left ventricular dilation and/or dysfunction

Left ventricular (LV) dysfunction caused by frequent premature ventricular complexes (PVCs) can be reversed by suppression of PVCs with antiarrhythmic agents or radiofrequency catheter ablation (RFA). However, there is a paucity of data on the efficacy and safety of RFA among the local population. We aimed in this study to evaluate the effect of RFA of frequent PVCs originating from right ventricular outflow tract (RVOT-PVCs) on cardiac function in patients with depressed cardiac function and/or LV dilation. The study included sixteen patients with monomorphic RVOT-PVCs without overt underlying structural heart disease. Frequency of PVCs by 24-h Holter monitoring, left ventricular ejection fraction (LVEF), end-diastolic diameter (LVEDD), end-systolic diameter (LVESD), mitral regurgitation (MR) by echocardiogram and NYHA functional class were evaluated before and 3 and 6 months after RFA. All patients underwent RFA.ResultsThe higher the number of PVCs/24 h, the bigger the LVESD and the lower the EF. Procedural success was achieved in 13 (81%) of the patients with no complications. Six months follow-up after successful ablation, LVEDD decreased significantly (from 56.62 ± 5.87 to 49.23 ± 5.31 mm; p = 0.002), LVESD decreased significantly (from 41.85 ± 7.82 to 33.69 ± 4.66 mm; p = 0.002), LVEF increased significantly (from 46.69 ± 4.92% to 60.54 ± 5.39%; p < 0.001) and NYHA functional class improved in all patients after successful ablation.ConclusionRF catheter ablation of frequent RVOT-PVC has a beneficial effect on cardiac function in patients with depressed cardiac function.It carries a high degree of success and safety. Frequent RVOT-PVCs are burden on LV function even in patients without overt underlying structural heart disease.     

El fracaso de la ablación por catéter de la fibrilación auricular se asocia con mayor remodelado y menos eficacia de una posterior ablación toracoscópica

Introduction and objectivesRecent observations suggest that patients with a previous failed catheter ablation have an increased risk of atrial fibrillation (AF) recurrence after subsequent thoracoscopic AF ablation. We assessed the risk of AF recurrence in patients with a previous failed catheter ablation undergoing thoracoscopic ablation.MethodsWe included patients from 3 medical centers. To correct for potential heterogeneity, we performed propensity matching to compare AF freedom (freedom from any atrial tachyarrhythmia > 30 s during 1-year follow-up). Left atrial appendage tissue was analyzed for collagen distribution.ResultsA total of 705 patients were included, and 183 had a previous failed catheter ablation. These patients had fewer risk factors for AF recurrence than ablation naïve controls: smaller indexed left atrial volume (40.9 ± 12.5 vs 43.0 ± 12.5 mL/m², P = .048), less congestive heart failure (1.5% vs 8.9%, P = .001), and less persistent AF (52.2% vs 60.3%, P = .067). However, AF history duration was longer in patients with a previous failed catheter ablation (6.5 [4-10.5] vs 4 [2-8] years; P < .001). In propensity matched analysis, patients with a failed catheter ablation were at a 68% higher AF recurrence risk (OR, 1.68; 95%CI, 1.20-2.15; P = .034). AF freedom was 61.1% in patients with a previous failed catheter ablation vs 72.5% in ablation naïve matched controls. On histology of the left atrial appendage (n = 198), patients with a failed catheter ablation had a higher density of collagen fibers.ConclusionsPatients with a prior failed catheter ablation had fewer risk factors for AF recurrence but more frequently had AF recurrence after thoracoscopic AF ablation than ablation naïve patients. This may in part be explained by more progressed, subclinical, atrial fibrosis formation.     

Asymptomatic damage of central nervous system defined by excess level of protein S100B by patients undergoing the radiofrequency ablation of ventricular tachycardia

AimEvaluation of the effect of radiofrequency catheter ablation of ventricular arrhythmias on asymptomatic central nervous system evaluation with the help S100B protein. Furthermore, identification of factors predicting elevation of S100B protein level after ablation.MethodsConsecutive patients undergoing RFA for ventricular arrhythmias between 11/2015 and 8/2016. Protein S100B was evaluated before the procedure, immediately after the procedure, in 8 and 24 h after the procedure. In the case of the excess values of the S100B protein within 24 h after computer tomography (CT) of CNS supplementation and neurological examination.Set of patients23 patients, of which there were 19 men and 4 women aged 62 ± 8. Coronary artery disease with a scar after myocardial infarction 18 patients (78%), 2 patients with dilated cardiomyopathy, 2 patients with idiopathic ventricular tachycardia, 1 patient with non-compact cardiomyopathy.Eject fraction of left ventricle was 29 ± 8%. All patients with implantable cardioverter defibrillator. 3 patients (13%) underwent RFA by combined endo-epicardial approach. By 5 patients (22%) the surgery was performed in general anesthesia.ResultsAt least one excess value of S100B protein was identified by 10 patients (43%). After 24 h, the cut off value of the protein S100B was exceeded by 3 patients (13%). Even in one of these patients, we did not see acute changes on CT of CNS or by neurological examination. Surgery duration, ablation time, necessity for defibrillation during the surgery, intensity of anticoagulation during the surgery were without statistically significant influence on elevation of S100B protein levels.A group of patients with S100B elevation had statistically significantly worse renal functions represented by serum creatinine level (127 ± 41 vs. 100 ± 25 μmol/l, p = 0.02). As another factor that statistically significantly predicted the postablation elevation of the protein S100B the stage of heart failure measured by the levels of NTproBNP (4417 vs 1634 ng/l, p = 0.05) was shown. A statistically significant effect on the elevation of S100B protein in our set was the use of total anesthesia with sevoflurane (p = 0.03).ConclusionThe elevation of the S100B protein after catheter ablation for ventricular arrhythmias is relatively common in our set. We did not identify any macroscopic changes on CT of CNS even by neurological examination.The level of renal insufficiency, the progression of cardiac failure, and the use of inhaled anesthesia with sevoflurane correlate with the amount of S100B as the biomarker of asymptomatic disability of CNS by patients receiving radiofrequency catheter ablation for ventricular arrhythmias.     

Hypoglycemia symptoms are reduced in hospitalized patients with diabetes

AimsHospitalized patients with diabetes are have an impaired ability to detect hypoglycemia events. The purpose of this study was to compare hypoglycemia symptom scores (HSS) in hospitalized patients with diabetes after a documented blood glucose (BG) <70 mg/dl with recalled HSS with outpatient hypoglycemia events.MethodsNon-critically ill hospitalized patients with diabetes grouped as symptomatic (n = 23) or asymptomatic (n = 32) at time of index hypoglycemia completed a standardized HSS-Questionnaires (HSS-Q) related to the inpatient event and to recall of symptoms with outpatient hypoglycemia.ResultsAfter controlling for BG at time of index hypoglycemia (49.8 ± 11.4 vs. 57.4 ± 6.8 mg/dl, p = 0.02), symptomatic patients reported higher HSS than asymptomatic patients with the inpatient event (11.6 ± 7.3 vs. 1.5 ± 3.4, p < 0.001) and in the outpatient setting (13.9 ± 8.6 vs. 10.1 ± 10.6, p < 0.01). Recurrent hypoglycemia was more frequent in asymptomatic patients (13% vs. 44%, p = 0.015) during the hospitalization.ConclusionsCompared to symptomatic patients, asymptomatic patients had lower inpatient and outpatient HSS and more frequent recurrent hypoglycemia events. These results suggest modification of glycemic management strategies in high risk patients to reduce risk for hypoglycemia events.     

Usefulness of ablation of complex fractionated atrial electrograms using nifekalant in persistent atrial fibrillation

BackgroundAdditional ablation of complex fractionated atrial electrograms (CFAE) after pulmonary vein isolation (PVI) has been shown to improve the success of ablation of persistent atrial fibrillation (AF). However, extensive ablation is often necessary to eliminate all CFAE or to terminate AF. We assessed the usefulness of the administration of an antiarrhythmic drug (AAD) before CFAE ablation.Methods and resultsOne-hundred and ten patients with persistent AF first underwent PVI, roof and floor linear ablation (box isolation). One hundred patients who remained in AF after box isolation were then randomized to either receive (AAD group, n = 50) or not receive (no-AAD group, n = 50) intravenous nifekalant (0.3 mg/kg) followed by a CFAE ablation. In the AAD group, nifekalant terminated AF in 19 (38%) patients and ablation of localized CFAE was performed in 31 patients who remained in AF after nifekalant, and terminated AF in 11 (35%) patients. In the no-AAD group, ablation of CFAE terminated AF in 13 (26%) patients. The AAD group had a significantly lesser number of radio frequency applications at CFAE sites (18 ± 12 versus 36 ± 10, p < 0.0001) and shorter procedure time (162 ± 34 versus 197 ± 29 min, p < 0.0001) compared with the no-AAD group. However, there was no significant difference in success rate at 12 months after a single ablation procedure between the two groups (AAD group, 74% versus no-AAD group, 76%).ConclusionsAn approach to ablation using nifekalant may be useful in localizing areas of CFAE, reducing the number of applications at CFAE sites and procedure time. Ablation of only CFAE localized with nifekalant may be sufficient for clinical outcome.     

Impact of catheter ablation on P-wave parameters on 12-lead electrocardiogram in patients with atrial fibrillation

BackgroundCatheter ablation has emerged as a widely used treatment modality for atrial fibrillation (AF). P-wave abnormalities have been described in the patients with AF, and catheter ablation may potentially further impact P-wave parameters due to ablation of atrial tissue.MethodsWe reviewed data on P-wave parameters (P-wave duration, amplitude and P-wave duration and amplitude product) in leads V1 and aVF and changes in the P-terminal force (Ptf; product of duration and amplitude of terminal part of P-wave) in lead V1 from 12-lead electrocardiograms obtained prior to and after CA of a total of 46 (28 paroxysmal and 18 persistent) AF patients.ResultsThe median age of patients in our study was 63 (range: 30–77) years. We noticed a significant reduction in the P-wave duration (from 87.39 ± 28.62 ms at baseline to 72.09 ± 24.59 ms; p = 0.0072) and the product of P-wave duration and amplitude in lead V1 (12.16 ± 5.54 mV ms at baseline to 8.30 ± 5.78 mV ms, p = 0.0015) after CA. There was also a significant decrease in P-wave duration (from 92.57 ± 19.67 ms at baseline to 76.48 ± 16.32 ms after CA, p = 0.0001) and P-wave duration and amplitude product in lead aVF (12.61 ± 4.05 mV ms at baseline to 9.77 ± 3.86 m V ms after CA, p = 0.0001). CA also led to a significant decrease in Ptf (from 4.56 ± 1.88 at baseline to 2.85 ± 1.42 mV ms, p < 0.0001).ConclusionRadiofrequency catheter ablation of AF leads to modification of P-wave parameters with substantial diminution in both the amplitude and duration of the P-wave in leads V1 and aVF. This likely represents reduction in electrically active atrial tissue after ablation, and may serve as a marker for the extent of ablated atrial tissue.     

Modified balloon aortic valvuloplasty in fragile symptomatic patients unsuitable for both surgical and percutaneous valve replacement

BackgroundBalloon Aortic valvuloplasty (BAV) is considered as a bridge therapy to percutaneous valve implantation or a palliative treatment in patients with aortic valve stenosis (AVS). Potential risk of complications, in particular in fragile patients, is still not negligible.AimTo describe the technique and outcomes of modified BAV in fragile symptomatic patients unsuitable for other treatments using no-pacing and minimally invasive approach.MethodsSymptomatic fragile patients with severe aortic valve stenosis judged unsuitable by the heart team for surgical or percutaneous valve implantation from 1 September 2013 to 1 September 2017 were offered modified BAV. Simplified procedural protocol included a 4F right radial artery access for gradient check, a 8F compatible undersized balloons, two partial inflations-trial before a full inflation with no-pace maker back-up, final pressure gradient recording and aortography.ResultsThirty-four symptomatic fragile patients (mean age 80.9 ± 4.9, range 73 to 91 years, 100% Katz > 6, mean Euroscore I 30.0 ± 11.7%) underwent modified BAV in the last 5 years with immediate success in all (100%). Mean aortic valve area increased from 0.58 ± 0.2 cm² to 1.1 ± 0.2 cm² (p < 0.01) whereas mean peak gradient decreased from 75.6 ± 11.3 to 35.8 ± 11.2 mm Hg (p < 0.01). Procedural complications were 14.7%. Thirty-day mortality was 11.8%. On a mean follow up of 38.4 ± 4.6 months four patients successfully repeated the procedure, while global mortality was 23.5% (8 patients). The other 22 patients maintained a NYHA class of 2.1 ± 0.7.ConclusionsNo-pacing minimally invasive BAV seems to have acceptable outcomes in patients with severe AVS and no other treatment options.     

Thoracoscopic radiofrequency ablation for lone atrial fibrillation: Box-lesion technique

BackgroundWe report the feasibility and outcomes of box-lesion ablation technique to treat stand-alone atrial fibrillation (AF).MethodsThere were 31 patients with a mean age of 63.3 ± 8.4 years who underwent bilateral totally thoracoscopic ablation of symptomatic paroxysmal AF (n = 8; 25.8%) and long-standing persistent AF (n = 23; 75.2%). The box-lesion procedure included bilateral pulmonary vein and left atrial posterior wall ablation using irrigated bipolar radiofrequency with documentation of conduction block.ResultsThere were no intra- or perioperative ablation-related complications. There was no operative mortality, no myocardial infarction, and no stroke. Skin-to-skin procedure time was 152.1 ± 36.7 min and the postoperative average length of stay was 6.26 ± 1.24 days. At discharge, 29 patients (93.5%) were in sinus rhythm. Median follow-up time was 20.4 ± 8.3 months. At three months postsurgery, 20 patients of 30 (66.6%) were free from AF without the need of antiarrhythmic drugs. Six patients (20%) underwent catheter reablation. Twenty-three patients (76.6%) were in sinus rhythm at one year after the last performed ablation (surgical ablation or catheter reablation).ConclusionThe thoracoscopic box-lesion ablation procedure is a safe, effective, and minimally invasive method for the treatment of isolated (lone) AF. This procedure provided excellent short-term freedom from AF.     

Hypoadiponectinemia in lipodystrophic HIV individuals: A metabolic marker of subclinical cardiac damage

Background and aimTo evaluate cardiovascular abnormalities in highly active antiretroviral therapy (HAART) treated HIV patients with no signs or symptoms of cardiovascular impairment, and to assess the relative role of multiple concomitant risk factors.Methods and resultsForty-four consecutive HIV subjects (mean age 41 ± 6 yrs) were enrolled. Inclusion criteria were HIV infection, CD4 + cell count > 150/ml, HAART treatment for at least 4 years. Metabolic serum levels, morphological and functional echocardiographic parameters were assessed in all subjects. Sixteen healthy age and sex matched subjects with no cardiovascular risk factors were recruited as controls.HIV patients showed increased left ventricular mass index with reduced mid-wall fractional shortening (mFS) when compared to controls (50.2 ± 10.5 vs. 38.6 ± 14.4, p = 0.05 and 18.3 ± 0.6 vs. 21.9 ± 0.7, p < 0.05, respectively). Twenty-nine patients were lipodystrophic (LD) and showed a longer HAART period (p = 0.0004) and greater use of protease inhibitors (PI) (p = 0.001). Coronary flow reserve (CFR) was significantly reduced in HIV patients as compared to controls (p < 0.0001), as it was in LD subjects when compared to non-lipodystrophic ones (NLD) (p < 0.001). Adiponectin concentrations were found to be significantly lower in LD subjects than in NLD ones (7.8 ± 0.8 vs. 13.8 ± 1.2 μg/ml, p = 0.01), and showed a direct correlation with CFR. In multiple regression analysis, insulin, HDL and adiponectin accounted for 63% of CFR variations.ConclusionsLeft ventricular hypertrophy, depressed mFS and reduced CFR represent the main signs of subclinical cardiac damage in HIV subjects treated with HAART. Hypoadiponectinemia in these subjects seems to be a metabolic risk factor of cardiovascular impairment.     

The impact of commissural morphology on clinical outcome in patients undergoing percutaneous balloon mitral valvuloplasty

AimWe aimed to evaluate the prognostic value of commissural morphology on immediate and short term outcome after Percutaneous balloon mitral valvuloplasty (PBMV).MethodsThe study included 30 patients with symptomatic mitral stenosis (MS) scheduled for PBMV with these exclusion criteria: left atrial thrombi, High echocardiography score, Moderate to severe mitral regurgitation (MR), Atrial fibrillation (AF) or Calcification. After PBMV, they were randomized into 2 groups: Group I: 12 patients with only opened one commissure and group II: 18 patients with bilateral opened commissures.ResultsFollowing PBMV, the mean mitral valve area (MVA) increased from 0.94 ± 0.19 to 1.86 ± 0.27 cm² in group I & from 0.91 ± 0.18 to 2.29 ± 0.33 cm² in group II (p = 0.001). The mean transmitral gradient (MG) decreased from 21.83 ± 4.1 to 8.08 ± 2.9 mmHg in group I and from 18.28 ± 5 to 5.2 ± 1.76 mmHg in group II (p = 0.003). The MVA was 1.85 ± 0.23 cm² in group I and 2.25 ± 0.31 cm² in group II (p = 0.001) and MG was 8.09 ± 2.90 mmHg in group I and 5.47 ± 1.79 mmHg in group II (p = 0.001). Three month follow-up: there was no patient developed AF, embolization or severe MR. Also, there was no mortality, redo, or surgery.ConclusionWe concluded that degree of commissural opening and MVA are closely related. The complete bilateral commissural opening is associated with better sustained MVA and functional status. Thus, evaluation of the degree of commissural opening can be considered as a complementary measure of the procedural success in PBMV.     

Endoscopic band ligation of internal haemorrhoids versus stapled haemorrhoidopexy in patients with portal hypertension

Background and study aimPortal hypertension is common in Egypt as a sequela to the high prevalence of hepatitis C virus and bilharziasis. In portal hypertension internal haemorrhoids are frequently found. The aim of this work was to compare the outcome of endoscopic band ligation (EBL) of symptomatic internal haemorrhoids with that of stapled haemorrhoidopexy (SH) in Egyptian patients with portal hypertension.Patients and methodsIn this study, 26 portal hypertensive patients (with oesophageal and/or fundal varices) with a grade 2–4 internal haemorrhoids who had no coagulation disorders were randomised to treatment by EBL (13 patients) or SH (13 patients) after doing colonoscopy. Symptom scores of bleeding and prolapse were assessed before and after the intervention. Complications were recorded. Patients were followed up for 12 months.ResultsGoligher’s grades of internal haemorrhoids improved significantly (p = 0.018) 12 weeks after SH (from 2.9 ± 0.8 to 0.4 ± 0.5; p = 0.001) and after EBL (from 2.8 ± 0.8 to 1.1 ± 0.8; p = 0.001). Symptom (bleeding and prolapse) scores significantly improved 4 weeks after both EBL (from 1.6 ± 0.8 to 0.6 ± 0.8; p < 0.001 and from 1.6 ± 0.9 to 0.5 ± 0.5; p = 0.002, respectively) and SH (from 1.8 ± 0.8 to 0.2 ± 0.4; p = 0.002 and from 1.5 ± 0.9 to 0.2 ± 0.4; p = 0.001, respectively). The differences after 4 weeks between EBL and SH were not significant (p = 0.168 and p = 0.225). Pain requiring analgesics occurred in five patients (38.5%) after EBL, compared with six (46.2%) after SH (p = 0.691). Minimal bleeding occurred in two patients (15.4%) after EBL but not with SH; urinary retention was observed in one patient after EBL compared with two after SH; and anal fissures were observed in one patient after EBL. During 1-year follow-up, increased frequency of stool occurred in one patient after EBL. Recurrence of symptoms was observed in three patients after EBL and in one after SH.ConclusionFor portal hypertensive patients with internal haemorrhoids and without coagulation disorders SH seems to be superior to EBL. However further studies are needed to evaluate EBL in different grades of cirrhosis.     

Impact of pre-excitation syndrome on left ventricular systolic function and cardiac synchronization assessed by tissue Doppler imaging and speckle tracking techniques

BackgroundThe pathogenic mechanism for the development of left ventricular (LV) dysfunction in patients with asymptomatic pre-excitation syndrome has not yet been fully elucidated. We sought to assess the impact of pre-excitation on LV systolic function and whether the use of tissue Doppler imaging (TDI) and speckle tracking is more helpful in detection of the LV dyssynchrony than conventional echo parameters in these patients.MethodsThis observational case control study was carried out on adults with manifest pre-excitation syndromes. A detailed echocardiographic assessment was performed including TDI and speckle tracking examination.ResultsOur study patients were divided into two groups, group 1: with lateral accessory pathways (AP) (23 patients aged 31.65 ± 6.5 years), group 2: with septal AP (25 patients, 34.84 ± 10.8 years). Echocardiography showed a lower ejection fraction (EF) in group 2 than in group 1 (0.60 ± 0.07% in group 1 vs. 0.50 ± 0.08% in group 2, p = 0.000). The radial strain dyssynchrony index was higher in group 2 than in group 1 (58.78 ± 33.47 vs. 139.52 ± 21.14 ms; p < 0.0001) with a significant negative correlation with EF (r = −0.8, p = 0.000). Dyssynchrony detection was higher using speckle tracking technique than M mode/Doppler methods (p = 0.006).ConclusionPatients with pre-excitation syndrome may have depressed LV function unrelated to tachyarrhythmia, especially if the AP has a septal location. This dysfunction may be associated with the LV dyssynchronus contraction caused by pre-excitation. The use of TDI and speckle tracking echocardiographic techniques may be associated with an increase in the identification of manifest pre-excitation patients with significant LV dyssynchrony.     

Maternal and fetal outcomes in pregnant women undergoing balloon mitral valvotomy for rheumatic mitral stenosis

BackgroundRheumatic mitral stenosis constitutes a major cause of acquired heart disease complicating pregnancy in India. In the present study, we have studied the fetal and maternal outcomes of women undergoing balloon mitral valvotomy during pregnancy.Methods and results49 pregnant ladies were included in this study in whom balloon mitral valvotomy was performed. The mean age of these patients was 25.7 ± 3.1 years. The mean gestational age was 23.5 ± 5.2 weeks (12–36 weeks). The procedure was successful in 48 patients (95.9%). Mean two-dimensional MVA increased from baseline value of 0.93 ± 0.17 cm² to 1.75 ± 0.27 cm² (p value <0.0001). Pre-procedure peak pulmonary artery pressure was 43.05 ± 15.88 mmHg, which decreased to 22.31 ± 6.36 mmHg (p value <0.0001). Hemodynamic data showed pre-BMV left atrial mean pressure of 29.6 ± 6.6 mmHg, which decreased to 13.7 ± 4.8 mmHg after the procedure (p value <0.0001). Mean fluoroscopy time was 6.4 ± 1.2 min. There was no maternal mortality in our study. One procedure had to be abandoned, because of failed septal puncture. One of the patients developed cardiac tamponade and another patient developed severe mitral regurgitation, which were managed medically. The patient who developed severe mitral regurgitation later underwent mitral valve replacement. Post-procedure follow-up showed an improvement in NYHA status by at least one class in 81.3% of patients. Thirty-nine (81.3%) patients had a term normal vaginal delivery and 8 (16.7%) underwent cesarean section for obstetric indications. One of the patients had abortion on the second day of the procedure.ConclusionPercutaneous mitral valvotomy during pregnancy is safe and provides excellent symptomatic relief and hemodynamic improvement. This should be considered as the treatment of choice when managing pregnant women with severe mitral stenosis.     

Initial experience of using intracardiac echocardiography (ICE) for guiding balloon mitral valvuloplasty (BMV)

Background and aimsBMV is an established treatment for rheumatic mitral valve stenosis. The procedure is historically guided by fluoroscopy, and the role of intracardiac echocardiogram (ICE) guidance is not well defined. We report our initial experience of using ICE to guide BMV procedures.MethodsDuring BMV procedure, ICE catheter was inserted into the right atrium from the right femoral vein, and the septal puncture was monitored by ICE, as well as positioning of the balloon in the mitral valve. Comparisons were made between ICE, transthoracic echocardiography (TTE), and catheterization derived hemodynamic measurements (cath).ResultsSeventeen patients with mitral stenosis underwent the procedure. The mean age was 44.4 ± 21 years. The mean MV area increased from 0.9 ± 0.1 cm² to 1.7 ± 0.2 cm², P < 0.0001 and the mean gradient decreased from 12.6 ± 5.8 mmHg to 4.9 ± 1.8 mmHg, P < 0.001. Atrial septum puncture and guidance of the balloon into the MV apparatus were obtained in all patients under ICE guidance. Severe MR developed in one patient and was readily detected by ICE. ICE derived gradient measurements were comparable to those obtained by TTE, and cath.ConclusionICE guidance of BMV is feasible, and useful in monitoring safe septal puncture, optimizing balloon positioning, and in detecting complications. The hemodynamic measurements obtained were comparable to those obtained by TTE, and cath.     

First Egyptian experience of Transcatheter Aortic Valve Implantation: Immediate results and one year follow up

BackgroundTrans-catheter Aortic Valve Implantation (TAVI) offers a less invasive modality to manage aortic stenosis (AS) especially in high risk patients. It was not available in Egypt until the end of 2011.AimThe aim of this study is to report immediate and one year follow up results of first TAVI implantations in Egyptian patients.Patients and methodsTen patients with severe symptomatic AS underwent TAVI implantation using Edwards SAPIEN™ and SAPIEN XT™ valves.ResultsThe mean age was 78.6 ± 4.6 years and 5 (50%) were males. The mean Logistic EuroSCORE and EuroSCORE II were 21.9 ± 11.5% and 12.6 ± 7.2%, respectively. Procedural success was achieved in all (100%) patients using SAPIEN™ (n = 8) and SAPIEN XT™ (n = 2) valves. Almost all (n = 9) patients underwent a trans-femoral approach and percutaneous closure devices were used in the last 2 patients. Post procedural NYHA grade (1.3 ± 0.3), aortic valve area (2.0 ± 0.1 cm²) and mean pressure gradient (14.1 ± 2.7 mmHg) were nearly maintained all over the one-year-follow-up period.ConclusionTAVI provides a safe and effective alternative to the surgical AVR in high risk patients with severe symptomatic AS. Financial issues, however, limits its application in developing countries.