Takayasu arteritis associated with heart valve diseases (pulmonary and aortic) and arteritis (coronary and renal)]

The most severe arteritis due to Takayasu's disease are those related to renal and coronary arteries. The first one because it produces severe arterial hypertension and the second one because it puts the patient in high risk of suffering either myocardial ischemia or infarction. These situations worsen when this entity is associated to valvular heart lesions. The authors present the clinical cases of two female patients with Takayasu's disease. One of them in acute phase of the illness, where coronary arteritis, mild coarctation of the aorta, right pulmonary artery stenosis, and pulmonary valve stenosis were present. The second patient was seen during the remission phase of the disease with obstruction of the left subclavicular artery, renal arteritis, severe arterial hypertension and aortic valve insufficiency. The authors discuss the prognosis of patients with Takayasu's disease associated to valvular heart disease and its role in the etiology of pulmonary valvular stenosis. Finally, the authors point out the importance of recognizing the active and non active phases of the Takayasu's disease in relation of the adequate stage for surgical treatment of the lesions caused by this disease.     

Management of significant left main coronary disease before and after trans‐apical transcatheter aortic valve replacement in a patient with severe and complex arterial disease

We report the case of an 81‐year‐old woman with symptomatic severe aortic stenosis, extremely significant peripheral arterial disease, and obstructive coronary artery disease who underwent percutaneous coronary intervention via a transaxillary conduit immediately before a trans‐apical transcatheter aortic valve replacement performed with a transfemoral device. After deployment of the transcatheter heart valve, there was a left main coronary obstruction and the patient required an emergent PCI. This multifaceted case clearly underlines the importance of a well functioning heart team including the interventional cardiologist, the cardiovascular surgeon, and the echocardiographer. © 2013 Wiley Periodicals, Inc.     

Transcatheter aortic valve implantation through a diseased left common carotid artery: Combined approach with endarterectomy and left carotid‐subclavian bypass

We report a case of transcatheter aortic valve implantation (TAVI) with the self‐expanding Medtronic CoreValve bioprosthesis (Medtronic, Minneapolis, MI) through a diseased left common carotid (LCC) artery. This 81‐year‐old male patient presented with heart failure due to a severe degenerative aortic valve stenosis. Comorbidities included diabetes, hypertension, and dyslipidemia as well as peripheral and coronary artery disease, resulting in a logistic EuroScore II of 25.9%. Consequently, he was rejected to undergo surgery and a transcatheter approach was planned. Due to severe peripheral vascular disease with iliofemoral lesions, significant calcifications and unfavourable angulations of the innominate artery as well as prior bypass surgery precluding a direct aortic and subclavian approach, none of the established access sites were suitable. Therefore, we considered a left carotid access, which had to be combined with a surgical endarterectomy for treatment of a significant common carotid bifurcation stenosis and left subclavian‐LCC permanent tunnel bypass graft. The procedure was successful without cardiac, cerebrovascular, or access complications. This case illustrates a true heart team approach, establishing a unique access for TAVI for patients without regular access options. © 2012 Wiley Periodicals, Inc.     

Successful minimal approach transcatheter aortic valve replacement in an allograft heart recipient 19 years post transplantation for severe aortic stenosis: A case report

BACKGROUND Aortic stenosis is one of the rare valvular complications in a transplanted heart.Over the past 8 years, transcatheter approach for aortic valve replacement(TAVR) has been slowly evolving to be the preferred approach in these patient population when compared to the surgical approach. We report a second case in the United States with successful transfemoral minimal approach with minimal sedation for TAVR in a heart transplant recipient 19 years post transplantation for severe symptomatic calcified aortic stenosis.CASE SUMMARY We present a case of 73-year-old male who has undergone successful minimal approach transcatheter aortic valve replacement in an allograft heart. Patient had received orthotopic heart transplantation 19 years ago for non-ischemic cardiomyopathy. Follow up transthoracic echocardiograms as per routine protocol did not show any aortic valve disease until 15 years post transplantation.Aortic valve was noted to be mildly sclerotic at that time and gradually progressed to severe symptomatic aortic stenosis over the next 4 years. Patient had complaints of worsening shortness of breath that limited his functional capacity. Overall his post heart transplantation period has been mostly uneventful except for allograft non occlusive vasculopathy and aortic stenosis.His Society of Thoracic Surgery risk score was 12.205% and he was considered to be a high-risk surgical candidate by surgeon. Decision was made to undergo transcatheter aortic valve replacement.CONCLUSION With the improved survival of these patients, we think it is time to look intopathophysiology of valvular disease in transplant heart recipients. Some other unanswered questions include, underlying donor and recipient risk factors for valvular diseases in heart transplant recipients.     

Transcatheter Aortic Valve Implantation Despite Challenging Vascular Access

We describe transcatheter aortic valve implantation in a patient who had severe peripheral artery disease. The patient''s vascular condition required additional preliminary peripheral intervention to enable adequate vascular access.A 78-year-old man with severe aortic stenosis, substantial comorbidities, and severe heart failure symptoms was referred for aortic valve replacement. The patient''s 20-mm aortic annulus necessitated the use of a 23-mm Edwards Sapien valve inserted through a 22F sheath, which itself needed a vessel diameter of at least 7 mm for percutaneous delivery. The left common femoral artery was selected for valve delivery. The left iliac artery and infrarenal aorta underwent extensive intervention to achieve an intraluminal diameter larger than 7 mm. After aortic valvuloplasty, valve deployment was successful, and the transaortic gradient decreased from 40 mmHg to less than 5 mmHg. The patient was discharged from the hospital 4 days postoperatively. We conclude that transcatheter aortic valve implantation can be successfully performed in patients with obstructed vascular access, including stenosis of the infrarenal aorta and the subclavian and coronary arteries.     

Percutaneous aortic valvuloplasty as a bridge to a high-risk percutaneous coronary intervention

We describe a novel approach of using percutaneous aortic valvuloplasty as a bridge to percutaneous coronary intervention in a patient with refractory congestive heart failure, severe aortic stenosis, severe left ventricular dysfunction and severe 3-vessel coronary artery disease who was not a surgical candidate for aortic valve replacement and coronary artery bypass grafting.     

Apico-Aortic Conduit for severe aortic stenosis: Technique,applications, and systematic review

Patients referred for aortic valve replacement are often elderly and may have increased surgical risk associated with ascending aortic calcification, left ventricular dysfunction, presence of coronary artery disease, previous surgery, and/or presence of several co-morbidities. Some of these patients may not be considered candidates for conventional surgery because of their high risk profile. While transcatheter aortic valve replacement constitutes a widely accepted alternative, some patients may not be eligible for this modality due to anatomic factors. Apico-Aortic Conduit (AAC) insertion (aortic valve bypass surgery) constitutes a possible option in those patients. Apico-Aortic Conduit is not a new technique, as it has been used for decades in both pediatric and adult populations. However, there is a resurging interest in this technique due to the expanding scope of elderly patients being considered for the treatment of aortic stenosis. Herein, we describe our surgical technique and provide a systematic review of recent publications on AAC insertion, reporting that there is continued use and several modifications of this technique, such as performing it through a small thoracotomy without the use of the cardiopulmonary bypass.Abbreviations: AAC, Apico Aortic Conduit; AS, aortic stenosis; AVR, aortic valve replacement; BSA, body surface area; CABG, coronary artery bypass grafting surgery; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CPB, cardiopulmonary bypass; DHCA, deep hypothermic circulatory arrest; FEM-FEM, femoro-femoral; ITA, internal thoracic artery; LITA, left internal thoracic artery; LVH, left ventricular hypertrophy; LVOT, left ventricle outflow tract; NYHA, New York Heart Association; MDCT, multidetector-computerized tomography; MVR, mitral valve replacement; OPCAB, off pump coronary artery bypass; PH, pulmonary hypertension; RITA, right internal thoracic artery; TEE, transesophageal echocardiography; TAVI, transcatheter aortic valve implantation     

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??Abstract??The severity of congenital heart disease varies and how to select the appropriate timing and therapeutic approach is an important prerequisite to get the best efficacy and reduce the mortality.Percutaneous balloon pulmonic valvuloplasty is the first choice for the management of pulmonary valve stenosis in patients at any age.Either surgery or interventional therapy for aortic valve stenosis is as a palliative treatment in childhood.Percutaneous balloon aortic valvuloplasty or stent implantation is the therapeutic approach for coarctation of the aorta in patients during early childhood and adolescence.Congenital heart diseases with left to right shunt??which develop a significant pulmonary hypertension??need early interventional treatment or surgery.As for the complicated congenital heart diseases??how to determine the timing of surgery and to select surgical approach are based on pulmonary artery pressure??size of pulmonary artery and the existence of hypoxemia.     

Pulmonary hypertension in Takayasu arteritis

Takayasu arteritis (TA) is a rare chronic vasculitis primarily involving the aorta and its main branches. The disease affects women much more frequently than men, the ratio being 8:1. The onset occurs in the teenage years, always before age of 40. Aortic regurgitation is rare. The pulmonary artery stenosis may also rarely occur. We report the case of a 49-year old female patient with Takayasu arteritis who presented with severe left pulmonary trunk stenosis resulting in pulmonary hypertension, severe aortic regurgitation due to the dilatation of the ascending aorta, mitral insufficiency, critical left renal artery stenosis, and probably with left main coronary artery stenosis. No severe stenosis or occlusion in the mid portion of mid subclavian artery lesion were present. Because the patient presented with serious congestive heart failure, she underwent mitral valvuloplasty and aortic valve replacement. However, the patient died in early postoperative period due to pulmonary hypertension which failed to respond to pharmacotherapy.     

Transcatheter therapy for aortic coarctation with severe systemic hypertension during pregnancy

Aortic coarctation is an unusual cause of hypertension during pregnancy and its management is not clarified. We report transcatheter balloon dilatation and stenting for native aortic coarctation in a 22‐year‐old pregnant woman with severe and uncontrolled systemic hypertension. Arterial blood pressure could be successfully controlled with medical treatment during the rest of the pregnancy and the patient underwent uneventful delivery. No adverse events or recoarctation was observed during 24 months clinical follow‐up. In conclusion, native aortic coarctation can be successfully treated during pregnancy with transcatheter therapy. More experience is needed to confirm the safety and efficacy of such management. © 2012 Wiley Periodicals, Inc.     

Transapical aortic valve implantation and 'off-pump' arterial coronary bypass in a patient with a porcelain aorta

A simple hybrid procedure, namely transapical aortic valve implantation combined with 'off-pump' coronary artery bypass using an internal thoracic artery, was performed in a patient with porcelain aorta, aortic valve stenosis and coronary artery disease. This approach does not require cardiopulmonary bypass, and avoids aortic or peripheral arterial cannulation and clamping of the aorta. This hybrid approach can be regarded as a 'new technique' being applied to an 'old idea'.     

Asymptomatic severe aortic coarctation in an 80-year-old man

Survival to advanced age is exceptional in patients with unrepaired aortic coarctation. We report the case of a hypertensive 80-year-old man with coarctation of the aorta who was otherwise asymptomatic. Coarctation was suspected when a femoral-radial pulse delay was noted during his routine physical examination. A 25-mmHg systolic blood pressure gradient between the upper and lower extremities was detected. Subsequent magnetic resonance angiography, aortography, and coronary angiography revealed severe coarctation of the aorta, well-developed collateral vessels, and severe coronary artery disease that included the left main artery. Coronary artery bypass grafting was performed, and the coarctation was managed conservatively with antihypertensive medication. At the 1-year follow-up visit, the patient was still asymptomatic and maintained a normal blood pressure with medication.     

Asymptomatic severe aortic stenosis,bicuspid aortic valves and moderate aortic stenosis in heart failure: New indications for transcatheter aortic valve implantation

Aortic stenosis (AS) remains one of the most common valvular heart diseases, with enormous impact on patient survival. Over the past years, transcatheter aortic valve implantation (TAVI) has become a reality worldwide, offering a less invasive method to treat AS. Apart from the classical indications for aortic valve disease, recent studies tried to address unanswered questions for TAVI – asymptomatic severe AS, bicuspid aortic valves and moderate AS in patients with heart failure. This review discusses the rationale of those possible indications, pitfalls and current evidence in the medical literature.     

The relation between homocysteine and calcific aortic valve stenosis

BACKGROUND: In patients diagnosed with calcific aortic valve stenosis, cardiac risk factors are similar to those of coronary artery disease; homocysteine concentration is an independent risk factor for coronary artery disease. The aim of this study was to investigate the correlation between plasma homocysteine levels and aortic valve stenosis and the influence of homocysteine levels on the coexistence of coronary artery disease in patients with moderate to severe aortic valve stenosis. METHODS: Fifty-eight patients who had been diagnosed with moderate to severe aortic stenosis formed the test group of this study, and 47 healthy subjects without coronary artery disease or aortic valve stenosis formed the control group. The patients with aortic stenosis were divided into two groups according to the presence or absence of coronary artery disease in their coronary angiograms. After 12 h fasting venous blood samples were collected and total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides and homocysteine levels were measured and compared between the two groups. MEASUREMENTS AND RESULTS: The mean blood homocysteine level was 10.8 +/- 3.3 micromol/l in patients with aortic valve stenosis and 8.1 +/- 4.7 micromol/l in the control group; the difference between these levels was statistically insignificant. The patients with aortic valve stenosis had significantly higher levels of total cholesterol and hypertension and were more likely to have a positive family history for coronary artery disease. When the two subgroups of patients with aortic valve stenosis were compared, mean blood homocysteine levels were 13.2 +/- 3.1 and 8.3 +/- 2.2 micromol/l, respectively, showing significantly higher levels in the group with coronary artery disease. In this comparison patients with coronary artery disease were also found to have significantly higher levels of total cholesterol and LDL and they were more likely to be smokers. CONCLUSIONS: Although there was no relation between blood homocysteine levels and the existence of aortic valve stenosis, in cases with both coronary heart disease and aortic stenosis homocysteine levels were significantly higher than in the patients with pure aortic valve stenosis.     

A case of severe aortic stenosis with severe coronary artery disease that was successfully treated by balloon aortic valvuloplasty and percutaneous coronary intervention

We describe an 85-year-old woman with severe aortic stenosis, who also had severe coronary artery disease. She suffered from dyspnea on exertion and frequent syncope. Echocardiography revealed an immobile and heavily calcified aortic valve, and coronary angiography revealed two-vessel disease including chronic total occlusion. Open-heart surgery was refused and she was referred to our department. She underwent percutaneous coronary intervention (PCI) for the right coronary artery and left anterior descending artery. Following PCI, percutaneous balloon aortic valvuloplasty (BAV) was performed on the same day. We chose balloons of 15 × 60 mm, 18 × 60 mm, and 20 × 60 mm, respectively. Improvement in the mean aortic valve pressure gradient (PG) and calculated aortic valve area (mean PG 48-23 mmHg, 0.8-1.2 cm(2), respectively) was observed after the final balloon dilatation. No significant complications occurred. The combination of BAV with PCI may be a useful treatment for relief of the associated symptoms of severe aortic stenosis and coronary artery disease, though it does not improve the long-term prognosis.     

First human case of retrograde transcatheter implantation of an aortic valve prosthesis

The transcatheter route is an emerging approach to treating valvular disease in high-risk patients. The 1st clinical antegrade transcatheter placement of an aortic valve prosthesis was reported in 2002. We describe the first retrograde transcatheter implantation of a new aortic valve prosthesis, in a 62-year-old man with inoperable calcific aortic stenosis and multiple severe comorbidities. Via the right femoral artery, a Cook introducer was advanced into the abdominal aorta. The aortic valve was crossed with a straight wire, and a pigtail catheter was advanced into the left ventricle to obtain pressure-gradient and anatomic measurements. An 18-mm valvuloplasty balloon was then used to predilate the aortic valve. Initial attempts to position the prosthetic valve caused a transient cardiac arrest. Implantation was achieved by superimposing the right coronary angiogram onto fluoroscopic landmarks in the same radiographic plane. A balloon-expandable frame was used to deliver the valve. After device implantation, the transvalvular gradient was <5 mmHg. The cardiac output increased from 1 to 5 L/min, and urine production increased to 200 mL/h. The patient was extubated on the 2nd postimplant day. Twelve hours later, he had to be reintubated because of respiratory distress and high pulmonary pressures. His condition deteriorated, and he died of biventricular failure and refractory hypotension on day 5. Despite the severe hypotension, valve function was satisfactory on echo-Doppler evaluation. In our patient, retrograde transcatheter implantation of a prosthetic aortic valve yielded excellent hemodynamic results and paved the way for further use of this technique in selected high-risk patients.     

Sinus of valsalva aneurysm with congenital aortic stenosis and aortic coarctation

A 52-year-old female was diagnosed with the extremely rare combination of sinus of Valsalva aneurysm, congenital unicuspid aortic valve stenosis, and coarctation of the aorta. She was successfully treated in a two-stage operation. The first operation consisted of a bypass graft to correct the coarctation. The second, performed 31 days later, included aortic valve replacement, patch closure of the aneurysm, and translocation of the right coronary artery.     

Transcatheter aortic valve implantation 10 years after valve‐in‐valve transcatheter aortic valve implantation for failing aortic valve homograft root replacement

Valve‐in‐valve transcatheter aortic valve implantation (ViV‐TAVI) is an established therapy for a degenerated surgical bioprosthesis. TAVI‐in‐TAVI following ViV‐TAVI has not been previously performed. We report a high‐risk patient presenting with severe left ventricular failure secondary to undiagnosed critical aortic stenosis due to degeneration of the implanted transcatheter heart valve more than a decade after initial ViV‐TAVI for a failing stentless aortic valve homograft. Successful TAVI‐in‐TAVI reversed the clinical and echocardiographic changes of decompensated heart failure with no evidence of coronary obstruction.     

Feasibility of complex coronary intervention in combination with percutaneous aortic valve implantation in patients with aortic stenosis using percutaneous left ventricular assist device (TandemHeart®)

Coronary atherosclerosis is a common finding in patients with severe aortic stenosis. Indeed, aortic stenosis is associated with risk factors similar those of coronary atherosclerosis such as older age, hypertension, diabetes, hypercholesterolemia and smoking. In light of the evolution of percutaneous aortic valve implantation (PAVI) and ongoing improvements in techniques of PCI, a combined approach using PCI and PAVI can be proposed for patients with complex coronary artery and aortic valve disease. This report describes the feasibility of the combination of percutaneous coronary intervention and percutaneous aortic valve implantation with peripheral left ventricular assist device (TandemHeart) support in 3 elderly patients with complex coronary altery disease and aortic stenosis considered too high risk for conventional surgical therapy. © 2009 Wiley‐Liss, Inc.     

Ochronosis of the aortic valve and aorta

A 64-year-old male patient with unknown alkaptonuria and severe aortic stenosis and ischemic heart disease was admitted to the authors' institution for elective surgery. The patient underwent aortic valve replacement with a 25-mm aortic valve (ATS Medical, Inc.) and single venous aortocoronary artery bypass grafting for a right coronary artery. Aortotomy revealed typical ochronotic pigmentation of a severely calcified aortic valve and aortic intima. A diagnosis of alkaptonuria was confirmed by evidence of homogentisic acid in the patient's urine, together with histopathological analysis.