Plaster pipes and crystalized graphite: Open transventricular transcatheter aortic valve replacement for failed mechanical aortic valve prostheses in the porcelain aorta

Patients with a true porcelain aorta and a failed mechanical aortic valve prosthesis have limited treatment options. Using a hybrid of an open trans-ventricular approach with peripheral cardiopulmonary bypass and integration of transcatheter techniques this challenge can be overcome. Trans-ventricular mechanical valve extraction (with transcatheter endovascular occlusion and cardioplegia) followed by direct ante-grade transcatheter heart valve implantation offers a potential solution to this conundrum. The procedure described is a novel technique that allows for the effective treatment of patients with failed mechanical surgical aortic valve prostheses in the setting of an inoperable porcelain aorta. In addition, a collaborative integrated multi-disciplinary heart team environment is required for the management of these complex patients.     

Primary percutaneous balloon pericardiotomy for malignant pericardial effusion

Objectives : Pericardial effusion associated with malignancy is a life‐threatening complication of late‐stage disease. While simple drainage is effective in relieving the symptoms, reaccumulation of effusion may cause further symptomatic episodes, often during a period when overall patient management is focused on improving the quality of remaining life. Over a 16‐year period, we have adopted a strategy of managing such patients with balloon pericardiotomy as the initial preferred treatment. The results are described and compared to alternative management strategies. Methods : A retrospective analysis of patients who presented with symptomatic, malignant pericardial effusion, their management, procedural complication rates, and the need for further therapy for the same condition was made. Survival, reaccumulation rates, and readmissions after the index procedure were recorded and compared. Results : Forty‐three patients were treated for malignant pericardial effusion. Balloon pericardiotomy was the primary treatment in 27/43 patients, simple drainage in 14/43, and surgery in 2/43. Reaccumulation rates between balloon pericardiotomy and simple aspiration (7.4% vs. 14.3%, respectively, P = 0.48) and complication rates (7.4% vs. 7.1%, respectively, P = 0.98) were not statistically different. Survival following intervention was driven by the underlying pathology and was poor, with overall median survival of 56 days. Conclusions : Balloon pericardiotomy, as initial management of symptomatic malignant pericardial effusions, allows a definitive procedure to be performed at presentation. This can be achieved with low complication rates, similar to treatment by simple drainage. © 2008 Wiley‐Liss, Inc.