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ABSTRACT: Severe paravalvular leakage following mitral valve replacement, a rare but potentially serious complication, may result in heart failure and significant hemolysis. Reoperation is considered standard of care. However, in selected patients, re-do sternotomy carries excessively high surgical risk. Percutaneous closure of paravalvular leaks has become a viable option for these patients. We present a case of a highly symptomatic 42-year-old male who underwent successful percutaneous closure of two paravalvular leaks and a post-operative atrial septal defect after re-do mitral valve replacement surgery. As access to the left atrium was expected to be difficult following percutaneous atrial septal defect closure, a two-step approach of paravalvular leak closure followed by atrial septal defect closure was chosen. Difficulties of atrial septal defect closure following closure of a paravalvular leak next to the inter-atrial septum will be discussed.
Catheterization and Cardiovascular Interventions 03/2011; 78(1):145-50. · 2.29 Impact Factor
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ABSTRACT: Massive or high-risk pulmonary embolism (PE), defined as PE in the setting of (transient) arterial hypotension or frank cardiogenic shock, is associated with a poor prognosis. Fibrinolytic therapy is the mainstay of therapy, although data to support its effectiveness are limited. Although rarely performed, an alternate, accepted treatment strategy is surgical embolectomy. Contraindications to fibrinolytics are common in the setting of high-risk PE, and surgical embolectomy is frequently not performed owing to excessively high surgical risk. Under those circumstances, percutaneous, catheter-based thrombectomy or thrombus fragmentation is a reasonable alternative. In this article, we summarize the data available to date, evaluating the three different treatment options. We also attempt to synthesize a treatment algorithm to guide the practitioner in the treatment of patients with high-risk or massive PE.
Expert Review of Cardiovascular Therapy 06/2010; 8(6):863-73.
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Southern medical journal 04/2010; 103(5):396-7. · 0.92 Impact Factor
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ABSTRACT: Obesity is an independent risk factor for recurrent events among patients with established coronary heart disease (CHD). The goal of the present study was to identify potential mechanisms underlying this association. We measured the waist-to-hip ratio and body mass index in 979 outpatients with stable CHD and followed them for a mean of 4.9 years. We used proportional hazards models to evaluate the extent to which the association of obesity with subsequent heart failure (HF) hospitalization or cardiovascular (CV) events (myocardial infarction, stroke, or CHD death) was explained by baseline co-morbidities, cardiac disease severity, inflammation, insulin resistance, neurohormones and adipokines. Of the 979 participants, 128 (13%) were hospitalized for HF and 152 (16%) developed a CV event. Each standard deviation (SD) increase in the waist-to-hip ratio was associated with a 30% increased risk of HF hospitalization (unadjusted hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.1 to 1.6). This association was not attenuated after adjustment for potential mediators (HR 1.6, 95% CI 1.2 to 2.1). Likewise, each SD increase in the waist-to-hip ratio was associated with a 20% greater risk of CV events (unadjusted HR 1.2, 95% CI 1.0 to 1.4), and this remained unchanged after adjustment for potential mediators (adjusted HR 1.3, 95% CI 1.0 to 1.5). The body mass index was not associated with the risk of HF or CV events. In conclusion, abdominal obesity is an independent predictor of HF hospitalization and recurrent CV events in patients with stable CHD. This association does not appear to be mediated by co-morbid conditions, cardiac disease severity, insulin resistance, inflammation, neurohormones, or adipokines.
The American journal of cardiology 10/2009; 104(7):883-9. · 3.58 Impact Factor
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ABSTRACT: Percutaneous mechanical thrombectomy (PMT) for treatment of massive pulmonary embolism (PE) has been shown to be technically feasible, although the complication rate of the procedure appears relatively high. Whether a conservative treatment approach defined by an early termination of the PMT procedure once hemodynamic and clinical parameters of the patient have improved is associated with lower complication rates is unknown. We report our experience of PMT in patients with massive PE using the Angiojet system following a conservative treatment strategy.
From April 2003 until November 2007, 13 patients underwent PMT with the Angiojet system. Indications for PMT were massive PE and either failed thrombolysis or contraindications to thrombolytic therapy. All patients were deemed high risk for surgical thrombectomy.
Technical success was achieved in 12 patients (92%). Mean systemic arterial pressure increased from 87 to 106 mmHg following PMT (P = 0.011), while the heart rate decreased from 119 to 97 beats per minute (P = 0.041). In-hospital mortality was 15% (2 of 13 patients). No complications occurred which were attributable to the PMT procedure. Right ventricular size and function improved in the majority of patients following the PMT procedure.
Using a conservative treatment approach of PMT for the treatment of massive PE carries a low periprocedural complication rate. The low morbidity was achieved without compromising clinical outcome, documented by an in-hospital mortality of 15%. PMT using a conservative treatment approach may result in comparable mortality, but lower morbidity than PMT using more aggressive, angiographically guided treatment strategies.
Journal of Interventional Cardiology 01/2009; 21(6):566-71. · 1.18 Impact Factor
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ABSTRACT: Introduction: Percutaneous mechanical thrombectomy (PMT) for treatment of massive pulmonary embolism (PE) has been shown to be technically feasible, although the complication rate of the procedure appears relatively high. Whether a conservative treatment approach defined by an early termination of the PMT procedure once hemodynamic and clinical parameters of the patient have improved is associated with lower complication rates is unknown. We report our experience of PMT in patients with massive PE using the Angiojet system following a conservative treatment strategy.Methods: From April 2003 until November 2007, 13 patients underwent PMT with the Angiojet system. Indications for PMT were massive PE and either failed thrombolysis or contraindications to thrombolytic therapy. All patients were deemed high risk for surgical thrombectomy.Results: Technical success was achieved in 12 patients (92%). Mean systemic arterial pressure increased from 87 to 106 mmHg following PMT (P = 0.011), while the heart rate decreased from 119 to 97 beats per minute (P = 0.041). In-hospital mortality was 15% (2 of 13 patients). No complications occurred which were attributable to the PMT procedure. Right ventricular size and function improved in the majority of patients following the PMT procedure.Conclusion: Using a conservative treatment approach of PMT for the treatment of massive PE carries a low periprocedural complication rate. The low morbidity was achieved without compromising clinical outcome, documented by an in-hospital mortality of 15%. PMT using a conservative treatment approach may result in comparable mortality, but lower morbidity than PMT using more aggressive, angiographically guided treatment strategies.
Journal of Interventional Cardiology 11/2008; 21(6):566 - 571. · 1.18 Impact Factor
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ABSTRACT: Elevated concentrations of adiponectin are associated with a favorable metabolic profile but also with adverse cardiovascular outcomes. This apparent discrepancy has raised questions about whether adiponectin is associated with an increased or decreased risk of coronary heart disease (CHD). We sought to determine whether higher adiponectin levels are associated with exercise-induced ischemia in patients with stable CHD.
We measured total serum adiponectin concentrations and evaluated exercise-induced ischemia by stress echocardiography in a cross-sectional study of 899 outpatients with documented stable CHD. Of these, 217 (24%) had inducible ischemia. Although adiponectin levels correlated negatively with diabetes prevalence, body mass index, serum insulin, fasting glucose, low-density lipoprotein cholesterol, and triglycerides and positively with high-density lipoprotein cholesterol (all P<0.005), elevated adiponectin concentrations were also associated with a greater risk of inducible ischemia. Each standard deviation (0.08 microg/mL) increase in log adiponectin was associated with a 35% greater odds of inducible ischemia (unadjusted odds ratio 1.35; 95% confidence interval 1.15-1.57; P=0.0002). Although attenuated, this association remained present after multivariable adjustment for traditional cardiovascular risk factors and other measures of cardiac function (adjusted odds ratio 1.21; 95% confidence interval 1.02-1.43; P=0.03).
Elevated concentrations of adiponectin are independently associated with inducible ischemia in patients with stable CHD. These findings raise the possibility that the presence of chronic inducible ischemia may alter the cardio-protective effects afforded by adiponectin secretion in the healthy population.
Atherosclerosis 11/2008; 205(1):233-8. · 3.79 Impact Factor
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ABSTRACT: Transcatheter closure of secundum atrial septal defect (ASD) and patent foramen ovale (PFO) has become a routine procedure. Little is known about the effect of atrial septal device implantation on the occurrence of atrial fibrillation (AF). We evaluated the frequency of AF occurring after transcatheter PFO and ASD closure in a large population. From 1994 until 2007 a total of 1,062 patients underwent transcatheter closure of an interatrial communication. New-onset AF was defined by 12-lead electrocardiogram or Holter monitoring in patients without a history of AF at baseline. Of the 1,062 patients, 822 had a PFO and 240 had an ASD. During a median follow up of 20 months, new-onset AF was documented in 8% of patients. New-onset AF occurred in 7% of patients after PFO closure and in 12% of patients with underlying ASD. The annual incidence of new-onset AF was 2.5% and 4.1% in patients with PFO and ASD, respectively. Generally, patients with new-onset AF were older than those without AF. Device type or size did not influence the occurrence of AF. In the group of patients with PFO, residual shunt was more common in patients with AF compared with the non-AF group. In conclusion, AF is more common after PFO and ASD closure compared with the general population; although device type or size did not impact the occurrence of AF, residual shunt may influence the occurrence of AF after intervention in patients with underlying PFO.
The American Journal of Cardiology 11/2008; 102(7):902-6. · 3.37 Impact Factor
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ABSTRACT: 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.
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.
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.
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.
Catheterization and Cardiovascular Interventions 11/2008; 72(7):966-70. · 2.29 Impact Factor
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ABSTRACT: Transcatheter patent foramen ovale (PFO) closure can be performed with various devices. However, their handling, safety, presence of residual shunt and impact on recurrent thromboembolic events (TEs) are rarely compared with one another. Our goal was to compare the clinical performance of contemporary devices designed for PFO closure.
PFO closure with the Cardia PFO occluder (n = 405), Intrasept (n = 301) and Amplatzer PFO occluder (n = 89) was attempted in 795 patients with presumed paradoxical embolism.
The procedure was successful in all patients. The periprocedural complication rate of 1.8% was comparable among the three groups. Residual shunting immediately following the procedure was higher in patients treated with the Cardia PFO occluder (24% vs. 14% [Intrasept] and 16% [Amplatzer]; p = 0.004). After a mean follow-up period of 26 months, no difference in residual shunting was seen (8% [Cardia] vs. 7% [Intrasept] vs. 8% [Amplatzer]; p = 0.736). The annual incidence of recurrent TE was 1.4%, which was not affected by the presence of a residual shunt or the type of device used. New-onset atrial fibrillation (AF) following PFO closure was the only predictor of recurrent TE and was more common in patients treated with the Amplatzer (10% vs. 5% [Cardia]) and 5% [Intrasept]; p = 0.057).
The clinical performance of the three PFO occluders evaluated in this study seems comparable. Device design does not seem to impact the success of the PFO closure procedure. AF was the only predictor of recurrent TEs, underscoring the importance of aggressive therapy for atrial arrhythmias early following PFO closure.
The Journal of invasive cardiology 10/2008; 20(9):442-7. · 1.84 Impact Factor
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ABSTRACT: Post-operative ventricular septal defect (VSD) following septal myectomy in patients with hypertrophic obstructive cardiomyopathy (HOCM) is a rare complication which may warrant closure. Repeat early sternotomy for surgical closure of the VSD seems undesirable and transcatheter VSD closure may be a valid alternative. We report the case of successful closure of a 10-mm VSD following surgical therapy for HOCM using an Amplatzer Muscular VSD Occluder.
Cardiology 07/2008; 112(1):31-4. · 1.71 Impact Factor
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ABSTRACT: We report our experience of transcatheter patent foramen ovale (PFO) closure with the new Intrasept occluder.
The Intrasept device is the fourth generation of the Cardia occluder family. Developed for transcatheter closure of PFO, the main difference between the Intrasept and prior generations of the Cardia occluder is its articulating center post. This modification allows better alignment of the umbrellas on both sides of the atrial septum. We report our experience with this new PFO occluder.
From July 2002 until October 2006, PFO closure with the Intrasept occluder was attempted in 247 patients with presumed paradoxical embolism. Prior to PFO closure, a total of 269 cerebrovascular thromboembolic events (TEs) had occurred. Implantation of the device was guided by fluoroscopy and transesophageal echocardiography with conscious sedation.
Median age was 53 years (range, 21-77). One hundred twenty-seven (51%) patients had an atrial septal aneurysm. The device was implanted successfully in all cases. Acute complications occurred in 4 (1.6%) patients (air embolism = 2, pericardial effusion = 1, supraventricular tachycardia = 1). Follow-up information is available for all 247 (100%) patients. Median follow-up time was 14 months (range 6-56). Residual shunt at 6 months follow-up was 13%. After 1 year, the presence of residual shunt rate decreased to 10%. Following PFO closure, seven recurrent TEs (TIA = 4, CVA = 3) were observed in 6 patients. No wire fractures or device-associated thrombi were seen.
PFO closure with the Intrasept occluder is safe and efficient. Rates of residual shunt and recurrent TE compare favorably with other contemporary devices.
Catheterization and Cardiovascular Interventions 03/2008; 71(3):390-5. · 2.29 Impact Factor
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ABSTRACT: Transcatheter closure of large secundum atrial septal defects with deficient rims is difficult. Several techniques have been described to improve delivery of the occluder in anatomically challenging cases. Among these is a recently described technique using a modified delivery sheath with the creation of a bevel. However, the initial case report was complicated by malfunction and longitudinal splitting of the sheath. We describe the successful use of a modified delivery sheath for closure of a large atrial septal defect with a deficient rim.
Catheterization and Cardiovascular Interventions 09/2007; 70(2):286-9. · 2.29 Impact Factor
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ABSTRACT: The goal of this study is to evaluate the effect of stenting on Doppler ultrasonography (DU) [velocity] signals in an in-vitro carotid model.
Considerable debate exists about whether DU overestimates velocity signals and thus the degree of stenosis in previously stented carotid arteries.
Constant, pulsatile flow was simulated with an experimental circulatory system containing a nonstenotic ovine internal carotid artery segment. Peak systolic velocity (PSV) and peak diastolic velocity were measured with an intravascular flow wire (FW) and DU. Velocities were evaluated at five predetermined locations within the vessel immediately prior to and following stent placement.
Eleven stents were implanted. DU-derived PSV increased significantly following placement of the X-Act stent (80+/-26 cm/sec [pre] vs. 102+/-29 cm/sec [post], P=0.02), while FW-derived PSV (65+/-23 cm/sec [pre] vs. 66+/-9 cm/sec [post], P=0.93) did not change. The Precise stent did not influence PSV with either method (DU: 76+/-28 cm/sec [pre] vs. 72+/-35 cm/sec [post], P=0.95;), while the Acculink stent showed a trend towards a reduction in DU (69+/-37 cm/sec [pre] vs. 51+/-10 cm/sec [post], P=0.075) and FW (50+/-27 cm/sec [pre] vs. 40+/-12 cm/sec [post], P=0.14) derived PSV. Peak diastolic velocity revealed similar trends as PSV signals depending on the type of stent used.
Stent type may have significant impact on DU derived velocity signals. DU seems to overestimate PSV in carotid arteries treated with the X-Act stent, but not with the Precise or Acculink stent. Larger scale clinical comparison of various stent types and their impact on DU are needed in order to clarify the value of DU surveillance following carotid artery stenting.
Catheterization and Cardiovascular Interventions 09/2007; 70(2):309-15. · 2.29 Impact Factor
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ABSTRACT: Evaluation of: Di Tullio MR, Sacco RL, Sciacca RR, Jin Z, Homma S. Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J. Am. Coll. Cardiol. 49(7), 797-802 (2007).Several case-controlled studies have demonstrated an association between patent foramen ovale (PFO) and cryptogenic stroke. However, the risk of first stroke associated with a PFO in the general population is unknown. Di Tullio et al. sought to determine prospectively the relationship between PFO and the occurrence of first ischemic stroke in a population- based study of 1148 participants. No statistically significant association between PFO and ischemic stroke was found (hazard ratio: 1.64; 95% confidence interval: 0.87-3.09). Additional subgroup analysis stratifying groups according to age and gender also did not reveal a statistically significant association between the two conditions. Hence, this study demonstrates that a PFO conveys no increased risk for the development of ischemic stroke in the general population, a somewhat expected finding. However, considering all factors the main question should have been: which subset of PFOs causes cryptogenic stroke? A question that has not yet been addressed.
Expert Review of Cardiovascular Therapy 08/2007; 5(5):821-824.
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ABSTRACT: Transcatheter closure of secundum atrial septal defects (ASD) with the Amplatzer septal occluder (ASO) has become a standard procedure in most pediatric and adult patients. However, data addressing success rates and outcome in adults is limited. We sought to define the safety profile of the ASO in the community setting and identify the percentage of adults with ASD amenable to percutaneous closure with the ASO.
We performed a retrospective analysis of patients' records referred for transcatheter ASD closure from 1999 through 2005 at a single institution. Patients were evaluated with right heart catheterization and underwent closure of the ASD according to standard indications under transesophageal and fluoroscopic guidance.
Two hundred and seven consecutive patients were taken to the catheterization laboratory for hemodynamic evaluation and possible interventional closure of an ASD. Of those patients, 18 were excluded because the defect and the left-to-right shunt were hemodynamically insignificant (n = 7) or because there was no distinct defect, but instead a multi-perforated septum (n = 11). Nineteen cases were excluded for anatomic reasons. Of the remaining 170 patients, ASO implantation was attempted and successfully performed in 166 (83% of 200 patients with hemodynamically significant ASD). Complications occurred in 11 cases (6.5%) (device dislocation = 4, transient ST-segment elevation = 4, TIA = 1, hemoptysis = 1, pericardial effusion = 1); none of these events were associated with long-term sequelae. During a median follow-up period of 13 months (range 6-80) there were no major clinical events.
More than 80% of adults with a distinct, hemodynamically significant secundum ASD can be successfully treated with the ASO. The immediate success rates are excellent and follow-up data suggest that the ASO is a safe device well suited for transcatheter ASD closure.
Clinical Research in Cardiology 07/2007; 96(6):340-6. · 2.95 Impact Factor
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ABSTRACT: Our objective is to review the epidemiology and pathophysiology of migraine headache, its association with patent foramen ovale (PFO), and the impact of PFO closure on migraine. Upon reviewing English-language publications listed in MEDLINE relating to migraine headache, PFO, and transcatheter closure of PFO, we selected case series, retrospective and prospective studies relevant to the topic. Primarily retrospective case-control studies demonstrate a link between PFO closure and improvement of migraine headache. Few prospective data confirm the initial results. However, the only randomized, controlled trial finished to date analyzing the effect of PFO closure on migraine failed to reach its primary outcome of resolution of migraine following the intervention. The evidence of a benefit on migraine headache following PFO closure is not convincing, but certainly intriguing. With currently ongoing trials, more information related to this topic can be expected.
Journal of Interventional Cardiology 01/2007; 19(6):552-7. · 1.18 Impact Factor
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ABSTRACT: The authors reviewed the mechanisms and pathophysiology of typically encountered electrical injuries by searching English-language publications listed in MEDLINE and reference lists from identified articles. They included relevant retrospective studies, case reports, and review articles published between 1966 and 2005. The authors also searched the Internet for information related to electrocution and life-threatening electrical injuries. They found that familiarity with basic principles of physics elucidates the typical injuries sustained by patients who experience electrical shock. Death due to electrocution occurs frequently. However, patients successfully resuscitated after cardiopulmonary arrest often have a favorable prognosis. Approximately 3000 patients who survive electrical shock are admitted to specialized burn units annually. Patients with serious electrical burns admitted to the intensive care unit are trauma patients and should be treated accordingly. Initial prediction of outcome for patients who have experienced electrical shock is difficult, as the full degree of injury is often not apparent.
Annals of internal medicine 11/2006; 145(7):531-7. · 16.73 Impact Factor
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ABSTRACT: Urinary protein excretion has been linked to coronary heart disease (CHD); the relationship to stroke is less clear. We assessed whether urine dipstick screening for protein predicted stroke and CHD in the Honolulu Heart Program cohort.
Prospective, observational study of 6252 Japanese American men in Honolulu aged 45 to 68 years. Proteinuria was detected by means of urine dipstick screening during the first and third examinations. Subjects were classified as having no proteinuria if results were negative at both examinations, transient proteinuria if results were positive at 1 examination, and persistent proteinuria if results were positive at both examinations. Relative risk was derived using those subjects with no proteinuria as the reference. Outcomes were assessed through 27 years.
No proteinuria was found in 92.8% of subjects, transient proteinuria in 6.1%, and persistent proteinuria in 1.1%. The age-adjusted incident stroke rates were 3.7, 7.3, and 11.8 per 1000 person-years in subjects with no, transient, or persistent proteinuria, respectively (P<.001). Age-adjusted rates of incident CHD were 9.4, 15.8, and 35.2 events per 1000 person-years, respectively (P<.001). Using Cox proportional hazards models, adjusting for age, body mass index, physical activity, smoking status, cholesterol level, presence of hypertension or diabetes mellitus, and alcohol consumption, the relative risk for 27-year incident stroke was 1.66 (95% confidence interval, 1.21-2.30; P = .002) with transient proteinuria and 2.84 (95% confidence interval, 1.51-5.34; P = .001) with persistent proteinuria, and relative risk for 27-year incident CHD was 1.48 (95% confidence interval, 1.19-1.83; P<.001) with transient proteinuria and 3.72 (95% confidence interval, 2.62-5.27; P<.001) with persistent proteinuria.
Proteinuria detected at urine dipstick screening independently predicted increased risk for incident stroke and incident CHD over 27 years in this cohort.
Archives of Internal Medicine 04/2006; 166(8):884-9. · 11.46 Impact Factor
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ABSTRACT: We report our experience with three generations of the Cardia patent foramen ovale (PFO) occluder in patients with cryptogenic thrombo-embolic events (TE).
Between 1998 and 2004, interventional PFO closure was attempted in 403 patients. Prior to PFO closure, 605 TE occurred, translating into an annual incidence of 3.1%. PFO closure was successful in all patients. Peri-procedural complications occurred in eight patients (2.0%). At 6 months follow-up, residual shunt was present in 10.8% of patients. Transient thrombi developed on 10 devices (predominantly generation II) and asymptomatic wire fractures were detected in 14 cases (generation I and II). The annual incidence of recurrent TE was 2.0% (n=13). Atrial septal aneurysm and prior device-related thrombus formation were identified as predictors of recurrent TE.
Owing to technical improvements and modified adjunctive pharmacotherapy, the rate of thrombus formation has declined and wire fractures are virtually absent in generation III devices. The overall rate of recurrent TE is reduced by transcatheter PFO closure with the Cardia PFO occluder, and seems comparable to recurrence rates reported for other devices used for this purpose.
European Heart Journal 03/2006; 27(3):365-71. · 10.48 Impact Factor
