Dia: 24 de agosto de 2011

Knock knock knocking on: how to open stuck mitral valve prosthesis

Vihinen, Tapani; Lund, Juha; Airaksinen, K.E. Juhani

Author Information

Division of Cardiology, Department of Medicine, Turku University Hospital, Turku, Finland

Corresponding author. Tel: +358 2 3131005, Fax: +358 2 3132030, Email: juhani.airaksinen@tyks.fi

A 40-year-old man with congenital atrioventricular block and dilated cardiomyopathy presented with rapid worsening of dyspnoea and syncopal attacks during exercise. He had undergone mitral valve replacement 14 years ago and the pacemaker system was upgraded to a biventricular device 7 years ago. Echocardiography revealed severe left ventricular dysfunction (ejection fraction 25%). One disc of the prosthesis was stuck in closed position confirmed by fluoroscopy (Panel A) resulting in mean valve gradient of 8 mmHg (Panel B). Effective anticoagulation combined with aspirin was unsuccessful. New valve surgery was unacceptable and patient was referred for heart transplantation.

Severe symptoms led us to perform a percutaneous mobilization of the stuck prosthesis disc during full anticoagulation. After transseptal puncture, a deflectable ablation catheter was advanced (e.g. through a SL2 sheath) against the stuck disc which was knocked until normal disc motion could be confirmed in fluoroscopy with a decrease in pressure gradient (Panels C–E).

The symptoms ameliorated quickly and patient could be discharged. At 5 months of follow-up visit, the patient was free of syncope, but exercise tolerance had remained impaired (NYHA2–3). Echocardiography showed fully mobile discs with a mean valve gradient of 5mmHg. Later, a similar disc malfunction with a rapid deterioration of the condition was observed, but the patient could be discharged after successful disc liberation.

Our case demonstrates that stuck mitral valve prosthesis can be safely and easily mobilized by catheter manipulation through transseptal route. This quick approach may be helpful first aid in acute life-threatening situations.

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Cutucaram e prótese do cara anticoagulado, transeptalmente, com catéter de ablação, DUAS VEZES?!

Muito bacana! Adoro essas tigragens…

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Aqui, cálculo online do risco levando em consideração a história familiar e o perfil inflamatório.
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The role of exercise echocardiography in the diagnostics of heart failure with normal left ventricular ejection fraction

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Methods and results Eighty-four patients with exertional dyspnoea and normal LV EF and 14 healthy controls underwent spirometry, NT-proBNP plasma analysis, and exercise echocardiography. Doppler LV inflow and tissue mitral and tricuspid annular velocities were analysed at rest and immediately after the termination of exercise. Of the 30 patients with the evidence of HFNEF, 6 (20%) patients had only isolated exercise-induced HFNEF. When compared with the remaining patients, those with HFNEF had a significantly lower resting and exercise peak mitral annular systolic velocity (Sa) and the mitral annular velocity during atrial contraction, lower exercise peak mitral annular velocity at early diastole, and lower exercise peak systolic velocity of tricuspid annular motion. The multivariate logistic regression analysis including both parameters standardly defining HFNEF and the new Doppler variables potentially associated with the diagnosis of HFNEF revealed that NT-proBNP, LV mass index, left atrial volume index, and Sa significantly and independently predict the diagnosis of HFNEF.

Conclusion A significant proportion of patients require exercise to diagnose HFNEF. Sa appears to be a significant independent predictor of HFNEF, which may increase the diagnostic value of models utilizing the variables recommended by the European Society of Cardiology guidelines.
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Immediately after resting echocardiography, symptom-limited exercise was performed by bicycle ergometry (Kettler X7, Siemens, Germany) in a sitting position. The initial workload of 25 W was increased by 25 W every 2 min until the limited symptoms appeared (dyspnoea, leg, or general fatigue). Immediately after exercise, in the patient’s position corresponding to the pre-exercise examination at rest, the following images were obtained: transmitral pulsed Doppler filling flow and Doppler tissue recordings of septal and lateral mitral annular motion and of tricuspid annular motion.

Cellular adaptive response to chronic radiation exposure in interventional cardiologists
Eur Heart J (2011)
doi: 10.1093/eurheartj/ehr263
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Methods and results We enrolled 10 healthy exposed professionals (all interventional cardiologists, Group II, exposed: age = 38 ± 5 years) and 10 age- and gender-matched unexposed controls (Group I, non-exposed). Exposed subjects had a median exposure of 4 mSv/year (range 1–8) by film badge dosimetry (below lead apron). We measured reduced glutathione (GSH, a marker of antioxidant response) in erythrocytes and plasma generation of hydrogen peroxide (a marker of oxyradical stress) by ferrous oxidation-xylenol orange assay in plasma. In both groups, lymphocytes were isolated and caspase-3 activity (a marker of apoptotic response) measured at baseline and following 2 Gy in vitro irradiation. Exposed subjects showed a three-fold increase in hydrogen peroxide (Group I = 2.21 ± 1.03 vs. II = 6.51 ± 1.55 μM H2O2 equivalents) and a 1.7-fold increase in GSH (I = 12.37 ± 1.22 vs. II = 20.61 ± 2.16 mM). Exposed subjects also showed higher values of caspase-3 activity, both at baseline and—more strikingly—following high-dose radiation challenge.
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Conclusion
In interventional cardiologists, chronic exposure to low-dose radiation is associated with an altered redox balance mirrored by an increase in hydrogen peroxide and with two possibly adaptive cellular responses: (i) an enhanced antioxidant defence (increase in GSH, counteracting increased oxyradical stress) and (ii) an increased susceptibility to apoptotic induction which might efficiently remove genetically damaged cells.
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