Transapical aortic valve implantation – a rescue procedure for patients with aortic stenosis and “porcelain aorta”

Surgical aortic valve replacement (AVR) still remains the treatment of choice in symptomatic significant aortic stenosis (AS). Due to technical problems, extensive calcification of the ascending aorta (“porcelain aorta”) is an additional risk factor for surgery and transapical aortic valve implantation (TAAVI) is likely to be the only rescue procedure for this group of patients. We describe the case of an 81-year-old woman with severe AS and “porcelain aorta”, in whom the only available life-saving intervention was TAAVI

Conduction disturbances and permanent cardiac pacing after transcatheter implantation of the CoreValve aortic bioprosthesis: initial single centre experience

Background: The rate of significant conduction disturbances requiring permanent pacemaker implantation (PPI) following surgical aortic valve replacement (AVR) is 2&#8211;8%. Transcatheter aortic valve implantation (TAVI) is an alternative management approach in patients with severe aortic stenosis who are not considered candidates for AVR. The TAVI using the CoreValve (CV) bioprosthesis is associated with a nearly 30% rate of conduction disturbances requiring postprocedural PPI. Aim: To provide an initial evaluation of the rate of conduction disturbances and the need for PPI, and to analyse factors that increase the risk of this complication in patients undergoing TAVI using CV bioprosthesis. In addition, we evaluated the rate of permanent conduction disturbances in patients who underwent PPI at one year after TAVI. Methods: We studies 22 initial patients in a single centre who underwent CV bioprosthesis implantation in 2009&#8211;2010. After exclusion of 6 patients with preprocedural PPI, we ultimately evaluated 16 patients. Uni- and multivariate analyses were performed using &chi;2, Fisher, and Wilcoxon tests, and logistic regression analysis was performed using the SAS software. Results: Overall, 8 (50%) patients in our study group required PPI after TAVI (TAVI + PPI), and the remaining 8 patients did not require PPI (TAVI). The most common indication for PPI was complete heart block. The decision to implant a pacemaker was made on average at 9 &#177; 7 days following TAVI (range 3 to 22 days). When we analysed risk factors for PPI that were unrelated to the TAVI procedure, we found that the TAVI + PPI group was characterised (vs the TAVI group) by a significantly larger diameter of the native aortic valve (p = 0.03) and a larger left ventricular outflow tract (LVOT) dimension in the frontal (p = 0.02) and the corresponding frontal dimension in the transverse view (p = 0.01) by computed tomography angiography. Logistic regression analysis showed that the risk of PPI increased more than 2.5 times for each increase in the aortic annulus diameter by 1 mm (OR 2.64; 95% CI 0.90&#8211;7.74). None of the risk factors related to TAVI resulted in a significant increase in the rate of PPI. Among the patients who underwent PPI, we only noted a trend for a larger valvulotomy balloon diameter (p = 0.08), shorter procedure duration (p = 0.06), and deeper CV insertion within LVOT (p = 0.09). In addition, the bioprosthesis was inserted deeper in those patients who developed new LBBB after TAVI (p = 0.06). The ECG analysis at one day after the procedure showed a significant prolongation of PR, QRS, QT, and QTc intervals, and increased left axis deviation in the TAVI + + PPI group. In addition, the TAVI + PPI group showed increased QRS duration (p = 0.03) and increased left axis deviation (p = 0.049) compared to the TAVI group. Each increase in QRS duration by 10 ms was associated with 2.5-fold increase in the risk of PPI (OR 1.10; 95% CI 0.97&#8211;1.22), and each increase in PR interval duration by 10 ms with a 23% increase in risk (OR 1.02; 95% CI 0.99&#8211;1.05). New LBBB following CV implantation was noted significantly more frequently in the TAVI + PPI group vs the TAVI group (p < 0.0003). Pacemaker interrogation at one year after TAVI showed that the mean percentage of ventricular pacing in all patients with a pacemaker (DDD and VVI) pacing was 41%, and it was less than 10% in 2 patients. Conclusions: 1. Transcatheter implantation of a CV bioprosthesis is associated with an increased risk of persistent conduction disturbances and subsequent PPI. 2. New LBBB after TAVI may predict the need for PPI. 3. Careful ECG monitoring is necessary for one week after CV bioprosthesis implantation due to a risk of atrioventricular conduction disturbances and the need for PPI. 4. Patients at an increased risk of postprocedural PPI may be those with deep bioprosthesis insertion in LVOT, larger LVOT diameter, and larger aortic annulus diameter in the frontal view. These observations require confirmation in a larger group of patients.Background: The rate of significant conduction disturbances requiring permanent pacemaker implantation (PPI) following surgical aortic valve replacement (AVR) is 2&#8211;8%. Transcatheter aortic valve implantation (TAVI) is an alternative management approach in patients with severe aortic stenosis who are not considered candidates for AVR. The TAVI using the CoreValve (CV) bioprosthesis is associated with a nearly 30% rate of conduction disturbances requiring postprocedural PPI. Aim: To provide an initial evaluation of the rate of conduction disturbances and the need for PPI, and to analyse factors that increase the risk of this complication in patients undergoing TAVI using CV bioprosthesis. In addition, we evaluated the rate of permanent conduction disturbances in patients who underwent PPI at one year after TAVI. Methods: We studies 22 initial patients in a single centre who underwent CV bioprosthesis implantation in 2009&#8211;2010. After exclusion of 6 patients with preprocedural PPI, we ultimately evaluated 16 patients. Uni- and multivariate analyses were performed using &#967; 2, Fisher, and Wilcoxon tests, and logistic regression analysis was performed using the SAS software. Results: Overall, 8 (50%) patients in our study group required PPI after TAVI (TAVI + PPI), and the remaining 8 patients did not require PPI (TAVI). The most common indication for PPI was complete heart block. The decision to implant a pacemaker was made on average at 9 +- 7 days following TAVI (range 3 to 22 days). When we analysed risk factors for PPI that were unrelated to the TAVI procedure, we found that the TAVI + PPI group was characterised (vs the TAVI group) by a significantly larger diameter of the native aortic valve (p = 0.03) and a larger left ventricular outflow tract (LVOT) dimension in the frontal (p = 0.02) and the corresponding frontal dimension in the transverse view (p = 0.01) by computed tomography angiography. Logistic regression analysis showed that the risk of PPI increased more than 2.5 times for each increase in the aortic annulus diameter by 1 mm (OR 2.64; 95% CI 0.90&#8211;7.74). None of the risk factors related to TAVI resulted in a significant increase in the rate of PPI. Among the patients who underwent PPI, we only noted a trend for a larger valvulotomy balloon diameter (p = 0.08), shorter procedure duration (p = 0.06), and deeper CV insertion within LVOT (p = 0.09). In addition, the bioprosthesis was inserted deeper in those patients who developed new LBBB after TAVI (p = 0.06). The ECG analysis at one day after the procedure showed a significant prolongation of PR, QRS, QT, and QTc intervals, and increased left axis deviation in the TAVI + PPI group. In addition, the TAVI + PPI group showed increased QRS duration (p = 0.03) and increased left axis deviation (p = 0.049) compared to the TAVI group. Each increase in QRS duration by 10 ms was associated with 2.5-fold increase in the risk of PPI (OR 1.10; 95% CI 0.97&#8211;1.22), and each increase in PR interval duration by 10 ms with a 23% increase in risk (OR 1.02; 95% CI 0.99&#8211;1.05). New LBBB following CV implantation was noted significantly more frequently in the TAVI + PPI group vs the TAVI group (p < 0.0003). Pacemaker interrogation at one year after TAVI showed that the mean percentage of ventricular pacing in all patients with a pacemaker (DDD and VVI) pacing was 41%, and it was less than 10% in 2 patients. Conclusions: 1. Transcatheter implantation of a CV bioprosthesis is associated with an increased risk of persistent conduction disturbances and subsequent PPI. 2. New LBBB after TAVI may predict the need for PPI. 3. Careful ECG monitoring is necessary for one week after CV bioprosthesis implantation due to a risk of atrioventricular conduction disturbances and the need for PPI. 4. Patients at an increased risk of postprocedural PPI may be those with deep bioprosthesis insertion in LVOT, larger LVOT diameter, and larger aortic annulus diameter in the frontal view. These observations require confirmation in a larger group of patients

Analiza jakości kolonoskopii w Ogólnopolskim Programie Badań Przesiewowych dla Wczesnego Wykrywania Raka Jelita Grubego

Wstęp: Kolonoskopia wykonywana raz na 10 lat staje się preferowaną strategią w badaniach przesiewowych raka jelita grubego, co nakazuje szczególną dbałość o jej jakość. Celem badania była analiza jakości 50 148 kolonoskopii wykonanych w latach 2000-2004 w ramach Ogólnopolskiego Programu Badań Przesiewowych (PBP) dla Wczesnego Wykrywania Raka Jelita Grubego. Materiał i metoda: Analizowano parametry jakości kolonoskopii (osiągalność kątnicy, częstość wykrywania gruczolaków) w kolejnych latach trwania PBP. Liczba ośrodków biorących udział w programie zwiększała się stopniowo do 40 w 2004 roku. Dodatkowo, do analizy wybrano jeden z ośrodków, charakteryzujący się wysoką jakością wykonywanych zabiegów (wybrany ośrodek). Wyniki: Osiągalność kątnicy w kolejnych latach poprawiała się. W całym programie w 2000 roku wyniosła 85,4%, a w 2004 roku 93,5%. W wybranym ośrodku wyniosła odpowiednio 92,9% i 96,7%, osiągając rekomendowany poziom co najmniej 95%. W całym programie częstość wykrywania gruczolaków wyniosła 14,1% (11,4% u kobiet, 19,2% u mężczyzn). Nie zaobserwowano wzrostu tego parametru w kolejnych latach trwania programu, co mogło być spowodowane sukcesywnym włączaniem nowych ośrodków. W wybranym ośrodku częstość wykrywania gruczolaków wyniosła 21,1% (17,3% u kobiet i 29,0% u mężczyzn), przewyższając wymogi zawarte w wytycznych (&#8805; 15% u kobiet i &#8805; 25% u mężczyzn). Tu również nie zaobserwowano poprawy tego parametru w kolejnych latach. Badania wykonywane bez znieczulenia były bardzo dobrze lub dobrze tolerowane przez 75,1% badanych osób w całym programie i przez 79,1% w wybranym ośrodku. W odniesieniu do badań w znieczuleniu odsetki te wynoszą odpowiednio 81,8% i 97,7%. W wybranym ośrodku znieczulenia wykonywane były z udziałem anestezjologa, podczas gdy w większości pozostałych ośrodków stosowano głównie analgosedację z użyciem prostych leków przeciwbólowych i sedatywnych. U osób źle tolerujących badanie częstość wykrywania gruczolaków była niższa (11,0% dla całego programu i 14,1% w wybranym ośrodku) niż u osób z bardzo dobrą tolerancją (14,9% w całym programie i 22,4% w wybranym ośrodku). Wnioski: Kontrola jakości kolonoskopii stanowi ważny element PBP. Możliwe jest osiągnięcie parametrów jakości rekomendowanych w wytycznych światowych. Kolonoskopię bez znieczulenia dobrze lub bardzo dobrze toleruje większość badanych. Badania wykonywane przez endoskopistów z dobrymi parametrami jakości są lepiej tolerowane. W trakcie bardzo dobrze tolerowanych badań częściej stwierdza się gruczolaki. Gastroenterologia Kliniczna 2009, tom 1, nr 1, 45-5

Intravascular hemolysis after multiple valvular replacement procedures - a case raport

Intravascular hemolysis after multiple valvular replacement procedures - a case raport: A case of an intravascular hemolysis after multiple aortic and mitral valves replacement is described. Hemolysis was observed after second and third operation of mitral valve prosthesis due to prosthesis dysfunction - paravalvular leak. We discuss the possibilities of treatment, difficulties in decision making in a patient who is in good condition but hemolysis is clinically significant, not amenable to conventional treatment and there is an increased risk of another operation

Original articleEarly and long-term outcomes after surgical treatment in patients with aortic stenosis and severe left ventricular heart failure without concomitant coronary artery disease with respect to preoperative mean transvalvular pressure gradient

Wstęp: Dysponujemy niewielką ilością danych na temat wczesnego i odległego rokowania u chorych po wymianie zastawki aortalnej z powodu jej stenozy w okresie dysfunkcji lewej komory (LV) z frakcją wyrzutową (LVEF) &#8804;35% bez współistniejącej choroby wieńcowej. Cel: Ocena rokowania w zależności od średniego gradientu przez zastawkę aortalną (SGA). Metodyka: Do analizy włączono 60 chorych z ciasnym zwężeniem zastawki aortalnej i LVEF &#8804;35%. Wykluczono uprzednio chorych z chorobą wieńcową, z większą niż umiarkowana niedomykalnością zastawki aortalnej oraz innymi wadami zastawkowymi. Chorzy zostali podzieleni na dwie grupy w zależności od SGA: I &#8211; z SGA &#8804;35 mmHg, II &#8211; z SGA >35 mmHg. Wyniki: Śmiertelność wczesna po wymianie zastawki aortalnej wyniosła w grupie I &#8211; 14,2%, w grupie II &#8211; 5,1%. W okresie obserwacji, średnio 48 mies., odnotowano w grupie I 16,6% śmiertelność, zaś w grupie II &#8211; 2,6%. W obydwu grupach stwierdzono w okresie obserwacji znamienną poprawę czynnościową w skali NYHA, istotne zmniejszenie wielkości LV, jak również wzrost EF. Wnioski: Chorzy z ciasnym zwężeniem zastawki aortalnej, LVEF 35 mmHg należy zaliczyć do grupy nieznacznie zwiększonego ryzyka.Introduction: There are limited data on early and long-term prognosis in patients after aortic valve replacement who have left ventricular dysfunction, reduced ejection fraction (EF) &#8804;35% and no concomitant coronary artery disease. Aim: To assess the prognosis in this group of patients depending on the mean aortic gradient (MAG) value. Methods: This study involved 60 patients with severe aortic stenosis and EF &#8804;35%. Patients with coronary artery disease, more than moderate aortic regurgitation and any other valvular lesion were excluded. Patients were divided into two groups based on the MAG values: group I included patients with MAG &#8804;35 mmHg, and group II included patients with MAG >35 mmHg. Results: Early mortality after aortic valve replacement was 14.2% in group I, and 5.1% in group II. During a mean follow-up of 48 months mortality in groups I and II was 16.6% and 2.6%, respectively. In the follow-up period, a significant functional improvement according to NYHA scale as well as significant decrease of left ventricular dimensions and increase of EF was observed in both groups of patients. Conclusions:Patients with severe aortic stenosis, left ventricular ejection fraction 35 mmHg should be classified as the group of slightly increased risk