Early, mid and long term echocardiographic results of percutaneous closure in simple and complex patent foramen ovale.

Background. The interpretation of residual shunts after implantation of different devices for patent foramen ovale (PFO) with different morphologies after cerebrovascular events due to paradoxical embolism is controversial. Methods. Transcatheter PFO closure was performed in 123 patients with a history of ≥1 paradoxical embolism using three different devices: Amplatzer (n=46), Figulla Occlutech (n=41) and Atriasept Cardia (n=36). PFO was a simple flap (S-PFO) in 59 patients and complex (C-PFO) in 64 patients. Complex PFO included isolated aneurysmal septum, long tunnel–type, presence of a small additional atrial septal defect, septum primum deviation, and prominent Eustachian valve. All patients were studied with contrast-enhanced transesophageal echocardiography (TEE) before interventional procedure and thereafter at 1 and 6 months and every 6 to 12 months in case of incomplete closure. Definite closure was confirmed in at least two consecutive studies. Results. The diameter of the occluder varied according to the size of the atrial septum and the size of PFO at the TEE examination prior to implantation. The closure rate between simple and complex PFO concerning all implanted occluders was significantly different (p=0.03). Devices of 25 mm or less had a better occlusion rate. The difference between the closure rate of S-PFO and C-PFO concerning each device type was significant (Amplatzer, p<0.01; Figulla, p<0.01; Atriasept, p<0.05). In two patients thrombi were detected in the six month TEE controls and in two patients the implantation of an adjunctive device was necessary for residual shunt. The mean follow up period was 3.1 years (median 2.3 years) with a re-event-rate of 0.6% per year. Overall, no relation to residual PFO shunting or thrombus formation was seen. There were no peri-interventional major complications. Conclusions. The PFO closure rate is dependent on septal anatomy more than occluder size and type. An adjunctive device may be necessary in selected cases

Very late bare metal stent thrombosis with concomitant patent drug eluting stent in the same vessel: a case for a suggestive hypothesis

We report a case of very late stent thrombosis of a bare metal stent with a concurrent drug eluting stent’s patency in the same coronary vessel, in a patient undergoing primary angioplasty who discontinued his clopidogrel regimen a few weeks after successful deployment of the stents

Biatrial function before and after percutaneous closure of atrial septum in patients with and without paroxysmal atrial fibrillation. a two-dimensional and three-dimensional speckle tracking echocardiographic study

We aimed to analyze atrial function by two-dimensional (2DSTE) and three-dimensional (3DSTE) speckle-tracking echocardiography in patients with atrial septal devices and paroxysmal atrial fibrillation (PAF). One hundred sixteen patients and a subgroup of 22 patients who developed PAF after device insertion were studied. Left (LA) and right atrial (RA) peak longitudinal strain (PS) and standard deviations(SDs) of times to peak strain (TPS) were calculated using 2DSTE. LA-RA emptying fraction (EF) and expansion index (EI) were determined using 3DSTE. By multivariate analysis, pre-closure 3D-RA-EI, LA-TPS, and 3D-LA-EI were independently associated with PAF. ROC analysis showed better diagnostic accuracy of the combination of pre-closure TPS and 3D-EI for detecting PAF than the other indices. Patients with atrial septal devices have pre-existent left and right atrial dilatation and dysfunction as assessed by 2DSTE and 3DSTE that appear sensitive for the stratification of PAF risk in this population

Assessment of biventricular function by three-dimensional speckle tracking echocardiography in secondary mitral regurgitation after repair with the mitraclip system

Background. The goal of this study was to determine the changes of left (LV) and right (RV) ventricular function with three-dimensional speckle-tracking echocardiography (3DSTE) after percutaneous mitral valve repair with the MitraClip system in high-risk surgical patients with moderate-to-severe or severe secondary mitral regurgitation (MR). Methods. Thirty-two patients with MR undergoing MitraClip were prospectively included. Patients underwent two-dimensional and three-dimensional transthoracic echocardiography before clip implantation and after 6-month follow-up. LV and RV longitudinal strains were obtained by two-dimensional speckle-tracking echocardiography (2DSTE) and 3DSTE. LV circumferential, radial, and area strains were calculated by 3DSTE. Data analysis was performed offline. Results. At 6-month follow-up a significant improvement was shown in LV 2D global longitudinal strain (p&lt;0.005), 3D global longitudinal strain (p=0.0002), and 3D area strain (p=0.0003). Overall, a significant improvement was also shown in 3D RV ejection fraction (p&lt;0.05) and 3D RV free-wall longitudinal strain (p&lt;0.05). A poor increase in LV strains after clip implantation (p=ns) occurred in patients with pronounced pre-existing RV dysfunction. The areas under the ROC curve (AUC) for LV-RV 3DSTE parameters showed high discriminative values (0.87-0.91) in predicting unfavorable outcome with persistent symptoms (NYHA&gt;II) after the procedure. Conclusions. 3DSTE analysis showed overall LV-RV strain improvement after clip implantation as well as lower post-procedural LV strain values in patients with worse pre-existing RV function. These findings could help in guiding MR treatment strategies suggesting different therapies in the presence of marked RV impairment or viceversa anticipating the procedure in case of evolving RV dysfunction

Idiopathic, Serial Coronary Vessels Dissection in a Young Woman with Psychological Stress: A Case Report and Review of the Literature

Spontaneous coronary artery dissection (SCAD) is a very rare disease, associated with high mortality rate, whose etiology and pathogenesis are poorly understood. Its sporadic nature and the varied angiographic extent make firm recommendations regarding revascularization impossible. The case described is that of a young, otherwise healthy woman, without a known underlying condition which may lead to SCAD, but with a history of intense psychological stress. We managed the patient with a conservative approach based on watchful waiting, medical therapy, and plain old balloon angioplasty (POBA) with low inflation atmospheres

Dipyridamole versus verapamil for treatment of no-reflow during primary angioplasty

Background: No previous study has assessed the possible role of dipyridamole for treatment of no-reflow during acute myocardial infarction (AMI). Methods and Results: Forty-six consecutive patients (age 64 ± 13 years, 37 men) with no reflow during primary percutaneous coronary intervention were randomized to initial treatment with either dipyridamole (0.56 mg/kg i.c.) or verapamil (1 mg i.c.). Patients with unsuccessful response to the first drug were then switched to the second one (from dipyridamole to verapamil and vice versa). Angiographic end-points were similar in the two groups: TIMI flow was 2.9 ± 0.3 versus 2.8 ± 0.4 (P = 0.28), corrected TIMI frame count (cTFC) 26.4 ± 8.8 versus 31.6 ± 11.4 (P = 0.14) and TIMI myocardial perfusion grade (TMPG) 2.1 ± 1.2 versus 1.7 ± 1.2 (P = 0.12) in dipydidamole and verapamil group, respectively. Optimal myocardial perfusion (TMPG-3) was achieved by 56% of patients with dipyridamole and 39% with verapamil (P = 0.38). In patients with persistent no-reflow administration of dipyridamole on top of verapamil resulted in a significant further improvement of cTFC (from 31.6 ± 11.4 to 24.6 ±5.7 P = 0.009) and of TMPG (from 1.7 ± 1.2 to 2.6 ± 0.7, P = 0.007). Conversely, verapamil did not induce a significant improvement in coronary flow (cTFC changed from 26.4 ± 8.8 to 24.5 ± 8.5, P = 0.28 and TMPG from 2.1 ± 1.2 to 2.4 ± 1.2, P = 0.13). There were no significant side effects induced by dipyridamole, while verapamil caused AV block in 9% of cases. Conclusions: Dipyridamole is a safe and effective first-line drug for treatment of no-reflow. Dipyridamole can also be successfully used in patients with incomplete response to verapamil. © 2010 Wiley-Liss, Inc

Tako-Tsubo syndrome and reversible epicardial coronary spasm

[No abstract available

Echocardiographic findings in simple and complex patent foramen ovale before and after transcatheter closure

Aims. Percutaneous closure of patent foramen ovale (PFO) in cryptogenic cerebrovascular events is an alternative to medical therapy. The interpretation of residual shunts after implantation of different devices for PFO with different morphologies is controversial. Methods and results. Transcatheter PFO closure was performed in 123 patients with a history of ≥1 paradoxical embolism using three different devices: Amplatzer (n=46), Figulla Occlutech (n=41) and Atriasept Cardia (n=36). Fifty-six patients presented with simple PFO and 67 patients had complex morphologies. All patients were studied with contrast-enhanced transesophageal echocardiography (TEE) before interventional procedure and thereafter at 1 and 6 months and every 6 to 12 months in case of incomplete closure. Definite closure was confirmed in at least two consecutive TEE studies. Various PFO morphologies were identified by TEE before device implantation. The device size to PFO diameter ratio was significantly increased in patients with complex PFO compared to those patients with a simple PFO morphology (p<0.05). The difference between the closure rate of S-PFO and C-PFO concerning each device type was significant (Amplatzer p=0.0027, Figulla p=0.0043, Atriasept p<0.01). The mean follow up period was 3.4 years (median 2.7 years) with a cerebrovascular re-event-rate of 2.4% per year. In three patients thrombi were detected in the six month TEE controls and resolved after medical therapy. In three other patients the implantation of an adjunctive device was necessary for residual shunt. Conclusion. In our series of patients the closure rate was dependent on PFO morphology more than occluder size and type. An adjunctive device was implanted in selected cases

The role of Glycoprotein IIb/IIIa inhibitors in acute coronary syndromes and the interference with anemia

The role played by glycoprotein (GP) IIb/IIIa inhibitors (GPI) has continuously evolved until the most recent Guidelines whereby they were stepped down from class I to class II recommendation for treating acute coronary syndromes (ACS). GPI compete with a wider use of ADP inhibitors and novel anticoagulant drugs although GPI use has greatly narrowed. However, GPI may still have a role. Several criteria were proposed to define post-PCI anemia which is strictly related to bleeding and transfusion. In ACS, it should be important to define anemia in comparative terms versus baseline levels: ≥ 15% of red blood cell decrease should be a practical cut-off value. If one wishes to concentrate on hemoglobin (Hb), a ≥ 2 g/dl Hb decrease from baseline should be considered. It is important to recognize post-PCI anemia in the setting of ACS. There are sub-populations exposed to short-term hemorrhagic and/or long-term ischemic risks. Ischemic and hemorrhagic risks need to be carefully evaluated along with thrombocytopenia and its prognostic significance in order to put all these blood and rheological parameters into a clinically oriented perspective on which therapeutical decisions should be based. Definition of high risk procedures (complexity, angiographic characteristics and patient's risk profile, regardless whether STEMI or NSTEMI) may help selecting GPI. There are positive elements in GPI use: efficacy, rapid onset and reversibility of action, absence of pharmacogenomic variability, pharmacoeconomic considerations and the possibility of intracoronary administration. All these elements should be evaluated when selecting these agents for therapeutics