Zabieg przezskórnej naprawy niedomykalnej zastawki mitralnej za pomocą systemu MitraClip (Abbott)

Istotna niedomykalność zastawki mitralnej jest jedną z najczęstszych nabytych wad zastawkowych o wzrastającej częstości występowania. Preferowaną metodą leczenia jest operacyjna naprawa zastawki, jednak jak dotąd wykonuje się ją zbyt rzadko mimo obiektywnych korzyści płynących z takiego zabiegu. Ponadto z powodu współistnienia przeciwwskazań do operacji duża liczba chorych, zwłaszcza starszych, nie jest operowana. Potencjalne korzyści z przezskórnego leczenia niedomykalności zastawki dwudzielnej za pomocą systemu MitraClip to zmniejszona chorobowość, szybszy powrót do zdrowia, krótszy czas hospitalizacji, a także możliwość zastosowania w grupie chorych obarczonych dużym ryzykiem operacyjnym. Jak pokazują doświadczenia z przeprowadzonych dotąd na świecie oraz od niedawna w Polsce zabiegów, jest to metoda bezpieczna, o dużej skuteczności klinicznej. (Folia Cardiologica Excerpta 2010; 5, 5: 274-282

Rewaskularyzacja w niewydolności serca

Objawowa niewydolność serca jest chorobą o poważnym rokowaniu. Rozpoznanie niewydolności serca nigdy nie powinno być rozpoznaniem ostatecznym. Przyczyną ponad 2/3 przypadków niewydolności skurczowej jest choroba niedokrwienna serca, która dodatkowo pogarsza rokowanie. U podłoża niedokrwiennej niewydolności serca leżą takie zjawiska, jak: niedokrwienie, ogłuszenie, hibernacja i martwica miokardium. Rewaskularyzacja wieńcowa często pozwala uratować miokardium nawet u pacjentów z ciężką dysfunkcją skurczową i jest uznaną metodą leczenia, poprawiającą przeżywalność chorych. W większości przypadków pacjenci poddawani są zabiegowi operacyjnemu; rzadziej wykonuje się interwencje przezskórne. Kwalifikacja do zabiegów rewaskularyzacyjnych nie jest łatwa i jej podstawą powinna być skrupulatna ocena wyników badań nieinwazynych oraz inwazyjnych

Echocardiographic morphometry of the right chambers of the heart in permanent cardiac pacing

Permanent cardiac pacing is a method of choice in the treatment of specific arrhythmias and conduction disturbances. Clinical studies show that cardiac performance diminished at the site of impulse spreading. It determines local hypotrophy below the position of the pacing lead (early electric activation) with hypertrophic changes in the opposite lying myocardium (late electric activation). It seems that morphological changes, especially research by intravital methods, so relevant in permanent pacing to today™s invasive cardiologist, are not understood in full. In connection with this we decided, on the basis on the echocardiographic examination, to evaluate in detail the morphology of the right ventricle and atrium in patients with permanent pacing. Research was carried out on a group of 124 patients (68 males, 56 females) from 40±93 years of age (avg. 68 ± 14 yrs): 86 patients had implanted pacemakers or AICD (group I), the control group consisted of 38 patients with other cardiac diseases without any pacemaker devices (group II). We measured echocardiographically the following diameters: end-diastolic and systolic diameters of the right ventricle/atrium in short and long axis, diameter of the tricuspid orifice valve and calculated area of the tricuspid orifice based on a special formula. Regarding the morphometric parameters of the right ventricle and right atrium, we confirmed that all diameters of group I were overshooting in correlation to group II. Those differences, such as RVd-short and -long, RVs-long, RVinflow, RA-long and -short, TRId, were statistically significant. Regarding the area of the tricuspid orifice (TRIa), we did not observe any changes in the two examined groups. We concluded that patients with implanted devices have changes in the morphometric parameters of the right ventricle, atrium and orifice, but they do not depend on the duration of pacemaker implantation

Device-associated thrombus after percutaneous left atrial appendage closure: a case report and literature review

Introduction. In the setting of atrial fibrillation (AF), left atrial appendage (LAA) closure using the WatchmanTM device (WD) was proven to effectively prevent stroke, systemic embolism and cardiovascular death when compared with warfarin therapy. However, this procedure is potentially associated with the risk of complications, including device-attached thrombus formation. Case presentation. We report a case of a 65-year-old woman with permanent non-valvular AF, a history of ischemic stroke on warfarin treatment, hypertension, diabetes mellitus, heart failure with preserved left ventricular ejection fraction, labile values of the international normalized ratio, enlarged left atrium (LA) and spontaneous echo contrast in echocardiography, who was qualified for percutaneous LAA closure using the WD. The pre-procedural patient assessment indicated high thromboembolic (CHA2DS2-Vasc Score = 5) and bleeding risk (HAS-BLED Score = 4), and optimal morphology of LAA in transesophageal echocardiography (TEE). After a successful procedure using a 30 mm-sized WD, and despite appropriate antiplatelet and anticoagulation therapy, 6-month follow-up TEE revealed a mobile thrombus (2.4 cm × 0.6 cm) at the atrial side of the WD. Therapy with intravenous heparin was started. However, a control TEE examination after one week revealed progression of the thrombus size (4.2 cm × 0.7 cm) and its protrusion across the mitral valve orifice into the left ventricle. Although the patient remained asymptomatic, cardiosurgical excision of the thrombus was performed due to high risk of thrombus embolization. Conclusions. Late device-associated thrombus formation after implantation of the WD remains a rare but severe complication. Formal recommendations regarding prevention and management of device-related thrombosis are still lacking. In this complex clinical setting, we suggest: 1) careful long-term echocardiographic monitoring after percutaneous LAA closure, especially in patients with permanent AF, high thromboembolic risk, large LA and dense spontaneous echo contrast in echocardiography, and 2) an individualized treatment approach.

Usefulness of optical coherence tomography in the assessment of atherosclerotic culprit lesions in acute coronary syndromes. Comparison with intravascular ultrasound and virtual histology

In this paper, we present a case of a female patient with clinically unstable angina pectoris and a bordeline stenosis in the proximal segment of the left anterior descending coronary artery as assessed by coronary angiography and intravascular ultrasound. Virtual histology revealed morphological criteria of a vulnerable plaque forming the culprit lesion. Optical coherence tomography visualized both fibrous cap fracture and a significant stenosis of a coronary artery caused by soft structures identified as mural thrombus covering the plaque surface. The image of atherosclerotic plaque obtained by optical coherence tomography enabled explanation of the cause of coronary instability and influenced subsequent management. The presented case illustrates usefulness of optical coherence tomography as an imaging method complementary to virtual histology and intravascular ultrasound in the diagnostic evaluation of selected patients with acute coronary syndromes. Application of optical coherence tomography in the assessment of vulnerable atherosclerotic plaques is discussed as related to the presented case

Transcatheter closure of iatrogenic perimembranous ventricular septal defect after aortic valve and ascending aorta replacement using an Amplatzer membranous ventricular septal occluder

Iatrogenic perimembranous ventricular septal defect is a rare complication after surgical replacement of the aortic valve, and so transcatheter closure of such a defect is not a routine procedure. We report the successful closure of an iatrogenic perimembranous ventricular septal defect which occurred after the replacement of the aortic valve and ascending aorta. (Cardiol J 2008; 15: 189-191

A case of a patient treated with percutaneous edge-to-edge mitral valve repair, percutaneous left atrial appendage occlusion and implantable cardioverter-defibrillator

The article presents the case of a 55-year-old woman who suffered from anterior myocardial infarction andchronic complications of the underlying disease, heart failure with reduced left ventricular ejection fraction,severe secondary mitral regurgitation, and paroxysmal atrial fibrillation. Due to the severity of symptoms,which persisted despite the optimal pharmacotherapy, after exclusion of reversible causes, the patient wasqualified for different advanced percutaneous treatment methods. Within two years from the onset of thedisease, three percutaneous procedures were performed: mitral valve correction with the MitraClip system,left atrial appendage occlusion using the Watchman system, and implantation of cardioverter-defibrillator