Coronary Compression Research Articles

63. Clinical and angiographic profile of myocardial bridges in patients undergoing coronary angiogram for evaluation of chest pain

A myocardial bridge is a band of heart muscle that lies on top of a coronary artery, instead of underneath it. First described by pathologists in the early l920’s, myocardial bridges appear almost exclusively in the left anterior descending coronary artery. This occurrence has been recognized for more than 200 years but was first reported in depth by Geiringer in 1951. Systolic compression of the coronary artery by the overlying myocardial “bridge” was first recognized angiographically by Portsmann and Iwig in 1960 to assess both clinical and angiographic profile of myocardial bridge in patients undergoing coronary angiogram for evaluation of chest pain. 4527 patients were evaluated those who were admitted in NICVD, Al-Helal Heart Hospital, Urobangla Heart Hospital, Metropolitan Heart Centre and Lab-Aid Cardiac Hospital, Dhaka between August, 2003 and December, 2010 with diagnostic coronary arteriography. Each cineangiogram was reviewed by at least two qualified cardiologists who evaluated the angiogram and measured coronary lumen diameters were double blinded. Of the 4527 patients studied, 403 (8.9%) had no evidence of angiographically significant coronary artery disease. Thirty nine (39) of these patients were noted to have myocardial bridging, the total incidence of myocardial bridge was 0.87%. Most of the patients (75%) were 30–59 years age group and most of the patients were male (74.35%). 97% patients had history of chest pain and the resting electrocardiogram was normal in 21 patients (53%) whereas 4 patients (10%) had non-specific ST-T wave changes and 6 patients had minor conduction abnormalities. Of the 39 patients with myocardial bridges, 5 (12.8%) had mild systolic coronary compression; 9 (23.95%) had moderate systolic compression and 25 patients (64.25%) had significant compression. Site of myocardial bridges was mostly in mid LAD (51.30%). Other sites were Proximal LAD (25.65%), Distal LAD(12.82%), LCX (05.12%) and RCA (05.12%). The results of the present study would suggest that myocardial bridges are not a benign phenomenon. Only 0.87% of 4527 patients demonstrated myocardial bridges.

Aortic root compression during transcatheter pulmonary valve replacement.

To describe the incidence of aortic root compression (ARC) during transcatheter pulmonary valve replacement (TPVR). ARC can occur during balloon sizing of the right ventricular outflow tract (RVOT) or during coronary compression testing (BS/CCT) prior to TPVR, causing aortic valve dysfunction and/or root distortion with or without coronary compression. This has limited the use of TPVR in patients with native RVOTs, including those with a transannular patch (TAP). The characteristics of this patient cohort have not previously been described. A retrospective review was performed of all patients with congenital heart disease who presented for TPVR at UCLA from 2010 to 2015. ARC characteristics during BS/CCT were noted for all relevant cases. Inclusion criteria were met by 174 patients. ARC occurred in 16 patients (9%), of whom 14 had Tetralogy of Fallot with a native/TAP RVOT (14/42, 33%, of all native/TAP patients). Five ARC patients also had concomitant coronary artery compression. Isolated coronary compression occurred in six patients. Two patients underwent successful TPVR despite ARC by implanting the valves in the distal RVOT. One patient required surgical PVR and Sapien valve explantation after TPVR caused severe ARC. The majority of cases of ARC occur in patients with native/TAP RVOTs. ARC during BS/CCT may identify those at risk for ARC following TPVR. While ARC is a real phenomenon, it is unclear if it can be accurately predicted, what its clinical significance will be and how it is best avoided. Further studies are necessary to answer these questions. © 2016 Wiley Periodicals, Inc.

Imaging essentials before transcatheter closure of an atrial septal defect: Detection of an unusual contraindication

Currently there are few contraindications to transcatheter closure of secundum atrial septal defects (ASDs). Known device-related complications of percutaneous ASD closure are worsening of aortic regurgitation and cardiac erosion. Interference of a septal occluder with anatomic variant coronaries is a rare but important complication that can result in post-interventional fatalities. We report a woman with ASD and anomalous left circumflex artery arising from the right sinus of Valsalva with a retro-aortic course. Device closure was not attempted in her due to concerns about coronary compression by the device occluder and hence she underwent surgical closure.<Learning objective: Adequate imaging studies to detect coronary variants in patients scheduled to undergo transcatheter atrial septal defect (ASD) device closure are essential. Identifying anomalies that are at risk for compression from the occluder device prevents post-procedural complications. This case study highlights the importance of thorough imaging, including coronary angiogram and computed tomography angiogram to delineate coronary anomalies associated with ASD.>

Anomalous Origin of the Right Coronary Artery with Inter-Aorto-Pulmonary Course Highlighted by ECG-gated Cardiac CT Angiography

Case presentation: A 46-year-old male was referred to the echo laboratory for further investigations of a 6-months history with typical chest pain that is predictably exertional. His past medical history was largely unremarkable and so was his cardiac physical examination. Electrocardiogram showed sinus rhythm, poor R wave progression in anterior precordial leads and small Q waves with isoelectric T waves in inferior leads (Figure 1). Transthoracic echocardiography revealed prominent basal inferior and mid inferior hypokinesis with reduced regional myocardial longitudinal strain (-9% and -11% respectively) (Figure 2A). Left ventricular ejection fraction was estimated to be 50%. Myocardial perfusion scintigraphy was positive for a significant reversible stress-induced ischemia of the inferior wall. Coronary angiography showed normal left coronary system and anomalous origin of the right coronary artery (RCA). For further assessment, ECG-gated cardiac CT angiography (CTCA) was done and revealed RCA arising from left aortic sinus separately of left coronary artery, with inter-aorto-pulmonary course and ostial-post-ostial part severe luminal narrowing at the takeoff portion (Figures 2B-2F), coronary artery calcifications of the mid-RCA without significant stenosis (Figures 2B and 2C) and no significant atherosclerotic disease of left coronary system. Surgical treatment was required. In fact, aggressive surgical management is often recommended to avoid sudden cardiac death, especially in documented coronary ischemia as a result of a coronary compression when coursing between the great arteries. The CTCA has an incontestable place as a first imaging modality tool for the assessment of the origin and course of coronary arteries and the detection of inter-aortopulmonary course that implies an appropriate surgical management.

Recent advances in transcatheter pulmonary valve delivery.

Transcatheter pulmonary valve replacement has only been both approved and widely available for most congenital heart disease centers for a few years; its use and familiarity for interventionalists have greatly expanded our knowledge of its applicability to a multitude of clinical situations. Expanded worldwide use and longer time from implant have both served to better understand procedural limits and uncommon late adverse events. Although currently approved for implantation in the USA only in dysfunctional and circumferential right ventricle to pulmonary artery conduits, with expanded experience operators have been able to adapt the delivery of this valve in a large number of additional clinical scenarios. Rare technical limitations of the procedure, most importantly coronary compression, are now being better defined. Although not frequent, a significant number of infective endocarditis episodes have been reported, but more recently several studies have deepened our understanding of this late adverse event for the most commonly implanted transcatheter pulmonary valve prosthesis. Expanded and widened use has extended our understanding of who may benefit from transcatheter pulmonary valve implantation (TPVI), the current limits of TPVI, and uncommon but important late issues following TPVI.

Early operative comparison of two epicardial left atrial appendage occluding systems applied during off-pump coronary revascularisation in patients with persistent atrial fibrillation.

IntroductionAtrial fibrillation (AF) increases long-term mortality and stroke rate in patients having coronary artery bypass grafting (CABG). Because oral anticoagulation (OAC) is associated with both a significant incidence of discontinuation and well known complication rates, left atrial appendage occlusion might be beneficial for stroke prevention. This study presents the first clinical and practical comparison of two epicardial left appendage occluders (LAAO) accruing experience in application during off-pump coronary revascularisation in patients with persistent AF.Material and methodsFifteen consecutive patients with persistent AF were assigned to intraoperative LAA occlusion with either TigerPaw System II (n = 8) or AtriClip (n = 7) device during off-pump CABG and concomitant left atrial epicardial ablation. Both systems were analysed in terms of ease and safety of application along with intraoperative LAA occlusion success.ResultsSurgical risk was increased in the study population (mean EuroScore II: 3.2 ± 0.3%). In all patients in the AtriClip group successful off-pump LAA occlusion confirmed by intraoperative transoesophageal echocardiography was achieved. The TigerPaw application was quicker and easier, but in 2 patients it was unsuccessful. During the hospital stay there were no bleeding or thromboembolic events recorded.ConclusionsIn a pilot cohort epicardial LAAO during off-pump CABG in patients with persistent AF was performed safely and successfully with an AtriClip device. The TigerPaw System requires technological improvement. It might be useful to adapt the use of the type of occluding device to the LAA morphologic type and target revascularisation vessels to avoid the additional use of a heart positioner or obviate coronary compression.

Transcatheter Pulmonary Valve Replacement for Right Ventricular Outflow Tract Conduit Dysfunction After the Ross Procedure

Right ventricular outflow tract (RVOT) conduit dysfunction is a limitation of the Ross procedure. Transcatheter pulmonary valve replacement (TPVR) could alter the impact of conduit dysfunction and the risk-benefit balance for the Ross procedure. Retrospective review of databases from 3 prospective Melody TPV (Medtronic Inc, Minneapolis, MN) trials. Among 358 patients who were catheterized with the intent to implant a Melody TPV for RVOT conduit stenosis or regurgitation (PR) as part of 3 prospective multicenter studies, 67 (19%) had a prior Ross procedure. Of these, 56 (84%) received a Melody valve; in 5 of the 11 patients who did not, the implant was aborted due to concern for coronary artery compression, and 1 implanted patient required emergent surgery for left coronary compression. The RVOT gradient decreased from a median 38 mm Hg to 13.5 mm Hg (p < 0.001). There was no or trivial PR in all but 4 patients, in whom it was mild. At a median follow-up of 4.0 years, 1 patient died from sepsis. Twelve patients underwent 14 transcatheter (n= 8) or surgical (n= 6) TPV reinterventions for obstruction with stent fracture (n= 9), endocarditis with conduit obstruction (n= 3), or reoperation (n= 2). Freedom from TPV explant was 89% ± 5% at 4 years. Among patients who did not undergo reintervention for obstruction, there was no change in RVOT gradient over time, and all but 1 patient had mild or less PR at last follow-up. The TPVR with the Melody valve provides acceptable early outcomes and durable valve function in the majority of Ross patients. Recurrent RVOT obstruction associated with stent fracture was the main reason for reintervention. Coronary compression is not uncommon in Ross patients and should be assessed prior to TPVR.

Invited Commentary

Anomalous origin of a coronary artery from the contralateral sinus of Valsalva is associated with sudden death in young athletes. Mechanisms of exercise induced ischemia include; an abnormal slitlike coronary ostial origin and compression of the intramural portion of the coronary artery. Surgical unroofing of the intramural portion of the anomalous coronary removes the likely anatomic causes of ischemia. Although low risk in comparison to other commonly performed congenital, heart surgery is still a major surgical procedure with a definable morbidity and mortality. Surgery is indicated for patients with an anomalous coronary and evidence of ischemia, but the management of the asymptomatic patient remains controversial. Compounding this problem, in recent years an increasing number of asymptomatic patients are being identified. Risk stratification and management of the asymptomatic individual is challenging. Many patients are submitted for surgery despite the fact that the risks of surgical intervention outweigh the benefits. Others are given arbitrary activity restrictions that can affect their social development and quality of life while not substantially lowering their risk of sudden death. In this study, Harris and colleagues [1Harris M.A. Whitehead K.K. Shin D.C. Keller M.S. Weinberg P.M. Fogel M.A. Identifying abnormal ostial morphology in anomalous aortic origin of a coronary artery.Ann Thorac Surg. 2015; 100: 174-180Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] from the Children’s Hospital of Philadelphia used virtual angioscopy, reconstructed images from three-dimensional cardiac magnetic resonance imaging studies, to characterize the origins of these abnormal coronary arteries. They identified elliptical as opposed to circular coronary origins in all patients with anomalous origin of the coronary artery. Although it is not surprising that a coronary artery with acute angulation at the origin would have an elliptical shape, studies such as this are important in attempting to quantify the abnormal origin. Ultimately, improved noninvasive imaging of this kind will result in better characterization of the anatomy of anomalous coronary artery origin, with the goal of identifying the asymptomatic patient who is at increased risk of sudden death and therefore a candidate for prophylactic surgical intervention. Identifying Abnormal Ostial Morphology in Anomalous Aortic Origin of a Coronary ArteryThe Annals of Thoracic SurgeryVol. 100Issue 1PreviewAnomalous origin of a coronary artery from the contralateral sinus of Valsalva is associated with exercise-induced ischemia and sudden death. That is thought to be due to aortic enlargement in patients with an elliptical ostium. We hypothesize that virtual angioscopy can identify abnormal coronary ostial morphology in these patients. Full-Text PDF

Dynamic Systolic Compression of the Left Anterior Descending Coronary Artery by a Postinfarction Dyskinetic Left Ventricular Aneurysm

Dynamic systolic compression of the coronary arteries is almost always due to the existence of myocardial bridging that is most commonly localized in the middle segment of the left anterior descending coronary artery. However, it has rarely been reported in patients with pericardial adhesions, tumor, foreign body, or pseudoaneurysms. Only rare case reports exist regarding dynamic coronary compression by a dyskinetic left ventricular aneurysm. We present a patient with a myocardial bridge-like systolic compression of the distal left anterior descending caused by postinfarction dyskinetic left ventricular aneurysm.

Left Main Compression by a Giant Aneurysm of the Left Sinus of Valsalva: An Extremely Rare Reason for Myocardial Infarction and Cardiogenic Shock.

Aneurysms of the sinus of Valsalva are very rare and mostly located in the right coronary sinus. They might course with dyspnea, fatigue, and acute coronary syndromes. We present herein an extremely rare case report of a 61-year-old woman diagnosed with external left main coronary compression by a giant aneurysm of the left sinus of Valsalva, which was successfully managed with percutaneous coronary intervention.

Myocardial bridging: a review with emphasis on electrocardiographic findings.

Myocardial bridging (MB) occurs when a segment of an epicardial coronary artery takes an intra- myocardial course, thus leading to systolic compression. Most myocardial bridges involve the left anterior descending artery and are observed in 14-35% of patients. Different pathophysiological mechanisms can induce symptoms secondary to myocardial ischemia: systolic coronary compression, diastolic dysfunction associated with aging and coronary atherosclerosis, LV hypertrophy, vasospasm, microvascular and endothelial dysfunction, plaque development proximal to the bridge. We performed a literature review of MB, with a particular emphasis on electrocardiographic manifestations. Stable angina-like chest pain is the usual presentation and MB should be suspected in patients at low risk for coronary atherosclerosis which refer this symptom or which present myocardial ischemia at instrumental examinations. ECG changes are not specific for MB and resting ECG is often normal or presents ST segment anomalies. Exercise stress test often shows non specific signs of ischemia, conduction disturbances or arrhythmias which do not allow the distinction between myocardial bridging and other causes of myocardial ischemia; angina often appears during exercise, even in the absence of ECG changes. Myocardial perfusion deficits at scintigraphy are neither obligatory nor specific. Although the clinical significance of MB is still debated, MB has been associated with acute coronary syndrome, coronary vasospasm, and even sudden cardiac death. Although MB may lead to myocardial ischemia during stress, its clinical presentation and electrocardiographic findings are not specific.

Abstract 16608: Building of a Right Ventricular Conduit in Native Outflow Tract in Preparation of Edwards Sapien Valve Implantation

Background: Percutaneous valve implantation (PPVI) is now considered feasible and safe especially in patients with conduit between the right ventricle and the pulmonary arteries. However there are still no clear indications on valvolization in native outflow tract (RVOT), traditionally considered at risk because of the dynamic characteristics of the RVOT Aim: The aim of this study is to demonstrate the feasibility and safety of building a percutaneous conduit using a stent in the native RVOT before valve implant performing PPVI two months after stent implant, on the basis of previous animal studies, where endotelitation of the stent was shown to be reached within 60 days. Methods: From October 2010 to April 2014, 19 pts, with tetralogy of Fallot, (mean age 15 ± 6 yrs) previously corrected by transannular patch technique, underwent a cardiac catheterization in order to build a stent-conduit in the native RVOT. After a complete right catheterization a balloon was inserted through a long sheath in the RVOT. During the inflation of the balloon a right ventricular angiography and a left coronary artery angiography are performed. In the presence of a complete occlusion of the RVOT and no coronary compression, a stent was deployed in the RVOT. Two months later an Edwards Sapien Pulmonary valve was implanted. Results: Twenty two stents were implanted in 19 pts. The mean time of the procedures was 185 ± 89 min with a mean fluoroscopy time of 72 ± 33 min. Two main complications occurred: in 1 pt the stent partially occluded the right pulmonary artery and in a second pt the stent was dislocated in RVOT. In both cases the patients were treated surgically. In all other patients the procedure was successful and patients were discharged home two days later, on Aspirin therapy. The correct position of the stent was confirmed at the 1 month of follow-up by echocardiographic examination. Among the 19 pts , 152 underwent implantation of Edwards Sapien Pulmonary Valve, two months later. No complications occurred during the procedure and during the FU. Two patients are still waiting PPVI procedure Conclusions: A two-step procedure approach increases the safety of PPVI with no impact on clinical conditions or complications

Vitamin C Compromises Cardiac Resuscitability in a Rat Model of Ventricular Fibrillation

Resuscitation from cardiac arrest is partly limited by progressive reduction in left ventricular distensibility, leading to decreased hemodynamic efficacy of cardiopulmonary resuscitation (CPR). Reduction in left ventricular distensibility has been linked to loss of mitochondrial bioenergetic function that can result from oxidative injury. Attenuation of oxidative injury by administration of vitamin C during CPR may help maintain left ventricular distensibility and favor resuscitability and survival. Ventricular fibrillation was electrically induced in 2 series of 16 rats each and left untreated for 10 minutes. Resuscitation was attempted by 8 minutes of CPR and delivery of electrical shocks. Dehydroascorbate (DHA)-an oxidized form of vitamin C that enters the cell via glucose transporters-was used in series 1 and ascorbic acid (AA)-the reduced form of vitamin C that enters the cell via specialized AA transporters-in series 2. In each series, rats were randomized 1:1 to receive a 250 mg/kg right atrial bolus of DHA or AA or vehicle immediately before chest compression. Left ventricular distensibility-measured as the ratio between coronary perfusion pressure and compression depth-was numerically lower (not significant) in rats that received DHA (1.6 ± 0.2 vs. 1.9 ± 0.7 mm Hg/mm) and AA (1.8 ± 0.6 vs. 1.9 ± 0.3 mm Hg/mm). In addition, resuscitability was compromised by DHA (2/8 vs. 7/8; P = 0.041) and by AA (0/8 vs. 5/8; P = 0.026). AA levels in mitochondria were no different than control. Vitamin C failed to preserve left ventricular distensibility during CPR and had detrimental effects on resuscitability, suggesting possible disruption of protective signaling mechanisms during oxidative stress by vitamin C.

Coronary Compression in Transapical Transcatheter Aortic Valve Procedure

Coronary Compression in Transapical Transcatheter Aortic Valve Procedure

Coronary artery compression during intention to treat right ventricle outflow with percutaneous pulmonary valve implantation: Incidence, diagnosis, and outcome

Evaluate the incidence, diagnosis, and outcome of coronary compression (CC) during right-ventricular outflow tract interventions. The incidence, risk factors, diagnosis, and outcomes of CC during percutaneous pulmonary valve implantation are poorly defined. One-hundred consecutive patients (May 2008 to January 2012) undergoing transcatheter right-ventricular outflow tract treatment in two institutions were studied. CC occurred in six patients (6%) with a right ventricular outflow conduit stenosis, at a median age of 24.5 (13-49) years. It involved the left main coronary artery in four and the right coronary artery originating from the left anterior descending coronary artery in two patients. Conduit types were homograft (n = 3), bioprosthesis (n = 2), and a pericardial patch (n = 1). Median diameter was 23 (17-24) mm at surgical implantation. CC was diagnosed through a selective coronary angiogram during balloon dilation of the conduit in the first three patients and through an aortic root angiogram for the three next cases because we recognized that proximal compression could be masked during coronary artery cannulation. It was suspected on pre-procedure imaging (magnetic resonance imaging and/or computed tomography) in three cases. Patients with abnormal coronary anatomy tend to be at increased risk of CC (P = 0.0504). One institution had a higher incidence of CC (P = 0.04). CC resolved after balloon deflation. No patient underwent conduit stenting. Four patients underwent surgical reconstruction of right ventricular outflow tract. CC is accurately diagnosed during right-ventricular outflow tract interventions. We recommend an aortic root angiogram during dilation with a non-compliant balloon matching the diameter and length of the intended conduit implant.

The Prevalence of Coronary Sinus and Left Circumflex Artery Overlap in Relation to the Mitral Valve

Characterize where the circumflex artery crosses between the coronary sinus and mitral valve in order to minimize the occurrence of coronary compression during percutaneous indirect mitral valve interventions. Treatment of mitral valve regurgitation using an indirect percutaneous approach via access through the coronary sinus remains under active research and development. Characterization of anatomical locations where the circumflex artery crosses between the coronary sinus and mitral valve is important for mitigation of serious ischemic complications. Magnetic resonance images were obtained for 65 perfusion-fixed human hearts. Three-dimensional reconstructions of anatomical orientations of the coronary sinus, circumflex artery, and mitral valve annulus were generated. The prevalence and location of sites where the circumflex artery coursed between the coronary sinus and mitral valve were assessed. The circumflex artery coursed between the coronary sinus and mitral valve in 88% of specimens. Overlaps between the circumflex artery and coronary sinus were less prevalent more proximal to the coronary sinus ostium. The coronary sinus did not lie in the same plane as the mitral annulus in roughly 20% of the hearts. The prevalence of circumflex overlap between the coronary sinus and mitral valve was common across the sample size. The large variability in anatomy confirms the value of imaging individual patient cardiac anatomy prior to performing indirect percutaneous mitral valve annuloplasty to avoid impairment to the circumflex artery. This novel database can be utilized in the development of additional cardiac therapies that require access to the coronary sinus, such as therapeutic ablations.

Feasibility and Short-Term Outcomes of Percutaneous Transcatheter Pulmonary Valve Replacement in Small (&lt;30 kg) Children With Dysfunctional Right Ventricular Outflow Tract Conduits

In 2010, the Melody transcatheter pulmonary valve (TPV) received Food and Drug Administration approval for treatment of dysfunctional right ventricular outflow tract conduits in patients ≥30 kg. Limited data are available regarding use of this device in smaller patients. We evaluated technical and short-term clinical outcomes of 25 patients <30 kg (10 patients <20 kg) who underwent TPV replacement for treatment of conduit dysfunction at 3 centers. Median age and weight were 8.0 years (3.4-14.4) and 21.4 kg (13.8-29.0). The median conduit diameter at the time of surgical implant was 17 mm (12-23). Two patients did not undergo TPV implant (risk of coronary compression in 1; inability to advance the delivery sheath beyond the common femoral vein in 1). After successful TPV implant, the peak conduit gradient fell from 29±16 to 9±6 mm Hg (P<0.001), and all but 2 patients had no/trivial regurgitation (down from moderate or severe preimplant in 20). TPV implant was via the femoral vein in 17 patients, the right internal jugular vein in 4, and the left subclavian vein in 2 patients. At a median follow-up of 16 months, 1 patient underwent conduit replacement for recurrent conduit stenosis, 2 developed stent fracture requiring a second TPV, and 2 developed bacterial endocarditis treated with antibiotics, 1 of whom then underwent conduit replacement. The average Melody valve mean Doppler gradient and conduit regurgitation were unchanged from early postimplant. Percutaneous TPV replacement can be performed in small children with good procedural and early hemodynamic results in the majority of patients.

Imaging for Preintervention Planning

For many congenital heart defects treated in infancy (eg, tetralogy of Fallot, transposition of the great arteries, double outlet right ventricle), long-term right ventricular outflow tract (RVOT) dysfunction, in the form of pulmonary stenosis and regurgitation, is a common finding as patients become older (older children, adolescents, and adults). This dysfunction can lead to right ventricular (RV) dilatation, progressive dyspnea, arrhythmia, and sudden cardiac death.1,2 Patients are often treated with RV to pulmonary artery (PA) conduits or homograft, which have a finite lifespan and may require replacement every decade or sooner, with pulmonary valve replacement at open-heart surgery.3,4 Medical management has a limited role,5 and although conduit/homograft stenosis can be managed percutaneously with balloon dilatation and bare metal stent insertion6 to prolong conduit/homograft life, this has the inevitable consequence of inducing free pulmonary regurgitation. During the last decade, however, percutaneous pulmonary valve implantation (PPVI) has been developed to provide a minimally invasive, transcatheter-based approach to prolong conduit/homograft life by treating stenosis and regurgitation without the need for open-heart surgery, thereby reducing procedural risks, hospital stay, and the time it takes to return to normal daily activities. Since the first, pioneering human PPVI in 2000 by Bonhoeffer et al,7 the technique has gained acceptance, with >4000 procedures performed to date. Several studies have now demonstrated the short-term efficacy of PPVI8–13 and defined the potential complications of the procedure, including device migration and fractures,14 coronary compression,15 and infective endocarditis. Sustained relief from stenosis and regurgitation has also been demonstrated in the medium term, with freedom from reoperation of 93%, 86%, 84%, and 70% at 10, 30, 50, and 70 months, respectively, with similar freedom from redo interventions 95%, 87%, 73%, and 73% at the same intervals. Survival at …

Native Aortic Valve Endocarditis Complicated by Pseudoaneurysm of Mitral-Aortic Intervalvular Fibrosa

Pseudoaneurysm of mitral-aortic intervalvular fibrosa (PA-MAIVF) is a rare complication of native aortic valve endocarditis. This region is a relatively avascular area and prone to infection during endocarditis and subsequent aneurysm formation. The rupture into the pericardial cavity and left atrium or aorta, systemic embolism, myocardial infarction secondary to left coronary compression, and sudden death are the reported complications. Herein, we present a 9-year-old boy who was diagnosed with bicuspid aortic valve endocarditis complicated by PA-MAIVF, cerebral embolism, and hemorrhage. PA-MAIVF was visualized by both two- and three-dimensional transthoracic echocardiography and ruptured into pericardial space causing a fatal outcome.

Unusual cause of acute coronary syndrome: dynamic coronary compression by an aortic pseudoaneurysm

A 77-year-old man was admitted to our institution for acute coronary syndrome (ACS) with anterior ST depression on EKG and troponin rise. He had a history of aortic valve endocarditis 4 years earlier, treated with aortic valve replacement using a homograft. Close follow-up was arranged for a silent aortic pseudoaneurysm that developed early after surgery without evidence of recurrent infection. Two bare metal stents were implanted 6 months earlier in the setting of ACS. He was admitted for recurrent chest pain. Coronary angiogram showed a prolonged and critical systolic compression of the …