Critical Stenosis Research Articles

Abstract 16826: A Rare Case of an Emergent Third Valve in Valve Intervention

Introduction: Bioprosthetic valves are prone to structural degeneration due to an average lifetime of 10-15 years. Valve in Valve (VIV) TAVR has become an alternative to the high-risk surgical patients as the growing number of successful bioprosthetic valve placements and the deteriorations over time. Emergent VIV intervention effectiveness with prior multiple artificial valves is less studied. Hypothesis: We report a case of a 54-year-old male presenting with obstructive shock with history of substance abuse and bicuspid aortic valve status post bioprosthetic aortic valve with aortic root repair at age of 15(1983), aortic stenosis requiring repeat surgical bioprosthetic Aortic Valve Replacement (SAVR) (25 mm) at age 42(2011). Recalcitrant cardiogenic shock despite vasopressor. Emergent Heart catheterization showed mild coronary artery disease (CAD) and severe cardiomyopathy, Left Ventricle ejection Fraction 15-20%. Aortic valve Gradient was 80 mmHg. Transesophageal Echocardiography (TEE) ruled out endocarditis. Impella CP and Swan-Ganz catheter were placed for hemodynamic support and monitoring. Methods: The Heart Team approach was followed. Patient was at high risk of mortality and operative complications with redo sternotomy. He subsequently underwent valve in valve TAVR with self-expanding 26 mm valve. Prior surgical valve did not require fracturing post implantation. Results: Post Trans Aortic Valve Replacement (TAVR) the mean gradient on echocardiogram decreased to 10 mmHg and LVEF recovered to 55-60%. The patient was successfully weaned off Vaso-pressors and eventually discharged home. Conclusion: Most common cause of transcatheter bioprosthetic valve failure is stenosis from calcification and thrombosis. VIV TAVR in recent studies has proven to be safe with favorable outcomes. Our patient had already undergone two surgical valve interventions, presented with critical bioprosthetic valve stenosis requiring salvage TAVR for cardiogenic shock. After the Heart team approach, TAVR was opted as a more favorable option for the patient. Although, the life of a bioprosthetic valve results in multiple interventions but overall valve in Valve technique has been proven to provide expected results in emergent high-risk patients.

Right Heart Remodeling After Pulmonary Valve Replacement in Patients With Pulmonary Atresia or Critical Stenosis With Intact Ventricular Septum.

Background Patients with pulmonary atresia or critical pulmonary stenosis with intact ventricular septum (PA/IVS) and biventricular circulation may require pulmonary valve replacement (PVR). Right ventricular (RV) remodeling after PVR is well described in tetralogy of Fallot (TOF); we sought to investigate RV changes in PA/IVS using cardiac magnetic resonance imaging. Methods and Results A retrospective cohort of patients with PA/IVS who underwent PVR at Boston Children's Hospital from 1995 to 2021 with cardiac magnetic resonance imaging before and after PVR was matched 1:3 with patients with TOF by age at PVR. Median regression modeling was performed with post-PVR indexed RV end-diastolic volume as the primary outcome. A total of 20 patients with PA/IVS (cases) were matched with 60 patients with TOF (controls), with median age at PVR of 14 years. Pre-PVR indexed RV end-diastolic volume was similar between groups; cases had higher RV ejection fraction (51.4% versus 48.6%; P=0.03). Pre-PVR RV free wall and left ventricular (LV) longitudinal strain were similar, although LV midcavity circumferential strain was decreased in cases (-15.6 versus -17.1; P=0.001). At a median of 2 years after PVR, indexed RV end-diastolic volume was similarly reduced; cases continued to have higher RV ejection fraction (52.3% versus 46.9%; P=0.007) with less reduction in RV mass (Δ4.5 versus 9.6 g/m2; P=0.004). Post-PVR, RV and LV longitudinal strain remained unchanged, and LV circumferential strain was similar, although lower in cases. Conclusions Compared with patients with TOF, patients with PA/IVS demonstrate similar RV remodeling after PVR, with lower reduction in RV mass and comparatively higher RV ejection fraction. Although no differences were detected in peak systolic RV or LV strain values, further investigation of diastolic parameters is needed.

Critical tracheal stenosis caused by endothoracic goiter

Critical tracheal stenosis caused by endothoracic goiter

Abstract 126: Bilateral Limb Shaking TIA secondary to Severe Bilateral Carotid Stenosis

Introduction A case describing bilateral limb shaking episodes in a patient with severe bilateral carotid disease ‐ a rare manifestation of limb‐shaking TIA. Methods '‐ Results CASE A 71‐year‐old male patient with a past medical history significant for type 2 diabetes mellitus and bilateral carpal tunnel syndrome is being followed for symptomatic management of known axonal sensorimotor diabetic polyneuropathy in the neuromuscular clinic. He reported on one of his follow‐up visits that he had been experiencing an eight‐month history of presyncopal to syncopal events occurring solely in the standing position, not followed by postictal state but amnesia to the syncope itself, and resulting in falls with mild injuries. He was experiencing new‐onset dry eyes and mouth but denied anhidrosis or early satiety, and cardiac event monitoring during one of these events was unremarkable for rhythmic causes. Examination was unchanged from previously and was significant for findings consistent with length‐dependent sensory loss with hyporeflexia/areflexia. The constellation of symptoms was suggestive of autonomic dysfunction, and while this may be seen with diabetic polyneuropathy, workup for alternative autonomic neuropathies (including SSA/SSB antibodies, paraneoplastic antibody panel, serum protein electrophoresis with immunofixation, serum free light chains, transthyretin amyloid) was obtained with plan for follow‐up. A few months later, he presented to the ED with intermittent upper extremity shaking (more pronounced on the right than on the left) preceding the syncopal events, which only occurred in the standing position or during physical activity and resolved with rest. There were no (transient) focal neurological deficits, including monocular vision loss or hemispheric syndrome. CTA of the head/neck was obtained and was notable for severe to critical stenoses of the bilateral internal carotid arteries (see figure 1). Duplex US revealed 80‐99% stenosis of both right and left proximal internal carotid arteries. The constellation of findings was most suggestive of bilateral limb‐shaking TIA secondary to bilateral carotid stenosis. He was started on secondary stroke prevention and referred to vascular surgery for evaluation of revascularization. The patient underwent left carotid endarterectomy briefly afterward and experienced resolution of the events – he later also underwent carotid endarterectomy of the right side and remains asymptomatic. DISCUSSION: Limb‐shaking TIA is a well‐described yet underrecognized manifestation of severe carotid disease reported by C.M. Fisher in 1962. The “limb shaking” episodes are typically unilateral, affecting the arm or leg, and are often mistaken for seizures [1]. Pathogenesis involves hemodynamic impairment related to extracranial/intracranial carotid stenosis or occlusion resulting in stereotypical recurrent contralateral limb shaking episodes precipitated by physical activity [2], [3]. The constellation of “limb shaking” spells precipitated upon standing or physical activity with resolution after activity cessation should raise suspicion for limb‐shaking TIA and warrant vascular imaging. Treatment includes medical secondary stroke prevention and revascularization procedures [4], which can alleviate or even resolve the transient symptoms [2]. Conclusion Limb‐shaking TIA is an important yet underrecognized manifestation of relative cerebral hypoperfusion related to severe cerebrovascular disease. This case describes bilateral limb shaking episodes in a patient with severe bilateral carotid disease ‐ a rare manifestation of limb‐shaking TIA.

X-RAY-GUIDED ENDOVASCULAR TREATMENT FOR CRITICAL STENOSIS OF A SOLITARY INTERNAL CAROTID ARTERY: A CLINICAL CASE

In this work, the authors present a clinical case of a 65 year-old man with a history of three acute cerebrovascular accidents similar to a transient ischemic attack and/or ischemic stroke with a minor neurological deficit with short-term weakness in the left or right limbs and loss of coordination. Carotid angiography showed that the blood supply to the brain was provided by a single internal carotid artery on the left and a potent collateral network on the same side. The patient underwent stenting of the internal carotid artery on the left. As a result, blood supply was restored through the stented artery and pronounced collateralization on the right. This clinical case demonstrated that even in complex clinical situations associated with multifocal lesions of the carotid arteries, the use of x-ray endovascular technologies can achieve good clinical results, and x-ray-guided endovascular treatment of critical stenosis of the solitary internal carotid artery will allow achieving significant regression of neurological deficit and designating prognosis optima.

Comparing functional and quality of life outcomes in transcatheter aortic valve implantation and surgical aortic valve replacement for aortic stenosis: a systematic review and meta-analysis

BackgroundTo compare functional and health related quality of life outcomes post-transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in patients with critical aortic stenosis (AS) across low to high-risk surgical candidates. These patient-centred factors will be compared between both groups in the short to medium term time frames and will aid in shared decision making between patients and healthcare workers.Materials and methodsWe conducted a systematic review and meta-analysis of randomised controlled trials which compared TAVI with SAVR and reported on quality of life (QoL) and functional scores.The scores used were the Kansas City Cardiomyopathy Questionnaire (KCCQ), Euroqol-5DL (EQ5DL), the short form-36/12 (SF-36/12) and the NYHA.ResultsWe identified eight trials with a total of 8898 participants. Both groups showed improvements from baseline at one month. At one month there was a statistically significant difference in standardised mean difference (SMD) in favour of TAVI for EQ5DL (SMD 0.37, 95% CI 0.26,0.49), KCCQ (SMD 0.53,95% CI 0.48, 0.58), SF physical summary (SMD 0.55, 95% CI 0.31 – 0.78) and SF mental summary (SMD 0.34, 95% CI 0.27 – 0.40). At one year there was no statistically significant difference between any of these QoL metrics. For NYHA, no significant difference in odds ratio of class III/IV was observed at one month between TAVI and SAVR (OR 0.94, 95% CI 0.83, 1.07), however, TAVI was associated with reduced odds ratio of NYHA class I/II at one year (OR 0.87, 95% CI 0.78, 0.98).ConclusionBoth groups were associated with improvements in QoL and functional outcomes with TAVI reporting more significant improvements in QoL at one-month post-procedures. No significant improvements between groups were seen at one year. This is the largest meta-analysis comparing post-operative health-related quality of life outcomes post SAVR and TAVI and has major implications in shared decision making for the treatment of aortic stenosis.

Failure-to-Salvage After Femoropopliteal Bypass Surgery is Associated With Nonmodifiable Risk Factors

IntroductionBypass graft failure and major amputation are among the worst complications after femoropopliteal bypass surgery. In this large multicenter analysis, we examined our incidence and risk factors for failure-to-salvage (FTS) following either bypass surgery or bypass graft failure. MethodsA regional multicenter database was retrospectively queried for all femoropopliteal bypass procedures performed between 2002 and 2021. Re-do bypasses were excluded. The primary outcome was FTS, defined as major ipsilateral limb amputation within 90 d following index bypass surgery or bypass graft failure. Bypass graft failure was defined as critical stenosis or occlusion of the bypass graft requiring reintervention. Graft rescue was defined as bypass graft failure without subsequent major ipsilateral limb amputation within 90 d. Multivariable logistic regression analysis was utilized to identify factors associated with bypass graft failure and FTS. ResultsOver the study period, 1315 femoropopliteal bypass procedures were performed across five hospitals. There were 25 major amputations within 90 d of initial bypass. Bypass graft failure was diagnosed in an additional 503 (38.3%) patients. Mean time to graft failure was 619 d. On multivariable analysis, bypass for tissue loss (adjusted odds ratio [aOR] 1.38 [95% confidence interval (CI) 1.03-1.83], P = 0.03) was associated with graft failure. Of patients with graft failure, 33 had major amputation, leading to an overall FTS incidence of 4.4% (n = 58) over a mean follow-up period of 3.4 y. Patient demographics, medical comorbidities, and bypass conduits were similar between the FTS and graft rescue groups (n = NS each). The FTS group more frequently underwent bypass for tissue loss (51.7% versus 29.8%, P = 0.002), and an infrageniculate bypass target was more frequently utilized in FTS compared to graft rescue patients (81.0% versus 60.4%, P = 0.002). Anticoagulation (34.5% in FTS versus 37.7% in rescue) and dual antiplatelet therapy (15.5% versus 22.1%, respectively) were similar between groups (P = NS each). On multivariable analysis, factors associated with FTS included infrageniculate target (aOR 2.42 [95% CI 1.22-4.08], P = 0.01), black race (aOR 2.47 [95% CI 1.04-5.84], P = 0.04), and bypass for tissue loss (aOR 4.75 [95% CI 1.41-16.0], P = 0.01). Anticoagulation and dual antiplatelet therapy were not associated with loss of graft patency or FTS. ConclusionsFailure-to-salvage after femoropopliteal bypass surgery is associated with nonmodifiable factors, and may represent progression of underlying disease. These data may help inform vascular surgeons in counseling patients with failing bypass grafts. Further investigation of care delivery factors improving likelihood of graft salvage may be warranted.

Carotid Artery Involvement in Patients Undergoing Coronary Angiography with Diabetes Mellitus

Background: Carotid artery disease would be high in patients having coronary artery disease with diabetes mellitus. Objective: The purpose of the present study was to see frequency, pattern and severity of carotid artery disease among patients with IHD and diabetes mellitus. Methodology: This case-control study was conducted in Department of Cardiology, UCC, BSMMU from July, 2007 to June 2009. Total 100 patients were included in this study. Of them 50 patients were coronary artery disease with diabetes mellitus and another 50 patients were coronary artery disease without diabetes mellitus. Both group were underwent coronary and carotid angiography. Coronary artery stenosis is assessed by different scoring system and carotid artery stenosis are categorized as mild (< 50% stenosis) moderate (50-69% stenosis) and critical (>_ 70% stenosis). Moderate and critical stenosis was considered as significant carotid artery disease. Morphological character of the lesion was also assessed. Results: The mean age was found 57.48 years with 6.04 standard deviation (SD) in DM and 55.64 years with 6.34 standard deviation in NDM group and also 56.56 years with 6.49 standard deviation in the whole study population. the indications of CAG were Post MI evaluation, unstable angina, stable angina, chest pain evaluation and positive ETT were 42.0%, 20.0%, 18.0%, 10.0% and 10.0% in DM group and 32.0%, 28.0%, 20.0%, 8.0% and 12.0 in NDM group respectively. LAD was the commonest artery involved (86.0%), followed by RCA (82.0%), LCX (68.0%) and LM (6.0%) in DM study subjects. Among the NDM LAD artery involved (76.0%), followed by RCA (72.0%), LCX (64.0%) and LM (4.0%) in NDM study subjects. Conclusion: In conclusion, patients of coronary artery disease with diabetic mellitus are having higher frequency and severity of Carotid artery disease than non-diabetic coronary artery disease patients. Journal of National Institute of Neurosciences Bangladesh, January 2023;9(1):30-34

TCT-493 Maternal and Fetal Outcomes Following Percutaneous Transluminal Mitral Commissurotomy in 70 Pregnant Women With Critical Mitral Stenosis: An Experience of a Tertiary Care Center

TCT-493 Maternal and Fetal Outcomes Following Percutaneous Transluminal Mitral Commissurotomy in 70 Pregnant Women With Critical Mitral Stenosis: An Experience of a Tertiary Care Center

Wellens’ syndrome in clinical practice

Despite the declining cardiovascular mortality, the incidence of myocardial infarction (MI) is still high, and therefore the issues of its timely diagnosis remain extremely relevant. In addition to the main diagnostic criteria and typical electrocardiographic (ECG) signs, there are many secondary patterns that suggest MI. Wellens’ syndrome (WS) is one of these ECG patterns, which indicates that the patient is at high risk of left ventricular anterior wall MI, caused by occlusion of the anterior interventricular artery (AIA) or its critical stenosis. Despite the relatively low incidence of WS, it is necessary to increase physicians’ awareness in order to prevent MI and reduce its possible negative consequences.This article presents clinical cases of WS, which show the importance of its diagnosis in the management of patients with anginal pain. The first patient is 43-year-old with a diagnosis of class III exertional angina, a history of anginal pain, and the presence of inverted T waves in V2-V3 leads. AIA stenting was performed on the 7th day of hospitalization. The second patient is 67-year-old with a similar diagnosis and history, biphasic T waves in I, aVL, V1-V3 and V5-V6 leads, deeply inverted T waves in V4. Stenting of the AIA and right coronary artery (RCA) was performed on days 5-6 after the most severe episode of anginal pain and after the anginal pain became recurrent. In both cases, WS was not diagnosed. The third patient, 57-year-old, with T wave inversion in II, III, aVF, leads ST segment elevation of less than 1 mm in lead III, minimal ST segment depression in aVL and V2-V3 leads, followed in less than 2 hours by ST segment elevation in II, III, aVF leads. In this patient, WS was diagnosed in a timely manner, urgent coronary angiography was performed, 99% RCA stenosis was detected, and RCA stenting was performed. The outcome is left ventricular inferior wall non-Q wave MI. The last cited case of WS indicates that this syndrome develops not only with AIA damage, but also with damage to other coronary arteries.

OA03 Trauma secondary to a horse riding accident as a potential accelerating factor in inflammatory axial sponyloarthropathy: a case report and literature review

Abstract Introduction Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease characterised by axial involvement and sacroiliitis. The etiology of AS remains elusive, with genetic and environmental factors implicated in disease development and progression. This case report aims to investigate the potential association between trauma and the acceleration of AS in individuals positive for HLA-B27. Furthermore one purpose of this case-report is to ascertain any link between horse riding accidents in jockeys or professionals undertaking horse riding as a career choice. Is there a correlation between trauma and development of inflammatory axial spondyloarthropathy subsequently or not. Case description A 24-year-old female patient with a medical history of eczema and Graves' disease, currently undergoing propylthiouracil treatment, was referred to the rheumatology clinic due to persistent back pain for the past six to seven years following a horse riding accident. The patient had previously received physiotherapy and found relief with naproxen and co-codamol. The pain primarily affects her lower spine and radiates down her legs. While movement provides some relief, lying down exacerbates the pain. The patient experiences stiffness for approximately 30 minutes in the morning but does not exhibit peripheral joint symptoms. Exercise helps alleviate her symptoms. The patient reported a family history of psoriasis but denied any history of uveitis, inflammatory bowel disease, weight loss, night sweats, heartblock or achilles tendinitis. She also gave a history of joint hyper mobility with reduced flexion at the spine over the years. Blood tests revealed normal levels of ANA, CCP, ESR, rheumatoid factor, B12, HbA1c, and thyroid function. Ferritin levels were 30.2, and HLA B27 was positive. Joint examination did not reveal any signs of synovitis. The patient exhibited good range of motion in the spine. SLR's were positive on both sides and no tenderness over spine or sacroiliac joints. Systemic Examination was normal. BASDAI score was 4. Occiput to wall distance of 0 centimeters. Beighton score 4/9. Subsequently MRI whole spine/SI Joints were organised and results indicated a central disc protrusion at the L4-L5 level leading to critical spinal stenosis and likely impinging on the transitioning L5 and S1 nerve roots. Additionally, a disc protrusion at the L5-S1 which was impinging on the left S1 nerve root. Bilateral sacroiliitis was also observed. Patient was treated with NSAIDs and physiotherapy with good results with a view for a subsequent MRI, and escalation to biologics if symptoms were to worsen. Discussion The presented case raises the question of whether trauma accelerates the progression of ankylosing spondylitis (AS) in individuals who are positive for HLA-B27. Although this specific case involves a 24-year-old female patient with a history of back pain following a horse riding accident, additional research and studies would be required to draw definitive conclusions regarding the relationship between trauma and the development or acceleration of AS in HLA-B27 positive individuals. The question this case report poses and there is little in terms of research and case reports present, whether the involvement of the lady in question in a horse riding accident unmasked her ankylosing spondylitis given her HLA B27 positivity and the presence of sacroilitis on MRI scans. Literature review revealed a potential role of trauma accelerating the progression of ankylosing spondylitis in individuals who are also positive for HLA B-27, in addition in some cases it lead to detection and unmasking of chronic back pain which was inflammatory in nature rather than mechanical or a combination of both. This was revealed by the horse riding accident given the nature of the pain which had been constant and worsening which lead to a suspicion of a possible inflammatory component and hence further investigations were done. In conclusion this case report highlights the importance of a possible correlation between AS in HLA B27 positive individuals and raises the question whether trauma secondary to sports injuries like horseback riding accidents in our patients case, accelerates the progression of AS in individuals who are positive for HLA-B27. Key learning points This case report highlights the potential role of trauma following a sports injury as a contributing factor in the acceleration of AS in individuals positive for HLA-B27. Further investigations, including prospective studies, are warranted to elucidate the complex interplay between trauma, genetic predisposition, and disease progression in AS. The purpose of this case report is to remind sports medicine physicians of the prevalence of rheumatologic diseases in general and ankylosing spondylitis in particular and of the various ways in which spondyloarthropathies may present in athletes/sports personnel. Increased suspicion may lead to earlier diagnosis and treatment, potentially reducing illness severity and duration and improving the performance of athletes with this condition.

Drug-induced arterial hypertension in a patient with ischemic stroke

Progressive ischemic stroke is the most frequent form of stroke with neurologic deterioration. The pathogenesis of progressive ischemic stroke is based on the expansion of the brain infarction zone and reduction of the "penumbra" zone in the area of focal ischemia. The leading role in maintaining the balance between irreversible and reversible ischemia belongs to cerebral collateral blood flow. Being a multifactorial phenomenon, collateral blood flow is caused by both morphological and functional characteristics of the collateral arterial channel and systemic factors, among which hemodynamics is of great importance. The tactic of purposeful increase in blood pressure to improve cerebral perfusion is called drug-induced arterial hypertension. A number of experimental studies have demonstrated the safety and efficacy of this method, but the small number and heterogeneity of data in the studies do not allow us to conduct a meta-analysis and form an optimal protocol for drug-induced arterial hypertension. In this article we want to describe the clinical observation of a patient with ischemic stroke on the background of critical stenosis of stroke-related internal carotid artery and atrial fibrillation, in the treatment of which we applied drug-induced arterial hypertension.

The role of myocardial perfusion imaging in predicting myocardial ischemia in patients diagnosed with long COVID.

Incomplete recovery with long-term complications weeks beyond the acute coronavirus disease 2019 (COVID-19) infection is referred to as long COVID. Among the well-known long-term complications of COVID-19, myocardial damage is a frequently encountered side effect. Yet there is a lack of data for identifying high-risk patients who are more likely to develop long-term cardiovascular complications following COVID-19. Myocardial perfusion imaging (MPI) is the primary functional imaging modality in evaluating myocardial ischemia This study aimed to investigate the role of MPI in predicting myocardial ischemia in patients diagnosed with long COVID. Subjects were selected from eligible long COVID patients and control subjects without a prior history of COVID-19 who were referred to the nuclear medicine department for stress and rest single-photon emission computed tomography (SPECT) MPI. All participants' past medical records and clinical, and demographic characteristics were scanned. In addition, patients undergoing coronary angiography (CAG) following SPECT MPI were documented and patients with critical coronary stenosis were identified. Our results revealed that long COVID patients had higher rates of abnormal summed stress scores compared to the control subjects (p < 0.05). Additionally, serum CRP level, SPECT lung-to-heart ratio (LHR), and the presence of long COVID were independent predictors of ischemia. The presence of long COVID was the best predictor of ischemia among the aforementioned parameters (p < 0.001). Our data indicate that SPECT MPI provides comprehensive information on myocardial perfusion and left ventricular function in long COVID patients.

Interventional correction of critical stenosis of the anterior descending artery in an old patient with severe comorbidity and small vessel

We present a clinical case of successful endovascular correction of critical stenosis of the anterior descending artery using a drug-eluting stent in an old patient with comorbidities. A 91-year-old man with non-ST elevation acute coronary syndrome (NSTE- ACS) with severe comorbidity underwent successful percutaneous coronary intervention (PCI). Critical 95% stenosis of the left anterior descending artery (LAD) and multiple lesions of other coronary arteries were revealed by coronary angiography. Resolute Integrity 2.25 × 18 mm drug-eluting stent (DES) was inserted successfully in LAD. The patient was discharged in symptom-free stable condition. Keywords: acute coronary syndrome, very elderly patient

Ross-Konno procedure as a rescue operation in a newborn with critical aortic stenosis.

Ross-Konno procedure as a rescue operation in a newborn with critical aortic stenosis.

Assessment of Right Ventricular Reverse Remodeling in Infants with Critical Pulmonary Stenosis after Balloon Pulmonary Valvuloplasty Using 3D Echocardiography

Abstract Aim and Objectives The aim of this study is to identify role of 3D echocardiographic assessment of RV volumes and function in infants with critical pulmonary stenosis undergoing balloon pulmonary valvuloplasty pre and post dilatation, the immediate and intermediate term outcome of relieving obstruction on RV volumes Patients and Methods The study included all infants who were referred for elective or urgent BPV in the congenital and structural heart disease Unit, Cardiology department, Ain Shams University because of critical pulmonary stenosis and are followed for 3-6 months after the procedure since first of December 2020 till end of august 2021. Results sixty infants with critical PS with a median age of 8.5 months were subjected to BPV, immediately after the procedure there was significant reduction in RVSP (P &amp;lt; 0.01), there was significant increase in TAPSE, Annulus and FAC by 2D echocardiography immediately post procedure and at 3-6 month follow up (P &amp;lt; 0.01), while there was significant decrease in PG immediately post procedure and throughout a follow up period of 3-6 month (P &amp;lt; 0.01), The indexed RV wall thickness and indexed RA area showed no significant change between pre and immediately post procedure while there was significant decrease at 3-6 month than pre and immediately post (P &amp;lt; 0.01), The indexed End-Diastolic and End systolic volumes by 3D Echocardiography decreased insignificantly immediately post procedure (P = 0.421) (P = 0.317) respectively while it decreased significantly at 3-6 month follow up (P &amp;lt; 0.05), The right ventricle Ejection fraction, FAC and TAPSE by 3D echocardiography increased significantly immediately post procedure and throughout a follow up period of 3-6 month (P &amp;lt; 0.01), The Basal RV dimension by 3D echocardiography decreased insignificantly immediately post procedure (P = 0.057)while there was significant decrease at 3-6 month than pre and immediately post (P &amp;lt; 0.01), The mid RV dimension and Longitudinal RV dimension by 3D Echocardiography decreased significantly immediately post procedure and at 3-6 month follow up (P &amp;lt; 0.01). Conclusion BPV is safe and effective to relieve critical PS. The balloon promotes advantageous changes in pulmonary annulus RVSP, PG and FAC by two dimensional echo across the RVOT. In addition, the Doppler gradient observations during the follow-up support the expectation that BPV is a ‘curative’ therapy and Three-dimensional echocardiography is an effective method to assess RV volumes and function Abbreviations RV: Right ventricle; CHD: Congenital heart disease; BPV: Balloon pulmonary valvuloplasty; LV: Left ventricle; PS: Pulmonary stenosis; HF: Heart failure; RVSP: Right ventricle systolic pressure; ASD: Atrial septal defect; TAPSE: Tricuspid annular peak systolic excursion; PFO: patent foramen ovale; FAC: Fractional area change; VSD: Ventricular septal defect; PG: Pressure gradient; PDA: patent ductus arterioses; RA: Right atrium; RVES: Right ventricle end systole; RVOT: Right ventricle outflow tract; RVED: Right ventricle end diastole; CMR: Cardiac magnetic resonance

Endoscopic Ultrasonography-Guided Biliary Drainage: Experience of a Moroccan Center

Background: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a relatively new therapeutic modality in the arsenal of endoscopists for attaining satisfactory biliary drainage when traditional ERC fails. The aim of our study is to describe the first Moroccan experience with EUS-BD in patients with malignant biliary obstruction after a failed or inaccessible ERCP. Methods: This is a retrospective study conducted at Ibn Sina Hospital, from Mars 2018 to July 2022, which include 27 patients with an inoperable or metastatic malignant biliary obstruction who underwent endoscopic ultrasonography-guided biliary drainage (EUS-BD) in case of endoscopic retrograde cholangiopancreatography (ERCP) failure. Results: From a total of 288 patients with malignant biliary obstruction,27 underwent EUS-BD (9,3%), 15 EUS-guided hepaticogastrostomy (55,5%) and 12 EUS-guided choledocoduodenostomy (44,4%) were performed. The mean age was 62.5 years (age range: 23-74 years), a male predominance of 59% was noted, cholestatic jaundice was present in 100% of patients and associated with pruritus in 92.59% of cases. The mean level of Total Bilirubin was 190 mg/l. The causes of biliary obstruction were: an inoperable pancreatic head mass in 13 patients(48,1%), a cholangiocarcinoma in 7 patients (25.9%), an ampullary mass in 4 patients(14,8%), a gallbladder cancer with hepatic and duodenal invasion in one patient (3,7%), a gastric antropyloric adenocarcinoma with pancreatic head invasion in one patient (3,7%) and Duodenal adenocarcinoma in one patient (3,7%).The leading causes of failed ERCP were secondary to tumor infiltration of the duodenal wall and critical duodenal stenosis in 11 cases (40,7%), in 9 cases due to a difficult cannulation (33.3%) and in 7 cases due to a failure to pass the stricture by ERCP (25.9%). In EUS-HG The technical and the clinical success rates were 86.6% (13/15) and 84.6% (11/13), respectively, the complication rate was 13.3% (2/15) including one case of stent migration complicated with bile leak and one case of cholangitis. In EUS-CD The technical and the clinical success rates were 91.6% (11/12) and 81.8% (9/11)), respectively, the complication rate was 16.6% (2/12) including two cases of cholangitis. The technical and the clinical success rates in all EUS-BD were 85.1% (24/27) and 83.3% (20/24), respectively. The complication rate was 14.8% (4/27). Conclusion: EUS-BD appears to be an effective and safe therapeutic option for biliary decompression in cases where ERCP fails.

Critical Stenosis Because of Vocal Cord Synechiae in a Child

Stridor is a clinical sign of an underlying disease and a common reason for pediatric emergency department (PED) consultation. Patients presenting with stridor must be evaluated to determine the origin of this abnormality. We present the case of a 7-year-old female patient who presented to our Pediatric Emergency Department with a history of recurrent episodes of stridor with increasing frequency over the previous 4 years, for this reason she was previously admitted to the pediatric intensive care unit. Findings from the otorhinolaryngologic assessment with flexible fiber-optic endoscopy led to a diagnosis of congenital synechia of the vocal cords. The cervical CT scan evidenced critical stenosis of the airway. An initial cordectomy and placement of a silicone device for fixation were performed. Subsequently, the patient required 6 additional interventions for progressive dilation of the glottic space at the level of the vocal cords and injections of mitomycin C injections (an antineoplastic that inhibits collagen proliferation). This case highlights the importance of additional studies (especially examination of the upper airway) when atypical or recurrent findings are revealed by the clinical history, physical examination, or disease course in patients with croup to prioritize cases severe enough to require pediatric intensive care unit admission.

Concomitant Intubation with Minimal Cuffed Tube and Rigid Bronchoscopy for Severe Tracheo-Carinal Obstruction.

Our aim was to report on the use of an innovative technique for airway management utilizing a small diameter, short-cuffed, long orotracheal tube for assisting operative rigid bronchoscopy in critical airway obstruction. We retrospectively reviewed the clinical data of 36 patients with life-threatening critical airway stenosis submitted for rigid bronchoscopy between January 2008 and July 2021. The supporting ventilatory tube, part of the Translaryngeal Tracheostomy KIT (Fantoni method), was utilized in tandem with the rigid bronchoscope during endoscopic airway reopening. Indications for collateral intubation were either tumors of the trachea with near-total airway obstruction (13), or tumors of the main carina with total obstruction of one main bronchus and possible contralateral involvement (23). Preliminary dilation was necessary before tube placement in only 2/13 patients with tracheal-obstructing tumors (15.4%). No postoperative complications were reported. There was one case of an intraoperative cuff tear, with no further technical problems. In our experience, this innovative method proved to be safe, allowing for continuous airway control. It enabled anesthesia inhalation, use of neuromuscular blockage and reliable end-tidal CO2 monitoring, along with protection of the distal airway from blood flooding. The shorter time of the procedure was due to the lack of need for pauses to ventilate the patient.

An Interesting Case of Wellens Syndrome Dissimulating an Acute Coronary Sub-Occlusion

Wellens syndrome is an electric pattern highly specific of critical stenosis of the proximal LAD. It’s defined by abnormalities of T waves in V2-V3 : type 1 (biphasic T waves), type 2 (negative T waves). Wellens also does not show signs of infarction by definition. Our work is about a young man of 33 yo who accused quickly resolving chest pain. His EKG showed biphasic T waves in V2 V3 V4 and V5 and negative T waves in DI aVL with 0,3mm ST suspension. His T waves kept changing: disappearing in V5 and becoming less negative in other derivations. The cardiac catheterization showed tight lesion of the ostium of proximal LAD artery with a high thrombotic load. Patient was put under glycoprotein IIb/IIIa inhibitors and taken back to the cath-lab 1 week after for PCI (percutaneous coronary intervention) which was successful. First we want to discuss electrical findings. T waves inversion extended to V4 V5, which is uncommon. We have also to put forward the abnormalities we found in high lateral territory. Other particularity of our patient is the dynamic EKG showing he was threatening. Furthermore, definitive treatment typically involves cardiac catheterization with PCI to relieve the occlusion and there’s no place for stress tests. Wellens syndrome is a real challenge, which is underdiagnosed and needs more attention from emergency physicians. The interest of thrombolysis in this pre-infarction condition still needs to be substantiated.