Critical Stenosis Research Articles

P245 IMPLICATIONS IN PHARMACOLOGICAL AND ELECTRICAL OPTIMIZATION IN HEART FAILURE: A EMBLEMATIC CASE

Abstract We describe the case of an 82–year–old man with permanent atrial fibrillation in oral anticoagulation therapy. Former smoker. Diabetes mellitus. In 2009, subacute MI with PTCA/DES of anterior descending artery and obtuse marginal branch, critical stenosis of circumflex artery, right coronary artery occluded. Infrarenal aorta occlusion. Echocardiography TT mild–moderate mitral regurgitation. Ejection fraction (EF) preserved. Inferior wall akinesia. In 2019 hospitalization for heart failure due to severe bradyarrhythmia in atrial fibrillation. In therapy with bisoprolol 10 mg/day Echocardiography FE 35%, moderate–severe functional mitral regurgitation, PAPs 55 mmHg. Arterial pressure 100/85 Sat 2O 90% Treatment at discharge: furosemide 75 mg/day, bisoprolol 7,5 mg/day, Metformina 500 mg/day, potassium canrenoate 50 mg/day atorvastatin 40 mgday and warfarin,Ramipril 2.5 mg/day, allopurinol 150 mg/day. In 2020 new hospitalization for heart failure. NYHA III–IV; BNP 1890 pg/ml. Beta–blocker therapy reduced to bisoprolol 3.75 day for pulmonary hypertension and bradycardia, furosemide increased to 100 mg/day, possibly further titratable on the basis of renal function, blood electrolytes and clinical response, maintaining restriction of daily liquids at about 1000 cc. Initiated Sacubitril/Valsartan 24/26 mgx 2 /day. Coronary angiography was not possible due to occlusion of the abdominal aorta and right radial artery (1,2,3). CT CORO performed with relief of the interventricular branch occluded in the middle section; patent obtuse marginal branch stent; right coronary artery occluded. Abdominal aorta occluded at the level of the renal arteries. The patient was submitted to CRT–D implant for bradycardia and wide QRS like left bundle branch block. Glyphozine associated with Metformin. Echocardiography TT LVEF 40%, moderate functional MR, PAPS 35 mmHg. NYHA II. Edema resolution No hospitalizations for decompensation. titrated ARNI at 49/51 mg x 2/day, and the beta blocker Cardicor 5mg/day. At remote monitoring decreased ventricular catheter impedance. What does the case tell us? The combination of Sacubitril/Valsartan and Glifozine determined an inverse remodeling of the heart. The combination of Sacubitril/Valsartan and Glifozine improved cardiac compensation and clinically stabilized the patient.

P166 LEFT VENTRICULAR SUMMIT PVC–INDUCED CARDIOMYOPATHY: A CASE REPORT

Abstract A 76 y.o. patient referred to our attention for syncopal and presyncopal episodes. His ECG showed several premature ventricular contractions (PVC) with the morphology of a right bundle branch block (RBBB)– positive concordance in precordial leads and transtion in V3 lead– and an inferior axis. Echocardiographic finding was a moderate reduced ejection fraction. Furthermore coronarography did not identify critical stenosis, excluding an ischemic etiology. Cardiac MRI was performed, confirming the reduce ejection fraction and excluding LGE. Because of high burden of 25000 PVCs on 24 h ECG registration and progressive deterioration of ejection fraction, despite antiarrhythmic drugs, catheter ablation was considered. An high density multielectrode mapping catheter was used and an initial right ventricular mapping was perfomed, recording local electrograms but without identification of a clear earliest site of activation. Therefore a retrograde transaortic left ventricular mapping was performed. Earliest site of activation was not significant (about 15 milliseconds), as well as percentage of correlation during pace–mapping. Epicardial mapping through coronary sinus into the anterior interventricular vein (AIV) showed a significant earliest activation site (greater than 30 ms) and a negative unipolar signal (QS) was detected. Pacing in this region highlighted a significant percentage of correlation with native PVC (92%), then catheter ablation was attempted. A first short duration application of radiofrequency was erogated on the endocardial side in front of the projection of the catheter in the AIV, because of possible risks of procedure, obtaining a temporary PVC suppression. Subsequently, after execution of a coronary angiogram proving a distance of the ablator in AIV and IVA/Cx vessels greater than > 1 cm, an endovenous approach was attempted with application of radiofrequency into the AIV, obtaing complete PVC suppression. At a 6 months follow–up ejection fraction improved (FE 50%) and PVC were not detected. Discussion Epicardial approach throught coronary sinus is an effective strategy to map and ablate arrhythmias of left ventricular summit. In addiction this stretegy allows a less invasive epicardial approach than other procedures, requiring a cardiosurgery standby.

P39 MANAGEMENT OF A CASE OF LAST REMAINING PATENT VESSEL

Abstract A 72–year–old hypertensive, dyslipidemic and smoker (20 cig/day) gentleman was admitted to the emergency department for pulmonary edema. Past medical history included COPD, anterior MI treated with PCI and stenting of proximal LAD 5 years back, recent TIA. He was admitted to cardiac intensive care unit and treated with CPAP, IV furosemide and norepinephrine. Echocardiogram showed severe ventricular dysfunction (LVEF 20%) and severe functional mitral regurgitation; lab tests pointed out mild troponin elevation (50 ng/L) and high levels of BNP (1300 pg/mL). After stabilization, he underwent coronary angiography: in–stent CTO of LAD, critical stenosis of distal LM and ostio–proximal LCX (last remaining patent vessel, LRPV); hypoplastic RCA. At the end of angiography, new episode of pulmonary edema that required treatment with inotropes, CPAP and diuretics. Considering hemodynamic instability and high surgical risk (combined STS 37%), the Heart Team decided to proceed to PCI with mechanical circulatory support with Impella CP. From left radial access we achieved advancement of JR4 guiding catheter with guide extension in right common iliac artery. We performed angiography and then put a coronary guidewire in superficial femoral artery to facilitate right femoral access (angio–guided). From this femoral access we implanted Impella CP device. From left radial access we performed PCI: cannulation with JL 3 guiding catheter, wiring with Sion Blue ES guidewire, pre–dilatation with NC balloons until 3.0 mm diameter, stenting of LM–LCX with 1 DES 4.0/32 mm, post–dilatation with NC balloons (4.5 and 5.0 mm diameter). Good angiographic result; IVUS examination revealed good expansion and apposition of stent. Femoral access was closed with 2 Perclose Proglide. Patient was then monitored in cardiac intensive care unit, with clinical improvement and without complications. 10 days after PCI the patient, asymptomatic, was discharged. The echocardiogram displayed betterment of contractile function (LVEF 28%) and of mitral regurgitation (now moderate). At 4–month follow–up visit, patient is paucisymptomatic (NYHA class II), without angina episodes, with good quality of life in guideline–directed optimal medical therapy. Critical disease of LRPV is a severe condition, with unpredictable evolution and poor prognosis. PCI of LRPV in HFrEF patients is an high–risk PCI scenario in which mechanical circulatory support with Impella can prove to be essential.

P475 RECURRENT CORONARY ARTERY VASOSPASM COMPLICATED BY CARDIAC ARRESTS IN HEART TRANSPLANT RECIPIENT: AN UNUSUAL ENEMY

Abstract Even if coronary vasospasm (CV) is considered a rare phenomenon in heart transplant (HT) recipients, during routine coronary angiography asymptomatic CV may be observed. We report the case of a 30–year–old male who underwent HT in 2007 for dilatative cardiomyopathy. He was maintained on tacrolimus and mycophenolate mofetil and had no significant rejection or coronary allograft vasculopathy (CAV) demonstration. In December 2020 patient presented with cardiac arrest preceded by angina. Coronary angiography demonstrated diffuse spasm of the right coronary artery (RCA) with resolution after intracoronary nitrate administration. An endomyocardial biopsy (EBM) revealed no signs of cellular rejection whilst cardiac magnetic resonance showed signs of acute rejection (Fig.1). Moreover, two major histocompatibility complex (MHC) Class 2 donor–specific antibodies (DSAs) were positive with a high title. Treatment for antibody–mediated rejection (AMR) was initiated with steroids and plasmapheresis, followed by immunoglobulin infusion. Cardiac defibrillator was implanted before discharge. In August 2021, patient experienced a second cardiac arrest. Left heart catheterization found diffuse CV and after nitrates administration, proximal critical stenosis of RCA was pointed out and treated with stent insertion (Fig. 2–3). EMB and DSAs assessment were both negative. The patient was discharged after medical therapy optimization for CV prevention including the switch from mycophenolate to everolimus. After two more episodes of ACS with angiography finding of CV we decided to empirically treat the patient with weekly photopheresis sessions. Despite aggressive AMR management, a third ACC occurred in March 2022. The patient was finally reintroduced to the HT waiting list. Most CV episodes run without any symptoms due to the denervated heart post–transplant so probably re–innervation occurred in our patient. Calcium channel blockers, nitrates, and beta–blockers failed in CV prevention, suggesting ineffectiveness in HT recipients because of a different pathogenetic mechanism when compared to healthy subjects. Furthermore, documentation of coronary disease progression after the second ACC supports the hypothesis that CV could be the first manifestation of CAV. An intriguing hypothesis would be the presence of pathological vasoreactivity in the donor‘s heart, ascribable to an “inherited” endothelial dysfunction that could last be exacerbated by multiple factors, including AMR.

Management of Cerebral 4-Vessel Disease With Anterior Circulation Symptoms by Stenting Both Vertebral Arteries at the Same Session.

Stroke is among the leading causes of mortality and morbidity worldwide. The coexistence of bilateral carotid and vertebral artery (VA) occlusion and/or stenosis is in the very rare entity group in the literature. Here, we present a case with bilateral carotid artery occlusion and bilateral VA stenosis, who presented with an atypical clinical presentation and underwent bilateral vertebral percutaneous transluminal angioplasty (PTA) and stenting in the same session. A 67 year old male patient was brought to the emergency department with complaints of inability to speak and weakness in both legs for 1 day. There were bilateral infarct areas in the anterior cerebral artery region and an additional infarct area in the left middle cerebral artery region. First, the right VA stenosis level was crossed using a 0.14 guidewire. After PTA, balloon-expandable stenting was performed with a 3.0×12 mm NC (non-compliant) balloon, and nearly complete recanalization was observed. Therefore, it was decided to perform an intervention on the left VA in the same session. As in this example case, in cases where cerebral perfusion is severely impaired, medical treatment after recanalization may be one of the best treatment options. The carotid arteries are the main arteries supplying the anterior circulation, and the vertebral arteries supply blood to the posterior circulation. However, in cases where both carotid arteries are occluded/dysfunctional, all cerebral perfusion remains over the vertebrobasilar system. However, in cases such as this, where both carotid arteries are occluded/dysfunctional, all cerebral perfusion remains over the vertebrobasilar system and may be responsible for anterior circulation strokes. The situation becomes more severe if both vertebral artery critical stenosis is added. Synchronous carotid and vertebral artery revascularization is not recommended in the guidelines for patients with combined carotid and vertebral artery disease. In patients with four-vessel occlusion/stenosis, as in this particular case, the intervention method and priorities are unclear. We achieved a favorable clinical outcome with simultaneous bilateral vertebral artery angioplasty and stenting, a hazardous method that can be a guide as an approach option in similar cases.

A case report on : Wellens syndrome- The widow maker

Wellens syndrome refers to typical clinical electrophysiological presentation in patient with critical LAD stenosis . This rare entity is often missed if unrecognized and has considerable implications due to critical stenosis associated with it. It is also knwon as “The Widow Maker”. It is further divided into Type A and B, type A is recognized by biphasic T-waves in leads V2 and V3, while Type B is characterized by deeply symmetrical T-wave inversions in leads V2 and V3, often including leads V1 and V4 and sometimes leads V5 and V6 . It is important to recognize this as symptoms are intermittent and often do not correlate with clinical severity. PCI is the management of choice. Here we present a case of Wellens syndrome who presented in our Institute with typical history found associated with it.

Treatment of Congenital Afibrinogenemia in a Neonate With Critical Pulmonary Stenosis.

Fibrinogen deficiencies in neonates can lead to bleeding complications. In this report, we describe a case of congenital afibrinogenemia in a newborn with critical pulmonary stenosis who presented with bilateral cephalohematomas after an uncomplicated delivery. The initial use of cryoprecipitate was followed by administration of fibrinogen concentrate. We estimated a half-life of 24 to 48 hours with the concentrate product. This patient received fibrinogen replacement and had a subsequent successful cardiac repair. The drug's shorter half-life in this neonate contrasts with prior reports of longer half-life in older patients and is important to note in treating future neonatal patients with this diagnosis.

A tale of two ASDs-Compliance matters.

Key Points Patients with secundum atrial septal defects (ASDs) who have pulmonary atresia with intact ventricular septum or critical pulmonary stenosis, exhibit different ASD physiology compared to patients with isolated secundum ASDs. The indication and timing of secundum ASD closure in these patients should be made on a case‐by‐case basis. Long‐term assessment of the physiological consequences of secundum ASD closure in this group of patients should be kept in mind, as these patients have right ventricles that represent a spectrum ranging from significantly restrictive right ventricles, to right ventricles with normal compliance.

Clinical outcomes of percutaneous balloon valvuloplasty in patients with critical mitral stenosis

Background: Clinical outcomes after percutaneous balloon valvuloplasty in patients with critical mitral stenosis is challenging and widely discussed. Aim of the study was to analyze the results of balloon mitral valvuloplasty (BMV) using the Inoue technique in patients with critical mitral valve stenosis. Material and Methods: From January 2020 to 2022, balloon mitral valvuloplasty was performed in 31 patients with critical mitral valve stenosis using the Inoue technique. There were 14 men (45.2%), women - 17 (54.8%). The patients were aged from 19 to 59 years, on average 42.4±6.1 years. All patients data were analyzed to evaluate the possible outcomes. Results: In 30 (96.4%) patients, a successful BMV was performed. In 1 (3.2%) patients, PMV failed, including puncture was unsuccessful, and it was not possible to pass a balloon catheter from the LA to the LV through the critically narrowed mitral valve opening. These failures took place at the initial stages of mastering the technique. A lethal outcome was noted in 0 (0.0%) case. In all 30 (96.8%) patients after BMV, positive results were obtained: the area of the mitral orifice increased by an average of 2.5 times, from 0.85±0.17 to 2.16±0.76 cm2 (p< 0.001), the maximum gradient at the level of the mitral valve decreased by 60.5%, on average from 26.9±2.95 to 8.9±0.6 mm Hg. (p<0.0001). The maximum pressure in the LA statistically significantly decreased from 40.29±6.01 mm Hg. Art. up to 21.43±3.83 mm Hg (p<0.05), in LA - from 49.7±10.9 to 29.7±8.2 mm Hg. (p<0.05). According to EchoCG data, regurgitation on the mitral valve after BMV appeared in 6 (24.1%) patients up to I degree, in 1 (3.2%) - up to II, and in 1 (3.2%) - up to III. In 16 (61.5%) of 26 patients with initial mitral insufficiency after BMV, the degree of regurgitation remained at the same level, in 8 (30.7%) the latter increased to II, in 2 (7.7%) - to III degree. Conclusion: BMV using the INOUE technique is a highly effective minimally invasive treatment method, accompanied by a low morbidity and mortality rate.

Modern views on treatment of critical mitral stenosis

Mitral stenosis - narrowing of the left atrioventricular orifice due to fusion of the leaflets of the bicuspid valve, changes in subvalvular structures and fibrous degeneration of the valve ring. This creates obstacles to the flow of blood from the left atrium and is accompanied by a decrease in stroke volume and cardiac output. Mitral stenosis leads to pulmonary hypertension syndrome. This review provides an update on rheumatic mitral stenosis, its possible causes, clinical picture diagnosis and modern treatment options in the evolving world. The latest therapeutic approaches, including lifestyle changes, medical, surgical, and transcatheter valvular interventions including percutaneous transcatheter mitral valvuloplasty will be discussed.

Clinical outcomes of percutaneous balloon valvuloplasty in patients with critical mitral stenosis

Clinical outcomes of percutaneous balloon valvuloplasty in patients with critical mitral stenosis

The Comparative Assessment of Wellens' Syndrome With Proximal Left Anterior Descending Artery (LAD) Stenosis Versus Right Coronary Artery (RCA) or Circumflex Coronary Artery Stenosis and Its Prevalence: A Systematic Review.

Wellens'syndrome is well-known for its critical stenosis of the proximal left anterior descending artery (LAD) with characteristic electrocardiographic findings of biphasic or deeply inverted T waves in V2-V6 under specific diagnostic criteria. Although the syndrome is known as a high-grade LAD lesion, its sequence of events can also be seen with the right coronary artery (RCA) and the left circumflex artery (LCX). This systemic review attempts to expand on these findings while analyzing the prevalence of Wellens' syndrome with the RCA and/or the circumflex artery. This study also comparatively indicated that Wellens'syndrome is seen in RCA and circumflex arterystenoses when present; the indication of the same medical management is warranted for effective treatment and survival. We extracted and analyzed 24 case reports each with an atypical presentation of acute coronary syndrome (ACS) and specific Wellens'syndrome pattern of electrocardiogram (ECG) presentation with critical stenosis in the LAD, RCA, and left circumflex artery.The risk of bias assessment was undertaken using internal risk analysis by utilizing medical libraries and certain search phrases to find research articles with the involvement of the LAD as opposed to the RCA and LCX in Wellens' syndrome. Based on the number of respective primary research articles found, a bias calculation was done on the reported respective coronary artery involvement. The finding of our systemic review confirms that Wellens'syndrome is a precordial lead disease with T wave abnormalities that presentwithcritical stenosis of not only the LAD but also the RCA and circumflex artery. The result of our systemic review affirmed that although most Wellens'syndrome cases reported involve the stenosis of the LAD, the critical occlusion of the RCA and/or the circumflex artery was found with Wellens'syndrome pattern of ECG presentation, meaning that the sequence of events is not limited to the proximal LAD.

Right bundle branch block evolving to myocardial ischemia in a patient with chronic middle back pain: a case report

BackgroundA right bundle branch block (RBBB) is rarely found in patients with myocardial infarction (MI). In addition, back pain is an atypical complaint in patients with angina.CaseA 77-year-old Javanese male was admitted with middle back pain that he had had for several months but that had become worse in the past week. He received an oral nonsteroidal anti-inflammatory drug as analgesic therapy but the pain did not improve. The patient came to the emergency room and an electrocardiogram (ECG) showed complete RBBB and first-degree atrioventricular block. Three days after hospital admission, his chief complaint of pain had worsened, and ECG showed new deep arrow-head inverted wave at V3–V6, II, III, and aVF, as well as infero-anterolateral ischemia. The coronary angiography revealed 95% critical stenosis in left circumflex artery.DiscussionIt is a challenge for clinicians to recognize and carefully assess a patient’s complaints even if they are admitted for pain that is “atypical” of MI. When ECG shows changes, clinicians need to pay attention to a tricky, hidden, and life-threatening occlusion of the coronary artery.

Characteristics of changes in the coronary arteries in patients with acute coronary syndrome on the background of chronic obstructive pulmonary disease

Aim. Study of the nature and characteristics of changes in the coronary bed in patients with acute coronary syndrome (ACS) and chronic obstructive pulmonary disease (COPD).Materials and methods. The study included 85 patients with ACS: group 1 included 47 patients with ACS and COPD, group 2 included 38 patients with ACS. All patients underwent a comprehensive clinical, instrumental and laboratory examination.Results. In the majority of patients of group 1 (76.6%), two- and three-vessel lesions of the coronary bed were revealed, and arterial stenoses were multiple, located mainly in the middle and distal parts of the arteries. In (76.3%) patients of the 2nd group, one- and two-vessel lesions of the coronary bed with localization of stenoses mainly in the proximal and middle segment of the coronary arteries (CA) were revealed. The total number of stenosis and hemodynamically significant stenosis was higher in group 1 compared to group 2 (p=0.01). Extended stenoses were more common in group 1 patients (p=0.04). Damage to the CA of the 2nd order was also higher in the 1st group of patients (p=0.01). The 1st group was divided into two subgroups: 1A (26 people) − patients with COPD of moderate severity and 1B (21 people) − patients with severe COPD. In patients of subgroup 1B, a more significant lesion of the coronary bed was noted due to an increase in the total number of stenoses (p=0.02), hemodynamically significant stenoses (p=0.01), localized in the proximal (p=0.04) and distal (p=0.02) segments of the coronary artery, in the branches of the 2nd order (p=0.02), as well as occlusions and critical stenoses of the coronary artery (p=0.02).Conclusion. The severity of COPD in patients with ACS significantly affects the number of hemodynamically significant proximal and distal stenoses, as well as branches of the second order coronary arteries, which reduces the effectiveness of surgical treatment and worsens the prognosis of patients with comorbidities.

Fetal cardiac interventions: First‐year experience of a tertiary referral center in Turkey

To present the first-year experience of fetal cardiac interventions (FCIs) in a tertiary referral hospital and to evaluate the outcomes. This retrospective study consisted of four pregnant women who underwent fetal pulmonary or aortic balloon valvuloplasty between November 2020 and June 2021. The procedures were performed with a percutaneous cardiac puncture under the ultrasonography guidance. Gestational age at intervention, procedural success, complications, and perinatal outcomes were evaluated. Procedural complications defined as fetal bradyarrhythmia requiring treatment, pericardial effusion requiring drainage, balloon rupture, and fetal death. The procedure was considered technically successful if the valve was dilated with a balloon catheter. Ultimately successful procedure was defined as the discharge of infants alive with biventricular circulation. A total of 5 FCIs attempted between 26 + 3 and 28 + 2 gestational weeks. While the procedure was technically successful in 2 cases with pulmonary stenosis, both attempts were unsuccessful in the fetus with pulmonary atresia. Although the procedure was technically successful in the patient with critical aortic stenosis, it ultimately failed. No fetal death occurred in our series and there were no procedure-related significant maternal complications. However, three interventions were complicated by fetal bradycardia and pericardial effusion necessitating treatment, and balloon rupture cropped up in one case. FCIs may lead to improving the likelihood of a biventricular outcome for selected fetuses. Careful selection of patients and centralization of experience are essential for obtaining favorable outcomes. Operators should be aware of procedural complications. Improved procedural techniques with a lower complication rate will be achieved through advanced medical technology and special balloon catheters.

A tale of 2 conversions: Dichotomous decision in the spectrum of Shone syndrome is still a dilemma

A tale of 2 conversions: Dichotomous decision in the spectrum of Shone syndrome is still a dilemma

Development of PR Restenosis after Percutaneous Balloon Pulmonary Valvuloplasty

Background: Pulmonary stenosis is not an uncommon congenital heart disease in our population. Various age groups present with severe pulmonary stenosis require intervention either surgical or percutaneous catheter-based. Often lifesaving surgical intervention is not feasible considering procedural risk, the patient’s physical condition, and young age. Percutaneous balloon pulmonary valvuloplasty is safe, effective, almost painless, economical, and less hospital stay in any age group with immediate and long-term success. This study aimed to analyze the rate of development of (Pulmonary Regurgitation) PR restenosis after Percutaneous Balloon Pulmonary Valvuloplasty (PBPV). Material Methods: This hospital-based prospective observational study was conducted in the Department of Paediatric Cardiology Combined Military Hospital (CMH), Dhaka from January to December 2021. 0-18 years aged 50 population with PS who were referred to the Paediatric Cardiology Department of CMH Dhaka during the study period were selected as study subjects as per inclusion criteria. The purposive Sampling technique was used in this study. Data were collected with a predesigned standard data collection sheet. Statistical significance was set as a 95% confidence level at a 5% acceptable error level. Categorical variables were expressed as frequency and percentages. Mean, standard deviation, and/or medians with interquartile ranges were used to express the continuous variables. Paired t-test was performed in categorical comparison. A p-value of <0.05 was considered statistically significant. Collected data were analyzed using SPSS Version 24. Written informed consent was taken from every parent. Ethical clearance was taken from the Ethics Review Committee of CMH Dhaka for conducting the study. Results: 50(6.39%) had isolated valvular PS. The international standard for the prevalence of isolated PS is 8-10% which is very close to this study’s result. In this study, male predominance was found with the male-female ratio of 3:2 though there was no gender dominance found in other studies. Out of 50 cases, 3(6%) are neonates,7(14%) are infants, 27 (54%) are 1-5 years aged, and 13(26%) are more than 5 years aged. A total of 13(26%) cases developed PR, and all 13 patients developed trivial PR on D1 echo, out of them 1 patient developed mild PR on D30 Echo but in D90 and D180 Echo patients persisted the same mild PR. Out of 50 cases, 46(92%) were successful and 4 cases were procedure failed. None of the successful cases developed restenosis. Out of 4 procedure failed cases 1 patient developed restenosis on D30 follow up and 2 patients develop restenosis on the D90 follow-up. At D180 follow up none of the patients developed restenosis. All the restenosis cases had dysplastic pulmonary valves. One patient’s PS gradient persisted at 30-50 mm of Hg throughout the follow-up period. Overall restenosis in 180-day follow-up is 3(6%) and the remaining 47(94%) cases lead a healthy life in 6 months follow-up. Reballooning was done immediately after diagnosis of restenosis in stenosed cases. Conclusion: Immediate and intermediate-term (6 months) follow-up with Doppler echocardiography showed excellent outcomes in all cases except 3 (6.0%) restenosis cases and 13 (26.0%) insignificant PR cases. The baby who all had restenosis, had the risk factor, like- dysplastic PV. It may be concluded that balloon valvuloplasty is the procedure of choice for moderate, severe, and critical pulmonary valve stenosis.

The outcomes of fetal aortic valvuloplasty in critical aortic stenosis: A systematic review and meta-analysis

BackgroundCritical aortic stenosis that appears in mid-gestation tends to develop to growth retardation of left ventricle, known as hypoplastic left heart syndrome (HLHS). Despite better clinical management of HLHS, the morbidity and mortality rates of univentricular circulation patients remain high. In this paper, we sought to perform a systematic review and meta-analysis to know the outcomes of fetal aortic valvuloplasty in critical aortic stenosis patients. MethodsThis systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. A systematic search on fetal aortic valvuloplasty procedure for critical aortic stenosis was performed through PubMed, Scopus, EBSCOhost, ProQuest, and Google Scholar. The primary endpoint of each group was overall mortality. We used R software (version 4.1.3) to estimate the overall proportion of each outcome using random-effects model of proportional meta-analysis. ResultsA total of 389 fetal subjects from 10 cohort studies were included in this systematic review and meta-analysis. Fetal aortic valvuloplasty (FAV) was successfully performed in 84% of patients. It revealed a successful conversion to biventricular circulation rate of 33% with a mortality rate of 20%. Bradycardia and pleural effusion requiring treatment were two most common fetal complications, whereas maternal complication reported was only placental abruption in one patient. ConclusionsFAV has a high technical success rate with the ability to achieve biventricular circulation and a low rate of procedure-related mortality if carried out by experienced operators.

Whether exercises and testosterone replacement therapy support a treatment for cardiovascular and atherosclerotic patients with iliac artery stenosis and low total testosterone and high-density lipoprotein cholesterol after endovascular procedure?

Serum levels of testosterone (ST) and high-density lipoprotein (HDL) are generally associated with atherosclerosis in male patients over 50 years with critic iliac stenosis (TASC II A and B) and cardiovascular disease with significant changes in HDL and low-density lipoprotein (LDL). In addition to the standard therapy, combined medicamentous therapy and adequate model of exercise are also important factors as medicines can improve HDL levels and primary bypass and endovascular potency impacting positively on improvement of ST or it can be the following testosterone replacement therapy (TRT) comprising cardiovascular disease prevention and vascular treatment as adjunct therapy options after endovascular and vascular surgical procedures. The aim of the study is to identify the association between HDL and ST after surgical and endovascular intervention on the iliac segment (TASCII A and B), as well as cardiovascular risk factors with modified medium activity (MET) <6 with short interval increase over >6 (MET), with total duration of 30–60 minutes. It also attempts to remodel a patient behavioral pattern, optimize ST levels and link them to outcomes and patency of vascular procedures on the iliac segment. Materials and methods. 108 selected male patients with cardiovascular disease combined with metabolic syndrome and critical iliac artery stenosis (TASC II A and B) were examined during 2014–2018, 4 years after invasive and minimal invasive treatment (54 patients were treated with surgical Dacron reconstruction and 54 patients – with endovascular treatment on short segment of critical iliac artery stenosis (TASC II A and B). Results. In the total population, no difference was observed in changes of constraint-induced movement therapy between the standard exercise group and the control one after 4 years from baseline. However, there was no significant interaction between the effect of exercise trainings and primary bypass potency within 4 years. Conclusions. Primary effects of endovascular procedure and Dacron bypass revascularization raise the risk of elevated testosterone levels after 4 years of group training but does not provide adequate answers to questions as to whether higher levels of ST have any major influence on primary bypass potency preventing further progression of cardiovascular disease and general symptomatic and asymptomatic atherosclerosis. However, exercise and TRT can be potential adjunctive therapeutic options for a future supporting postsurgical and endovascular illiac treatment in cardiovascular patients with low testosterone levels.

The Impact of Left Ventricular Performance and Afterload on the Evaluation of Aortic Valve Stenosis: A 1D Mathematical Modeling Approach.

The transaortic valvular pressure gradient (TPG) plays a central role in decision-making for patients suffering from severe aortic stenosis. However, the flow-dependence nature of the TPG makes the diagnosis of aortic stenosis challenging since the markers of cardiac performance and afterload present high physiological interdependence and thus, isolated effects cannot be measured directly in vivo. We used a validated 1D mathematical model of the cardiovascular system, coupled with a model of aortic stenosis, to assess and quantify the independent effect of the main left ventricular performance parameters (end-systolic (Ees) and end-diastolic (Eed) elastance) and principal afterload indices (total vascular resistance (TVR) and total arterial compliance (TAC)) on the TPG for different levels of aortic stenosis. In patients with critical aortic stenosis (aortic valve area (AVA) ≤ 0.6 cm2), a 10% increase of Eed from the baseline value was associated with the most important effect on the TPG (-5.6 ± 0.5 mmHg, p < 0.001), followed by a similar increase of Ees (3.4 ± 0.1 mmHg, p < 0.001), in TAC (1.3 ±0.2 mmHg, p < 0.001) and TVR (-0.7 ± 0.04 mmHg, p < 0.001). The interdependence of the TPG left ventricular performance and afterload indices become stronger with increased aortic stenosis severity. Disregarding their effects may lead to an underestimation of stenosis severity and a potential delay in therapeutic intervention. Therefore, a comprehensive evaluation of left ventricular function and afterload should be performed, especially in cases of diagnostic challenge, since it may offer the pathophysiological mechanism that explains the mismatch between aortic severity and the TPG.