Servicio de Geriatría Hospital Universitario La Paz – Cantoblanco Área Sanitaria 5 de Madrid.
Servicio de Cardiologı´a, Hospital Universitario La Paz ... de Cardiologı´a, Hospital...
3
The onset of NET can lead to general and hemodynamic deterioration in these patients and therefore early diagnosis and treatment are essential to reduce the risk of complications. The signs and symptoms of these tumors overlap with those associated with complications of CCHD, such as arrhythmias, hypertension, and heart failure. Thus, the presence of NET should be suspected with the onset of new symptoms in patients with CCHD, even after surgical correction, as these tumors are a potentially treatable cause of clinical deterioration in these patients. A multidisciplinary approach, with tumor resection in a specialized center, is associated with a high success rate, even in this population at risk. 2 This treatment is effective and is associated with good short- and long-term prognosis. CONFLICTS OF INTEREST A ´ . Sa ´ nchez-Recalde is an Associate Editor of Revista Espan ˜ola de Cardiologı´a. Ine ´s Ponz de Antonio, a, * Jose ´ Ruiz Cantador, a Ana E. Gonza ´ lez Garcı ´a, a Jose ´ Marı ´a Oliver Ruiz, b A ´ ngel Sa ´ nchez-Recalde, a and Jose ´ Luis Lo ´ pez-Sendo ´n a a Servicio de Cardiologı´a, Hospital Universitario La Paz, Madrid, Spain b Servicio de Cardiologı´a, Hospital Universitario Gregorio Maran ˜o ´n, Madrid, Spain * Corresponding author: E-mail address: [email protected] (I. Ponz de Antonio). Available online 13 January 2017 REFERENCES 1. Oliver JM, Gonza ´ lez AE. Sı ´ndrome hipoxe ´ mico cro ´ nico. Rev Esp Cardiol Supl. 2009;9:13E–22E. 2. Filgueiras-Rama D, Oliver JM, Ruiz-Cantador J, et al. Pheochromocytoma in Eisenmenger’s syndrome: a therapeutic challenge. Rev Port Cardiol. 2010;29: 1873–1877. 3. Opotowsky AR, Moko LE, Ginns J, et al. Pheochromocytoma and paraganglioma in cyanotic congenital heart disease. J Clin Endocrinol Metab. 2015;100:1325–1334. 4. Thompson RJ. Current understanding of the O 2 -signalling mechanism of adrenal chromaffin cells. In: Borges R, Gandı ´a L, eds. In: Cell biology of the chromaffin cell. Madrid: Instituto Teo ´ filo Hernando; 2004:95–106. http://dx.doi.org/10.1016/j.rec.2016.09.036 1885-5857/ ß 2016 Sociedad Espan ˜ola de Cardiologı ´a. Published by Elsevier Espan ˜a, S.L.U. All rights reserved. Stented Bovine Jugular Vein Graft (Melody Valve) in Mitral Position. Could Be an Alternative for Mechanical Valve Replacement in the Pediatric Population? Pro ´tesis de yugular bovina con stent (Melody) en posicio ´n mitral. ? Posible alternativa a la pro ´tesis meca ´nica en poblacio ´n pedia ´trica? To the Editor, Congenital mitral valve disease is an uncommon condition. Medical treatment can be very complicated in some cases, leaving surgery as the only option. Surgical valvuloplasty often fails in children, especially in neonates and young infants, due to the presence of dysplastic valves with a small annulus and special anatomic features. In such cases, valve replacement is generally the only solution. We present 3 cases of Melody valve implantation in the mitral position. Patient 1 was a 4-month-old infant weighing 4.6 kg with severe mitral regurgitation (MR) (valve with thickened leaflets, reduced mobility, and absence of central coaptation; annulus of 15 mm) that was refractory to medical treatment. Following Kay-Wooler annuloplasty, the boy showed moderate residual MR and was extubated, but he developed severe MR 14 days later and required ventilatory support. We decided to implant a Melody valve in the mitral position using the Boston technique 1 with some modifica- tions. 2 Before initiation of extracorporeal circulation, the valve was expanded to 18 mm and a 3-mm pericardial sewing cuff was added to the center of the stent using loose sutures anchored to the strut chordae; the triangular struts at the proximal and distal ends of the stent were bent outwards, but the 3 struts supporting the valve commissures were left intact. The mitral valve was exposed using a superior transseptal approach. The posterior leaflet and its subvalvular apparatus and part of the anterior leaflet were resected, sparing the anterosuperior zone with its attachments to the anterior papillary muscle. The mitral prosthesis was crimped (6 mm) and attached to the posterior wall of the left ventricle to prevent left ventricular outflow tract (LVOT) obstruction during systole. The pericardial cuff was sutured to the native annulus and the valve was inflated to 4 atm with an 18-mm balloon (annulus diameter + 1). The cuff was tied down and the interatrial septum was reconstructed with a fenestrated pericardial patch (Figure 1). An intraoperative transesophageal echocardiogram (TEE) showed grade III periprosthetic MR. The valve was reinflated with a 22-mm balloon, and the outcome was favorable (grade I-II MR). No postoperative complications were observed and the patient was asymptomatic 9 months later. The echocardiogram revealed a mean mitral valve gradient of 3.6 mmHg and grade II peripros- thetic MR. No LVOT obstruction was noted. Patient 2 was a 7-month-old girl weighing 4.7 kg, who had been treated for complete atrioventricular canal defect at another hospital using the double-patch technique with cleft closure and the Alfieri technique, following pulmonary artery banding. Postoperative clinical course was indolent and the patient required prolonged hospital stay. The infant had a severe double mitral valve lesion and an annulus of 15 mm. She failed to thrive and developed heart failure despite maximum medical treatment. It was decided to implant the Melody valve in the mitral position using the technique described above, with expansion of the prosthesis to 17 mm. Intraoperative TEE showed no evidence of residual MR or LVOT obstruction (Figure 2). The patient was asymptomatic at the 7-month follow-up visit and had no residual lesions (mean gradient, 3 mm Hg; no MR). Patient 3 was a 3-kg neonate with congenital aortic valve stenosis (peak gradient, 100 mm Hg). Valvuloplasty had been performed when the child was 2 days old, but the next day, extracorporeal membrane oxygenation was required due to ventricular dysfunction. The neonate was weaned off the oxygen- ation system after 5 days. The echocardiogram showed a residual aortic stenosis of 50 mmHg, a patent foramen ovale of 4 to 6 mm with a significant left-to-right shunt and moderate MR with Scientific letters / Rev Esp Cardiol. 2017;70(8):669–681 675 Downloaded for Anonymous User (n/a) at Hospital de la Paz from ClinicalKey.com by Elsevier on October 08, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
Transcript of Servicio de Cardiologı´a, Hospital Universitario La Paz ... de Cardiologı´a, Hospital...
Scientific letters / Rev Esp Cardiol. 2017;70(8):669–681 675
The onset of NET can lead to general and hemodynamicdeterioration in these patients and therefore early diagnosis andtreatment are essential to reduce the risk of complications. The
aServicio de Cardiologıa, Hospital Universitario La Paz, Madrid, SpainbServicio de Cardiologıa, Hospital Universitario Gregorio Maranon,
Madrid, Spain
signs and symptoms of these tumors overlap with those associatedwith complications of CCHD, such as arrhythmias, hypertension,and heart failure. Thus, the presence of NET should be suspectedwith the onset of new symptoms in patients with CCHD, even aftersurgical correction, as these tumors are a potentially treatablecause of clinical deterioration in these patients. A multidisciplinaryapproach, with tumor resection in a specialized center, isassociated with a high success rate, even in this population atrisk.2 This treatment is effective and is associated with good short-and long-term prognosis.
CONFLICTS OF INTEREST
A. Sanchez-Recalde is an Associate Editor of Revista Espanola de
Cardiologıa.
Ines Ponz de Antonio,a,* Jose Ruiz Cantador,a
Ana E. Gonzalez Garcıa,a Jose Marıa Oliver Ruiz,b
Angel Sanchez-Recalde,a and Jose Luis Lopez-Sendona
Stented Bovine Jugular Vein Graft (MelodyValve) in Mitral Position. Could Be an Alternativefor Mechanical Valve Replacement in thePediatric Population?
Protesis de yugular bovina con stent (Melody) en posicion mitral.
?
Posible alternativa a la protesis mecanica en poblacionpediatrica?
To the Editor,
Congenital mitral valve disease is an uncommon condition.Medical treatment can be very complicated in some cases, leavingsurgery as the only option. Surgical valvuloplasty often fails inchildren, especially in neonates and young infants, due to thepresence of dysplastic valves with a small annulus and specialanatomic features. In such cases, valve replacement is generally theonly solution. We present 3 cases of Melody valve implantation inthe mitral position.
Patient 1 was a 4-month-old infant weighing 4.6 kg with severemitral regurgitation (MR) (valve with thickened leaflets, reducedmobility, and absence of central coaptation; annulus of 15 mm)that was refractory to medical treatment. Following Kay-Woolerannuloplasty, the boy showed moderate residual MR and wasextubated, but he developed severe MR 14 days later and requiredventilatory support. We decided to implant a Melody valve in themitral position using the Boston technique1 with some modifica-tions.2 Before initiation of extracorporeal circulation, the valve wasexpanded to 18 mm and a 3-mm pericardial sewing cuff was addedto the center of the stent using loose sutures anchored to the strutchordae; the triangular struts at the proximal and distal ends of the
stent were bent outwards, but the 3 struts supporting the valvecommissures were left intact. The mitral valve was exposed using asuperior transseptal approach. The posterior leaflet and itssubvalvular apparatus and part of the anterior leaflet wereresected, sparing the anterosuperior zone with its attachmentsDownloaded for Anonymous User (n/a) at Hospital de la Paz frFor personal use only. No other uses without permission. C
* Corresponding author:E-mail address: [email protected] (I. Ponz de Antonio).
Available online 13 January 2017
REFERENCES
1. Oliver JM, Gonzalez AE. Sındrome hipoxemico cronico. Rev Esp Cardiol Supl.2009;9:13E–22E.
2. Filgueiras-Rama D, Oliver JM, Ruiz-Cantador J, et al. Pheochromocytoma inEisenmenger’s syndrome: a therapeutic challenge. Rev Port Cardiol. 2010;29:1873–1877.
3. Opotowsky AR, Moko LE, Ginns J, et al. Pheochromocytoma and paraganglioma incyanotic congenital heart disease. J Clin Endocrinol Metab. 2015;100:1325–1334.
4. Thompson RJ. Current understanding of the O2-signalling mechanism of adrenalchromaffin cells. In: Borges R, Gandıa L, eds. In: Cell biology of the chromaffin cell.Madrid: Instituto Teofilo Hernando; 2004:95–106.
http://dx.doi.org/10.1016/j.rec.2016.09.036
1885-5857/
� 2016 Sociedad Espanola de Cardiologıa. Published by Elsevier Espana, S.L.U. All
rights reserved.
to the anterior papillary muscle. The mitral prosthesis was crimped(6 mm) and attached to the posterior wall of the left ventricle toprevent left ventricular outflow tract (LVOT) obstruction duringsystole. The pericardial cuff was sutured to the native annulus andthe valve was inflated to 4 atm with an 18-mm balloon (annulusdiameter + 1). The cuff was tied down and the interatrial septumwas reconstructed with a fenestrated pericardial patch (Figure 1).An intraoperative transesophageal echocardiogram (TEE) showedgrade III periprosthetic MR. The valve was reinflated with a 22-mmballoon, and the outcome was favorable (grade I-II MR). Nopostoperative complications were observed and the patient wasasymptomatic 9 months later. The echocardiogram revealed amean mitral valve gradient of 3.6 mmHg and grade II peripros-thetic MR. No LVOT obstruction was noted.
Patient 2 was a 7-month-old girl weighing 4.7 kg, who had beentreated for complete atrioventricular canal defect at anotherhospital using the double-patch technique with cleft closure andthe Alfieri technique, following pulmonary artery banding.Postoperative clinical course was indolent and the patient requiredprolonged hospital stay. The infant had a severe double mitralvalve lesion and an annulus of 15 mm. She failed to thrive anddeveloped heart failure despite maximum medical treatment. Itwas decided to implant the Melody valve in the mitral positionusing the technique described above, with expansion of theprosthesis to 17 mm. Intraoperative TEE showed no evidence ofresidual MR or LVOT obstruction (Figure 2). The patient wasasymptomatic at the 7-month follow-up visit and had no residuallesions (mean gradient, 3 mm Hg; no MR).
Patient 3 was a 3-kg neonate with congenital aortic valvestenosis (peak gradient, 100 mm Hg). Valvuloplasty had beenperformed when the child was 2 days old, but the next day,
extracorporeal membrane oxygenation was required due toventricular dysfunction. The neonate was weaned off the oxygen-ation system after 5 days. The echocardiogram showed a residualaortic stenosis of 50 mmHg, a patent foramen ovale of 4 to 6 mmwith a significant left-to-right shunt and moderate MR withom ClinicalKey.com by Elsevier on October 08, 2017.opyright ©2017. Elsevier Inc. All rights reserved.
Scientific letters / Rev Esp Cardiol. 2017;70(8):669–681676
structural damage to the leaflets, and an annulus of 15 mm.Progress was not favorable and it was decided to perform apercutaneous aortic valvuloplasty and attempt to close the atrialseptal defect. This was not possible, however, because the borderswere too loose. After repeated failed attempts at extubation andepisodes of low cardiac output, we decided to surgically close theatrial septal defect to force antegrade flow. Extubation, however,was still not possible. As MR appeared to have an important role inthe patient’s progress, it was decided to replace the mitral valvewith a Melody valve expanded to 18 mm. Severe LVOT obstructiondue to the prosthesis was observed at the pump outlet and theRoss-Konno procedure was performed immediately. The outcomewas favorable, with disappearance of the LVOT obstruction and anormally functioning prosthesis. Postoperative recovery was slowdue to lung damage. Two months after surgery the patient hadgrade II MR.
The search for alternatives to mechanical valve prosthesescontinues in pediatric settings. Major obstacles to the use of
Figure 2. Transesophageal echocardiogram showing absence of
Figure 1. A and B: stented bovine jugular vein graft (Melody valve). C: sutured per3 struts supporting the valve commissures at the distal end are left intact (arrow
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mechanical valves in young patients are a lack of suitably sizedvalves (the smallest valve available is 16 mm), the need foranticoagulation therapy, and failure to accommodate somaticgrowth. Different techniques such as supra-annular implanta-tion3 and the chimney mitral valve replacement technique4 havebeen designed to reduce the risk of thrombosis by preventingthe hemidiscs from becoming blocked by surrounding tissue.They do not, however, resolve the other problems mentioned.The Boston group recently described the use of the stentedbovine jugular vein graft (Melody valve) in the mitral position.5,6
This device offers several advantages: it can be implanted invery small annuli as it adapts to different diameters; it istheoretically possible to expand the valve percutaneously overtime, and it avoids the need for anticoagulants becauseantiplatelet therapy is sufficient. Our initial experience withthe Melody valve has been very positive, although we recognizethe need to analyze the short- and mid-term durability of thisprosthetic valve.
stenosis (A) and regurgitation (B) with the implanted valve.
icardial bovine cuff (arrow). D: triangular struts bent outwards (asterisk); the). E: prosthesis implanted in the mitral position.
z from ClinicalKey.com by Elsevier on October 08, 2017.. Copyright ©2017. Elsevier Inc. All rights reserved.
c+
Tx21
2 5
C
Scientific letters / Rev Esp Cardiol. 2017;70(8):669–681 677
Alvaro Gonzalez Rocafort,a,b,* Angel Aroca,a
Cesar Abelleira,c,d Hernan Carnicer,e Carlos Labrandero,c,d andSandra Villagrad
aServicio de Cirugıa Cardiaca Infantil y Congenita del Adulto, Hospital
Universitario La Paz, Madrid, SpainbServicio de Cirugıa Cardiaca Infantil y Congenita del Adulto, Hospital
Universitario Madrid-Monteprıncipe, Madrid, SpaincServicio de Cardiologıa Infantil, Hospital Universitario La Paz, Madrid,
SpaindServicio de Cardiologıa Infantil, Hospital Universitario Madrid-
Monteprıncipe, Madrid, SpaineUnidad de Cuidados Intensivos Pediatricos, Hospital Universitario
Madrid-Monteprıncipe, Madrid, Spain
* Corresponding author:E-mail address: [email protected] (A. Gonzalez Rocafort).
Available online 23 March 2017
A Reversible Cause of Acute Right VentricularFailure After Heart Transplant
Una causa reversible de fracaso ventricular derecho agudotras el trasplante cardiaco
To the Editor,
We report the case of a 41-year-old man, who was an activesmoker, with no prior history of cardiac conditions or other history
A
Piet
PAPPAPDays
448
Pt T: 37.0 ºCETE. T: 40.3 ºC
TEEx7 - 2t11.0 cm
2D Gral. Gain 50 C 45 4/4/0
+63
–63400
300
200
cm/s
Color 4.0 MHz Gain 60 4/4/0 Med. Fltr.
CW 2.9 MHz
0
GRP
3.0 8.0
0 180
15
3065
115BPBP
14535
Sp02
Pulse
104104
99
125/75(90)
40/18(25)
10094
HR
100
0
4.1 cm Angle 0º 400 Hz Fltr
n/s
+ VTI (RVOT)Vmax RVOT
GPmax RVOT
54.9 cm304 cm/s
37.0 mmHg
C
Figure 1. A and B, Swan-Ganz catheter measurements. A: pulmonary hypertension aanastomosis. B: normal pulmonary artery pressures after the stenosis of the pulmon> 3 m/s, maximum gradient 38 mmHg. D: stenosis of the pulmonary artery along
Downloaded for Anonymous User (n/a) at Hospital de la Paz frFor personal use only. No other uses without permission. C
REFERENCES
1. Emani SM. Melody valve for mitral valve replacement. Oper Tech Thorac CardiovascSurg. 2014;19:454–463.
2. Hofmann M, Dave H, Hubler M, et al. Simplified surgical-hybrid MelodyW valveimplantation for paediatric mitral valve disease. Eur J Cardiothorac Surg.2015;47:926–928.
3. Kanter KR, Kogon BE, Kirshbom PM. Supra-annular mitral valve replacement inchildren. Ann Thorac Surg. 2011;92:2221–2227.
4. Gonzalez Rocafort A, Aroca A, Polo L, et al. Chimney technique for mitral valvereplacement in children. Ann Thorac Surg. 2013;96:1885–1887.
5. Abdullah I, Ramirez FB, McElhinney DB, et al. Modification of a stented bovinejugular vein conduit (Melody valve) for surgical mitral valve replacement. AnnThorac Surg. 2012;94:e97–e98.
6. Quinonez LG, Breitbart R, Tworetsky W, et al. Stented bovine jugular vein graft(Melody valve) for surgical mitral valve replacement in infants and children. J ThoracCardiovasc Surg. 2014;148:1443–1449.
http://dx.doi.org/10.1016/j.rec.2017.02.035
1885-5857/
� 2016 Sociedad Espanola de Cardiologıa. Published by Elsevier Espana, S.L.U. All
rights reserved.
of interest, and who was admitted to hospital for anterior ST-elevation myocardial infarction in Killip class IV. During admission,he experienced cardiac arrest unresponsive to advanced cardio-pulmonary resuscitation. Peripheral venoarterial extracorporealmembrane oxygenation was used initially during the arrest andwas subsequently switched to central extracorporeal membraneoxygenation. Intra-aortic balloon counterpulsation was alsorequired. Coronary artery disease was detected in 3 vessels withchronic occlusion of the circumflex artery and right coronaryartery and acute occlusion of the proximal left anterior descending
+57
–57
cm/s
EE7 - 2t0 Hz1.0 cm
D Gral. Gain 50 C 45 4/4/00 mm/s
olor 4.0 MHz Gain 60 4/4/0
Pt T: 37.0 ºCETE. T: 39.8 ºC0 0 180
B
Piet
PAP PAPDays
44
Sinus tachy
8
3065
115BPBP
14535
Sp02
12560
Pulse
104104
99
119/71(85)
22/15(19)
10094
HR
m/s–
Med. Fltr.
Gain 50
GRP
3.0 8.0D
ccording to pulmonary artery pressure prior to stenosis of the pulmonary arteryary artery anastomosis. C: stenosis of the pulmonary artery anastomosis: flow
the short axis of the aortic arch at the level of the esophagus.
om ClinicalKey.com by Elsevier on October 08, 2017.opyright ©2017. Elsevier Inc. All rights reserved.
