Explore the vast range of titles available.

Patients with aortic stenosis underwent transfemoral transcatheter implantation of a balloon-expandable bovine pericardial aortic valve. One-year mortality was lower with the balloon-expandable valve than with standard therapy, but the risk of stroke was higher. Aortic stenosis is an insidious disease with a long latency period 1 followed by rapid progression after the appearance of symptoms, 2 – 5 resulting in a high rate of death (approximately 50% in the first 2 years after symptoms appear) among untreated patients. 1 , 6 – 8 Surgical replacement of the aortic valve reduces symptoms and improves survival in patients with aortic stenosis, 9 – 11 and in the absence of serious coexisting conditions, the procedure is associated with low operative mortality. 12 , 13 However, in clinical practice, at least 30% of patients with severe symptomatic aortic stenosis do not undergo surgery for replacement of the aortic . . .

Development of functional tricuspid regurgitation (TR) because of chronic mitral disease and subsequent heart failure is common. However, the effect of TR on clinical outcomes after transcatheter mitral valve replacement (TMVR) remains unclear. We aimed to evaluate the impact of baseline TR on outcomes after TMVR. This was a single-center, retrospective analysis of patients who received valve-in-valve or valve-in-ring TMVR between 2012 and 2022. Patients were categorized into none/mild TR and moderate/severe TR based on baseline echocardiography. The primary outcome was 3 years all-cause death and the secondary outcomes were in-hospital events. Of the 135 patients who underwent TMVR, 64 (47%) exhibited none/mild TR at baseline, whereas 71 (53%) demonstrated moderate/severe TR. There were no significant differences in in-hospital events between the groups. At 3 years, the moderate/severe TR group exhibited a significantly increased risk of all-cause death (adjusted hazard ratio 3.37, 95% confidence interval 1.35 to 8.41, p = 0.009). When patients with baseline moderate/severe TR were stratified by echocardiography at 30 days into improved (36%) and nonimproved (64%) TR groups, although limited by small sample size, there was no significant difference in 3-year all-cause mortality (p = 0.48). In conclusion, this study investigating the impact of baseline TR on clinical outcomes revealed that moderate/severe TR is prevalent in those who underwent TMVR and is an independent predictor of 3-year all-cause mortality. Earlier mitral valve intervention before the development of significant TR may play a pivotal role in improving outcomes after TMVR.

This interactive feature about prevention of recurrent stroke offers a case vignette accompanied by essays that support recommending either surgery to close a patent foramen ovale or medical therapy and lifestyle changes alone.

After Hibbard and Smithells suggested a possible association between low folic acid levels and congenital neural-tube defects, 1 seven subsequent epidemiologic studies supported the proposition that periconceptional folic acid supplementation may reduce the occurrence of neural-tube defects. 2 Moreover, results of double-blind trials of primary 3 and secondary 4 prevention demonstrated that periconceptional daily intake of 0.8 mg and 4 mg of folic acid, respectively, reduced the incidence of neural-tube defects. The intake of folic acid derived from food by women of childbearing potential in the United States may be as low as 110 to 140 μg per day, 5 which is well below the . . .

Background A 73-year-old woman presented with a history of persistent atrial fibrillation, which had lasted more than five years. She also had a remote history of transient ischemic attack and had received warfarin therapy. The international normalized ratio had been carefully maintained at slightly subtherapeutic levels because of recurrent gastrointestinal bleeding, which was severe enough to require frequent blood transfusions. With colonoscopy, the source of bleeding was localized to multiple arterial-venous malformations. The patient underwent catheter ablation of the atrioventricular junction and received a single chamber pacemaker. Two years later, she received a dual chamber pacemaker followed by cardioversion to restore a sinus rhythm. Following brief cardioversion, her symptoms of atrial fibrillation returned after two days. Investigations Transesophageal echocardiography, pacemaker interrogation. Diagnosis Persistent atrial fibrillation, gastrointestinal bleeding requiring transfusion. Management Percutaneous left atrial appendage occlusion, antiplatelet therapy.

Doc number: P60

To evaluate the safety and cost of outpatient cardiac catheterization, we conducted a randomized trial at three hospitals of outpatient (n = 192) as compared with inpatient (n = 189) cardiac catheterization in low-risk patients. Outpatients had the following complication rates as compared with inpatients: hematoma, 12 versus 8.5 percent; numbness or weakness of extremity, 0.5 versus 1.6 percent; cold or blue extremity, 1.6 versus 1.1 percent; and acute myocardial infarction, 1.6 versus 0.5 percent. None of these differences were statistically significant. No deaths or strokes occurred in either group. Twenty-three patients (12 percent) assigned to the outpatient group required hospitalization because of complications of catheterization. In the outpatient group, the relative risk for hematoma was 1.42 (95 percent confidence interval, 0.77 to 2.29), and the relative risk for myocardial infarction within one week was 2.95 (95 percent confidence interval, 0.3 to 28.1). There were no significant differences between the two groups in whether they resumed normal activities or in the rates of rehospitalization within one week of the procedure. Total catheterization-related charges per patient were $679 lower for outpatients, with a savings in total hospital charges (including charges for subsequent therapeutic procedures) of $885 per patient. We conclude that elective cardiac catheterization as an outpatient procedure for selected patients is feasible and safe. Given the small size of our sample, however, we urge caution in interpreting these findings, since they do not exclude a small increase in complication rates with outpatient cardiac catheterization. (N Engl J Med 1988; 319:1251–5.) DIAGNOSTIC cardiac catheterization, including coronary arteriography, is performed more than 500,000 times a year in the United States. 1 Although it was formerly almost exclusively an inpatient procedure, technical improvements combined with an increased population of stable patients undergoing elective catheterization, efforts to control the lengths of inpatient hospital stays, the development of ambulatory care centers, and the emergence of free-standing cardiac-catheterization laboratories have prompted an evaluation of routine cardiac catheterization as an outpatient procedure. Several studies of outpatient cardiac catheterization have reported mortality and complication rates similar to those of historical inpatient studies. 2 3 4 5 6 7 8 9 10 11 Although several such studies have included large . . .

PERCUTANEOUS transluminal angioplasty is frequently used in selected patients to decrease stenoses in atherosclerotic peripheral arteries, 1 , 2 renal arteries, 3 4 5 6 and coronary arteries. 7 8 9 There has been much controversy over the mechanism of successful transluminal angioplasty. It was initially postulated that enlargement of the vascular lumen was due to compression of atheromatous plaque. 2 However, experiments in animals and autopsy studies in human beings 10 11 12 13 14 15 16 17 have shown that transluminal angioplasty produces endothelial desquamation and splitting of the atheromatous plaque. Attempts to extrapolate these findings to the mechanism of clinically successful angioplasty have been subjected to the criticism that post-mortem tissue and animal models of atherosclerosis . . .

The percutaneous treatment of mitral stenosis using balloon valvuloplasty is a reality. However, in Western countries there is only a low incidence of rheumatic valvular disease. Thus, attention is now focused on percutaneous, transcatheter approaches that will allow wider ranging treatment of pulmonic, aortic and mitral valve disease. These new approaches should result in percutaneous technologies that will allow replacement of pulmonic and aortic valves for both stenosis and regurgitation, repair of mitral regurgitation, and possibly even replacement of the mitral valve. Pulmonic and aortic valve replacement are already being studied in safety and efficacy trials in Europe. Investigators using percutaneous mitral valve repair will soon complete a Phase I US trial and the technology will be studied in a Phase II randomized trial. Patient care options for valvular heart disease are rapidly changing. 'Potential percutaneous replacement of the mitral valve still faces many practical hurdles, but sooner or later they will be overcome.

Figure 1. A 75-year-old man who was taking 8 mg of prednisone per day for systemic lupus erythematosus was admitted for the evaluation of an enlarging chest mass. Seventeen years earlier he had undergone aortocoronary saphenous-vein grafting. Two years before presentation, he had coronary angiography for recurrent chest pain. A chest x-ray film showed a small, rounded irregularity of the right lateral aspect of the cardiac silhouette (arrows in Panel A). A calcified 90 percent stenosis of the proximal native right coronary artery was found. The right saphenous-vein graft was patent and had an aneurysm measuring 8 by 10 mm . . .