Texas Heart Institute journal
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Review Case Reports
Two cases of Bezold-Jarisch reflex induced by intra-arterial nitroglycerin in critical left main coronary artery stenosis.
The Bezold-Jarisch reflex, a well-described phenomenon, occurs upon the stimulation of intracardiac mechanoreceptors and is mediated by vagal afferent nerve fibers. Several factors can sensitize the cardiovascular system to develop this reflex, including acute myocardial ischemia, natriuretic peptides, and, rarely, nitroglycerin administration in the setting of acute myocardial infarction. The development of the Bezold-Jarisch reflex in the presence of severe coronary artery stenosis, specifically left main coronary artery stenosis, has not been described. ⋯ Coronary angiography revealed critical (>90%) left main coronary artery stenosis in both patients. Critical left main coronary artery stenosis might sensitize mechanoreceptors or vagal afferents to the development of the Bezold-Jarisch reflex after intra-arterial nitroglycerin use; however, the mechanism of this possible relationship is unclear. In addition to discussing our patients' cases, we review the medical literature relevant to the Bezold-Jarisch reflex.
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Review Case Reports
Embolization of patent foramen ovale closure devices: incidence, role of imaging in identification, potential causes, and management.
Transcatheter patent foramen ovale (PFO) closure is an alternative to antiplatelet or anticoagulative therapy in patients with cryptogenic stroke, and it is associated with a small incidence of periprocedural sequelae. Because embolization of PFO closure devices is a very rare procedural complication, data on its frequency, causes, and management are sparse. We sought to review the medical literature and the cases of PFO closure-device embolization at our institution with the aim of identifying likely problems and reporting potential solutions. ⋯ In both patients, device embolization was identified in a timely fashion, the embolized device was safely retrieved, and the PFO was percutaneously closed with success. The incidence of PFO closure-device embolization is very low. The cases described here underscore the importance of imaging in the identification of morphologic predispositions to closure-device malpositioning, in the recognition of impending embolization, and in the timely management of embolization.
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We prospectively evaluated the hemodynamic performance of the SORIN Freedom SOLO aortic bioprosthesis, a stentless bovine pericardial valve designed for supra-annular implantation. Forty patients (mean age, 71.68 ± 5.25 yr; 29 men) with severe aortic stenosis underwent aortic valve replacement from January 2008 through August 2009. Patients were evaluated by transthoracic echocardiography and clinical examination, both preoperatively and again at 6 and 24 postoperative months. ⋯ Temporary thrombocytopenia was documented in all patients during early postoperative follow-up (lowest level at day 3); recovery to preoperative levels occurred by day 10. The Freedom SOLO aortic bioprosthesis is an easy-to-implant valve with excellent hemodynamic performance. The thrombocytopenia appears to be a transient laboratory finding.
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Cardiogenic shock resulting from acute rejection after heart transplantation is an infrequent but life-threatening condition. Intensified immunosuppressive therapy and the timely initiation of properly selected mechanical circulatory support can be life-saving and enable recovery of graft function. The few published reports on mechanical circulatory support for acute transplantation rejection have focused on short-term devices. ⋯ Allograft function recovered completely, and this enabled removal of the assist device. The patient was alive 18 months after biventricular assist device insertion. To our knowledge, this is the first description of a successful staged approach involving short- and long-term mechanical circulatory support to resolve allograft rejection and refractory cardiogenic shock after heart transplantation.