Transkatétrová implantace aortální chlopně (TAVI) je preferovanou metodou léčby u neoperabilních anebo vysoce rizikových nemocných se závažnou aortální stenózou. Základní princip krimplovatelné bioprotézy a její implantace do stenotické nativní chlopně zůstává neměnný, došlo však k vývoji několika rozdílných konceptů bioprotéz i přístupových cest. Všechny koncepty prokázaly svoji bezpečnost a účinnost, existují však limitovaná data porovnávající jednotlivé chlopně či přístupové cesty mezi sebou. Cílem článku je poskytnout přehled o běžně používaných přístupových cestách k TAVI a blíže je specifi kovat.
Background Refractory angina pectoris (AP) significantly impairs quality of life in patients with chronic coronary syndrome. Several minimally invasive methods (coronary sinus reducer, cell therapy, laser or shockwave revascularization, and spinal cord stimulation) or non-invasive methods (external counterpulzation) have been studied. However, their routine clinical use has not been widely implemented. Surgical or endoscopic sympathectomy is feasible for permanently relieving angina, but is often contraindicated due to the extent of complications associated with it. Neuromodulation by anaesthetic blockade of the left-sided stellate ganglion (SG) has been shown to relieve angina for days or weeks. To provide a long-term anti-anginal effect, novel pharmacological (phenol-based) or radiofrequency ablation techniques have been individually used to permanently destroy sympathetic pathways. Case summary We describe a first-in-man use of stereotactic radiosurgical SG ablation using a linear accelerator (CyberKnife) in a heart failure patient after myocardial infarction with chronic refractory AP. Repeated anaesthetic SG blockade in this patient resulted in a significant, but only short-term, clinical improvement. The left, and subsequently the right, SG was ablated by targeted irradiation. During the 1-year follow-up, the patient remained without angina. We did not observe any clinically relevant early or late complications. Atrial fibrillation that developed 2 months after the second procedure was deemed to be associated with a natural progression of co-existing heart failure. Discussion We conclude that stereotactic radiosurgical SG ablation has the potential to become a minimally invasive and low-risk procedure to treat refractory angina patients. However, this procedure needs to be evaluated in larger patient populations.
Background The occlusion of the left atrial appendage is the treatment of choice in patients with high both thrombembolic and bleeding risks. The optimal method for size selection and occluder placement is still evolving. Based on published data, the ability to print a 3D atrial model might be helpful in these processes. Minimizing the cost of this approach may contribute to a massive extension of the methodology. Aim To present a process of data acquisition for 3D left atrial printing without the need of using a premium software. Method Patients indicated for percutaneous left atrial appendage closure are prepared according to standard recommendations. Afterwards, DICOM CT scans were used for our purpose. This data was transfered to the segmentation software. With the help of 3D Slicer 4.10 (slicer.org), the cardiac chambers were segmented from the contrast CT (DS CorCTA 1.0 B26f BestDiast 72%). The “Paint” function was specifically used for segmentation, marking each chambe. “GrowFromSeeds” utility was then used to automatically initialize chambers with the option of manual correction. Segments were subsequently transfered to the 3D model format (STL, 3MF). The difficulty was, that from the aforementioned contrast CT, we were only able to acquire the left atrial “cavity”, not reflecting the true dimensions of the walls. Therefore, we subtracted this shape from a cuboid. Then, using function “Hollow” in 3D Builder, we gradually removed the outer part of the cuboid around the subtracted cavity, resulting in a true left atrial wall. This enabled a valid sizing of the appendage. Since this procedure was part of a blinded study, a small cuboid marker (10x10x3mm) was added to the cast for patient identification and correct 3D printing. For the printing itself, a flexible material with 30–35D hardness was used to simulate compliant cardiac tissue. Conclusion The segmentation of the left atrium using open source and free 3D software enables to minimize printing costs which may lead to extension of this method to everyday clinical practice. Figure 1. Sequention of work Funding Acknowledgement Type of funding source: None
Introduction Electrical storm (ES) is an emergent condition which requires a sofisticated approach. Massive sympathetic surge almost always connected with ES precipitates recurrent ventricular arrhythmias. Performing stellate ganglion block (SGB) to alleviate the sympathetic activity on myocardium is becoming a standard of care in many centers. However, there is no clear data to predict in which patients the SGB will be ineffective. Purpose To identify predictors of SGB failure in patients with ES. Methods We analyzed our case series of SGB – the procedure was performed in 31 patients with ES in our center from March 2017 to December 2018. Results Mean left ventricular ejection fraction was 27% (±9%), 74% of patients had ischaemic cardiomyopathy. The most frequent type of arrhythmia was monomorphic ventricular tachycardia (VT), occurring in 71% of patients, followed by polymorphic VT in 13% of cases. After SGB, the burden of ventricular arrhythmias failed to decrease by at least 50% in 10% of cases - these patients were marked as non-responders. Slow monomorphic VT (under 160/min) was observed in all of these patients. On the other hand, fast monomorphic VT or polymorphic VT seemed to respond very well to SGB. We also observed, that patients with ES after acute coronary syndromes were good responders as well. The effect of SGB was not related to age, gender, EF LK or the etiology of cardiomyopathy. Conclusions According to our experience, the failure of SGB in the treatment of ES is not frequent. It typically occurs in patients with slow monomorphic VT. It is probable that such arrhythmias are sustained primarily due to the extensive myocardial substrate, and not because of the sympathetic surge. The situation is quite the opposite in patients with fast VT and acute ischemia.
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