Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.

Treatment of severe aortic valve stenosis in high-risk patients with percutaneous implantation of the CoreValve prosthesis is feasible and associated with a lower mortality rate than predicted by risk algorithms.

Background— The morbidity and mortality of surgical aortic valve replacement are increased in elderly patients with multiple high-risk comorbid conditions. Therefore, a prospective, single-center, nonrandomized study was performed in high-risk patients with aortic valve disease to evaluate the feasibility and safety of percutaneous implantation of a novel self-expanding aortic valve bioprosthesis (CoreValve). Methods and Results— Symptomatic high-risk patients with an aortic valve area <1 cm 2 were considered for enrollment. CoreValve implantation was performed under general anesthesia with extracorporeal support using the retrograde approach. Clinical follow-up and transthoracic echocardiography were performed after the procedure and at days 15 and 30 after device implantation to evaluate short-term patient and device outcomes. A total of 25 patients with symptomatic aortic valve stenosis (mean gradient before implantation, 44.2±10.8 mm Hg) and multiple comorbidities (median logistic EuroScore, 11.0%) were enrolled. Device success and procedural success were achieved in 22 (88%) and 21 (84%) patients, respectively. Successful device implantation resulted in a marked reduction in the aortic valve gradients (mean gradient after implantation, 12.4±3.0 mm Hg; P <0.0001). The mean aortic regurgitation grade was unchanged. Major in-hospital cardiovascular and cerebral events occurred in 8 patients (32%), including mortality in 5 patients (20%). Among 18 patients with device success surviving to discharge, no adverse events occurred within 30 days after leaving the hospital. Conclusions— Percutaneous implantation of the self-expanding CoreValve aortic valve prosthesis in high-risk patients with aortic stenosis with or without aortic regurgitation is feasible and, when successful, results in marked hemodynamic and clinical improvement.

Background— Percutaneous aortic valve replacement is a new emerging technology for interventional treatment of severe aortic valve stenosis in surgical high-risk patients. This study was intended to provide a summary of the development and current safety and efficacy status of the self-expanding CoreValve Revalving prosthesis. Method and Results— Between 2005 and 2008, we have enrolled 136 consecutive patients with percutaneous aortic valve replacement using the CoreValve prosthesis. In this prospective nonrandomized, single-center trial, we analyzed procedural outcome, complications and clinical status up to 1 year. First, second, and third generation of the CoreValve prosthesis were implanted in 10, 24, and 102 consecutive high-risk patients (logistic EuroScore: 23.1�15.0%) with severe symptomatic aortic valve stenosis. Mean transvalvular pressure gradient was 41.5�16.7 mm Hg. The procedural success rate increased from generation 1/2 to 3 from 70.0%/70.8% to 91.2% ( P =0.003). The 30-day combined rate of death/stroke/myocardial infarction was 40.0%/20.8%/14.7% ( P =0.11) for generation 1, 2, and 3, with no procedural death in generation 3. Pressure gradients improved significantly with a final mean gradient of 8.1�3.8 mm Hg. Overall functional status assessed by New York Heart Association class improved from 3.3�0.5 (pre) to 1.7�0.7 (post) ( P <0.001) and remained stable in the follow-up. Conclusion— In experienced hands, percutaneous aortic valve replacement with the CoreValve system for selected patients with severe aortic valve stenosis has a high acute success rate associated with a low periprocedural mortality/stroke rate as well as remarkable clinical and hemodynamic improvements, which persist over time. Additional studies are now required to confirm these findings, particularly head-to-head comparisons with surgical valve replacement in different risk populations.

The results of our study suggest that thrombolysis may favorably affect the clinical outcome of hemodynamically stable patients with major pulmonary embolism.

In a prospective study, the clinical value of transoesophageal two-dimensional echocardiography (TOE) as compared with transthoracic two-dimensional echocardiography (TTE) was determined in patients with suspected infective endocarditis. Ninety-six patients were studied consecutively with an electronic sector scanner using 2.25 and 3.5 MHz probes for TTE and a 3.5 MHz probe embedded in tip of a flexible 12 mm gastroscope for TOE. Results of surgery and autopsy were available for 20 of the 96 patients with infective endocarditis and echocardiographically demonstrated vegetations and 70 control patients with valvular heart disease without infective endocarditis and no signs of vegetations, who were studied preoperatively with TTE and TOE. For TTE and TOE, the measured sensitivity was 63% and 100%, specificity 98% and 98%, positive predictive accuracy 92% and 95%, and negative predictive accuracy 91% and 100%, respectively. In 39 patients who had positive blood cultures, vegetations were found by TOE in 32 patients (82%), but in only 27 patients (69%) by TTE. Image quality was the main factor contributing to the superiority of TOE over TTE: it was reduced in 11/20 patients (55%) in whom vegetations were not detected by TTE. Another important factor was the size of vegetations. Only 6/24 vegetations (25%) of less than 5 mm but 9/13 vegetations of 6-10 mm, and 14/14 vegetations of greater than 11 mm detected by TOE were also observed with TTE. The clinical importance of detecting vegetations was demonstrated by the rate of embolism. In patients with vegetations embolism was 25% when blood cultures were positive and 21% when they were negative. In patients without echocardiographically detectable vegetations signs of embolism were seen in no patient with positive and 7% of the patients with negative blood cultures. Evidence of vegetations was found on the aortic valve in 14 patients and on the mitral valve in seven patients in whom valvular incompetence was not present, indicating that the valve had not yet been damaged significantly. TOE is superior to TTE in detecting vegetations in suspected infective endocarditis because of better image quality, particularly when vegetations are small. TOE seems to be indicated in patients with suspected endocarditis and reduced image quality or negative TTE results. Early detection of vegetations on valves may help confirm the diagnosis of infective endocarditis at an early stage and hopefully lead to an improved prognosis by reducing delay in instituting appropriate therapy.

This case report demonstrates a successful percutaneous implantation of a self-expanding aortic valve prosthesis with remarkable functional and clinical improvements in the acute and short-term outcome.

No abstract