1808
9.
10.
11.
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from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation 2008;117:e510 –e526. Pierdomenico SD, Lapenna D, Bucci A, Di Tommaso R, Di Mascio R, Manente BM, Caldarella MP, Neri M, Cuccurullo F, Mezzetti A. Cardiovascular outcome in treated hypertensive patients with responder, masked, false resistant, and true resistant hypertension. Am J Hypertens 2005;18:1422 –1428. Symplicity HTNI, Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Bohm M. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet 2010; 376:1903 –1909. Grassi G, Seravalle G, Brambilla G, Mancia G. The sympathetic nervous system and new nonpharmacologic approaches to treating hypertension: a focus on renal denervation. Can J Cardiol 2012;28:311–317. Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Bohm M. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet 2010;376: 1903 –1909. Bisognano JD, Bakris G, Nadim MK, Sanchez L, Kroon AA, Schafer J, de Leeuw PW, Sica DA. Baroreflex activation therapy lowers blood pressure in patients with resistant hypertension: results from the double-blind, randomized, placebo-controlled rheos pivotal trial. J Am Coll Cardiol 2011;58:765 –773.
S. Bangalore et al.
14. Waters DD, Guyton JR, Herrington DM, McGowan MP, Wenger NK, Shear C. Treating to New Targets (TNT) Study: does lowering low-density lipoprotein cholesterol levels below currently recommended guidelines yield incremental clinical benefit? Am J Cardiol 2004;93:154 – 158. 15. LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, Fruchart JC, Gotto AM, Greten H, Kastelein JJ, Shepherd J, Wenger NK. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med 2005;352:1425 –1435. 16. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560 – 2572. 17. Cuspidi C, Macca G, Sampieri L, Michev I, Salerno M, Fusi V, Severgnini B, Meani S, Magrini F, Zanchetti A. High prevalence of cardiac and extracardiac target organ damage in refractory hypertension. J Hypertens 2001;19:2063 – 2070. 18. Zannad F. Aldosterone antagonist therapy in resistant hypertension. J Hypertens 2007;25:747 –750. 19. Lane DA, Shah S, Beevers DG. Low-dose spironolactone in the management of resistant hypertension: a surveillance study. J Hypertens 2007;25:891 –894. 20. Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, Ward K, Ebrahim S. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013;1:CD004816.
doi:10.1093/eurheartj/ehu106 Online publish-ahead-of-print 18 March 2014
.............................................................................................................................................................................
Left atrial dissection after mitral valve replacement Patrick O. Myers1*, Afksendiyos Kalangos1, Franc¸ois Mach2, and Cedric Vuille2 1 Division of Cardiovascular Surgery, Geneva University Hospitals and School of Medicine, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland and 2Division of Cardiology, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
* Corresponding author. Tel: +41 223727638, Fax: +41 223727634, Email: [email protected]
An 80-year-old gentleman was referred for two vessel coronary artery disease and severe mitral regurgitation due to myxomatous P2 prolapse. The patient underwent coronary artery bypass grafting and mitral valve repair, which despite multiple attempts and due to highly fragile tissue, required mitral valve replacement during the same operation. A bioprosthetic valve (arrows) was implanted using everting pledgeted stitches placed on the atrial aspect of the mitral annulus, to avoid the risk of atrioventricular disruption given tissue fragility. Post-bypass echocardiography showed a trivial paravalvular leak with no significant gradient across the valve. The patient presented transient hypertension after transfer to the ICU, with a maximal systolic pressure of 170 mmHg. He later presented haemodynamic instability, prompting echocardiography to rule out tamponade, which showed a cavity within the left atrial (LA) wall, with high velocity flow (.3.5 m/s) originating from the posterior left ventricular wall, diagnostic for a LA dissection. There was no significant paravalvular leak and a small pericardial effusion (*). There was minimal flow from the dissection cavity to the LA. The absence of flow within the pericardium and stable haematocrit indicated this was a contained rupture into the LA wall. There was no supramitral stenosis. Haemodynamics stabilized with fluid resuscitation and vasoconstriction. Left atrial dissection is a rare complication after mitral valve replacement, and represents a variant of contained atrioventricular disruption. We preferred medical management given the friable tissue and technical difficulty in repairing this dissection, and critical state of this elderly patient. Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected]
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on November 13, 2015
CARDIOVASCULAR FLASHLIGHT
9.
10.
11.
12.
13.
from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation 2008;117:e510 –e526. Pierdomenico SD, Lapenna D, Bucci A, Di Tommaso R, Di Mascio R, Manente BM, Caldarella MP, Neri M, Cuccurullo F, Mezzetti A. Cardiovascular outcome in treated hypertensive patients with responder, masked, false resistant, and true resistant hypertension. Am J Hypertens 2005;18:1422 –1428. Symplicity HTNI, Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Bohm M. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet 2010; 376:1903 –1909. Grassi G, Seravalle G, Brambilla G, Mancia G. The sympathetic nervous system and new nonpharmacologic approaches to treating hypertension: a focus on renal denervation. Can J Cardiol 2012;28:311–317. Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Bohm M. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet 2010;376: 1903 –1909. Bisognano JD, Bakris G, Nadim MK, Sanchez L, Kroon AA, Schafer J, de Leeuw PW, Sica DA. Baroreflex activation therapy lowers blood pressure in patients with resistant hypertension: results from the double-blind, randomized, placebo-controlled rheos pivotal trial. J Am Coll Cardiol 2011;58:765 –773.
S. Bangalore et al.
14. Waters DD, Guyton JR, Herrington DM, McGowan MP, Wenger NK, Shear C. Treating to New Targets (TNT) Study: does lowering low-density lipoprotein cholesterol levels below currently recommended guidelines yield incremental clinical benefit? Am J Cardiol 2004;93:154 – 158. 15. LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, Fruchart JC, Gotto AM, Greten H, Kastelein JJ, Shepherd J, Wenger NK. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med 2005;352:1425 –1435. 16. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560 – 2572. 17. Cuspidi C, Macca G, Sampieri L, Michev I, Salerno M, Fusi V, Severgnini B, Meani S, Magrini F, Zanchetti A. High prevalence of cardiac and extracardiac target organ damage in refractory hypertension. J Hypertens 2001;19:2063 – 2070. 18. Zannad F. Aldosterone antagonist therapy in resistant hypertension. J Hypertens 2007;25:747 –750. 19. Lane DA, Shah S, Beevers DG. Low-dose spironolactone in the management of resistant hypertension: a surveillance study. J Hypertens 2007;25:891 –894. 20. Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, Ward K, Ebrahim S. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013;1:CD004816.
doi:10.1093/eurheartj/ehu106 Online publish-ahead-of-print 18 March 2014
.............................................................................................................................................................................
Left atrial dissection after mitral valve replacement Patrick O. Myers1*, Afksendiyos Kalangos1, Franc¸ois Mach2, and Cedric Vuille2 1 Division of Cardiovascular Surgery, Geneva University Hospitals and School of Medicine, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland and 2Division of Cardiology, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
* Corresponding author. Tel: +41 223727638, Fax: +41 223727634, Email: [email protected]
An 80-year-old gentleman was referred for two vessel coronary artery disease and severe mitral regurgitation due to myxomatous P2 prolapse. The patient underwent coronary artery bypass grafting and mitral valve repair, which despite multiple attempts and due to highly fragile tissue, required mitral valve replacement during the same operation. A bioprosthetic valve (arrows) was implanted using everting pledgeted stitches placed on the atrial aspect of the mitral annulus, to avoid the risk of atrioventricular disruption given tissue fragility. Post-bypass echocardiography showed a trivial paravalvular leak with no significant gradient across the valve. The patient presented transient hypertension after transfer to the ICU, with a maximal systolic pressure of 170 mmHg. He later presented haemodynamic instability, prompting echocardiography to rule out tamponade, which showed a cavity within the left atrial (LA) wall, with high velocity flow (.3.5 m/s) originating from the posterior left ventricular wall, diagnostic for a LA dissection. There was no significant paravalvular leak and a small pericardial effusion (*). There was minimal flow from the dissection cavity to the LA. The absence of flow within the pericardium and stable haematocrit indicated this was a contained rupture into the LA wall. There was no supramitral stenosis. Haemodynamics stabilized with fluid resuscitation and vasoconstriction. Left atrial dissection is a rare complication after mitral valve replacement, and represents a variant of contained atrioventricular disruption. We preferred medical management given the friable tissue and technical difficulty in repairing this dissection, and critical state of this elderly patient. Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected]
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on November 13, 2015
CARDIOVASCULAR FLASHLIGHT
