Showing papers on "Ostium published in 2009"

Role of multislice computed tomography in transcatheter aortic valve replacement

Abstract: Transcatheter aortic valve replacement (TAVR) required precise knowledge of the anatomic dimensions and physical characteristics of the aortic valve, annulus, and aortic root Most groups currently use angiography, transthoracic echocardiography (TTE), or transesophageal echocardiography (TEE) to assess aortic annulus dimensions and anatomy However, multislice computed tomography (MSCT) may allow more detailed 3-dimensional assessment of the aortic root Twenty-six patients referred for TAVR underwent MSCT Scans were also obtained for 18 patients after TAVR All patients underwent pre- and postprocedural aortic root angiography, TTE, and TEE Mean differences in measured aortic annular diameters were 11 mm (95% confidence interval 05, 18) for calibrated angiography and TTE, -09 mm (95% confidence interval -17, -01 mm) for TTE and TEE, -03 mm (95% confidence interval -11, 06 mm) for MSCT (sagittal) and TTE, and -12 mm (95% confidence interval -22, -02 mm) for MSCT (sagittal) and TEE Coronal systolic measurements using MSCT, which corresponded to angiographic orientation, were 32 mm (1st and 3rd quartiles 26, 39) larger than sagittal systolic measurements, which were in the same anatomic plane as standard TTE and TEE views There was no significant association between either shape of the aortic annulus or amount of aortic valve calcium and development of perivalvular aortic regurgitation After TAVR, the prosthesis extended to or beyond the inferior border of the left main ostium in 9 of 18 patients (50%), and in 11 patients (61%), valvular calcium was <5 mm from the left main ostium In conclusion, MSCT identified that the aortic annulus was commonly eccentric and often oval This may in part explain the small, but clinically insignificant, differences in measured aortic annular diameters with other imaging modalities MSCT after TAVR showed close proximity of both the prosthesis and displaced valvular calcium to the left main ostium in most patients Neither eccentricity nor calcific deposits appeared to contribute significantly to severity of paravalvular regurgitation after TAVR

In Vivo Assessment of High-Risk Coronary Plaques at Bifurcations With Combined Intravascular Ultrasound and Optical Coherence Tomography

Abstract: Objectives This study sought to evaluate the in vivo frequency and distribution of high-risk plaques (i.e., necrotic core rich) at bifurcations using a combined plaque assessment with intravascular ultrasound–virtual histology (IVUS-VH) and optical coherence tomography (OCT). Background Pathological examinations have shown that atherosclerotic plaque rich in necrotic core is prone to develop at bifurcations. High-risk plaque detection could be improved by the combined use of a technique able to detect necrotic core (IVUS-VH) and a high-resolution technique that allows the measurement of the fibrous cap thickness (OCT). Methods From 30 patients imaged with IVUS-VH and OCT, 103 bifurcations were selected. The main branch was analyzed at the proximal rim of the ostium of the side branch, at the in-bifurcation segment and at the distal rim of the ostium of the side branch. Plaques with more than 10% confluent necrotic core by IVUS-VH were selected and classified as fibroatheroma (FA) or thin-cap fibroatheroma (TCFA) depending on the thickness of the fibrous cap by OCT (>65 or ≤65 μm for FA and TCFA, respectively). Results Twenty-seven FA (26.2%) and 18 TCFA (17.4%) were found out of the 103 lesions studied. Overall the percentage of necrotic core decreases from proximal to distal rim (16.8% vs. 13.5% respectively, p = 0.01), whereas the cap thickness showed an inverse tendency (130 ± 105 μm vs. 151 ± 68 μm for proximal and distal rim, respectively, p = 0.05). The thin caps were more often located in the proximal rim (15 of 34, 44.1%), followed by the in-bifurcation segment (14 of 34, 41.2%), and were less frequent in the distal rim (5 of 34, 14.7%). Conclusions The proximal rim of the ostium of the side branch has been identified as a region more likely to contain thin fibrous cap and a greater proportion of necrotic core.

Anatomic variations and anomalies of the coronary arteries: 64-slice CT angiographic appearance.

Abstract: Purpose To retrospectively review the 64-slice computed tomography (CT) appearance of coronary artery anatomic variants and anomalies and determine their incidence in 700 patients. Materials and methods CT data of 700 patients who underwent 64-slice CT angiography (CTA) because of known or suspected coronary artery disease were retrospectively reviewed by two radiologists experienced in cardiovascular radiology. In each study, anatomic variants and anomalies were investigated. Results The coronary artery system was right dominant in 76%, left dominant in 9.1% and co-dominant in 14.8% of the cases. Ramus intermedius was present in 31%. Conus artery with a separate ostium in the right sinus Valsalva was observed in 22%, and in 0.2% two conus arteries originating with separate ostia were visualized. The sinus node artery (SNA) originated from the right coronary artery (RCA) in 79%, from the circumflex artery (Cx) in 20%, and from the left main coronary artery (LMCA) in 0.4%. In 0.4% of the cases SNA originating from the right sinus Valsalva with a separate ostium was seen. LMCA was absent in 0.4%. Cx was absent in 0.1%, and diagonals were absent in 0.1%. High takeoff of LMCA and RCA were observed in 0.7% and 0.1%, respectively. Myocardial bridging was observed in 37%. Anomalous origin of the coronary artery from the opposite sinus was observed in 1% of the cases. Conclusion Complex anatomy of the coronary artery system can accurately be depicted by 64-slice CTA. This modality is useful in detecting coronary artery variants and anomalies and is a valid alternative to conventional coronary angiography in their diagnosis.

Variations in Thebesian valve anatomy and coronary sinus ostium: implications for invasive electrophysiology procedures.

Abstract: Aims The coronary sinus (CS) is a commonly cannulated structure in patients undergoing electrophysiology studies, catheter ablation of arrhythmias, implantation of resynchronization therapy devices and, more recently, percutaneous mitral valve repair. The advent of these procedures has led to a renewed interest in the anatomy of the coronary venous system including its various components. To improve our understanding of this structure, we studied the anatomy of the human CS, including the valve that guards its ostium, the Thebesian valve. Methods and results In 75 randomly selected autopsied human hearts, we measured the transverse and craniocaudal dimensions of the CS ostium and characterized the shape, composition, per cent coverage, and attachment points of the Thebesian valve when present. Of the 75 hearts examined, 54 had organic heart disease including atherosclerotic coronary artery disease, left ventricular hypertrophy, dilated cardiomyopathy, rheumatic heart disease, infective endocarditis, and non-rheumatic valvular heart disease. A wide variety of Thebesian valve morphologies were seen, ranging from the absence of any valve to those where the valve was completely occluding the CS ostium. A Thebesian valve was present in the majority of the hearts examined (55/75 hearts—73%). The average transverse dimension of the CS ostium in hearts with Thebesian valves (7.3 ± 2.8 mm) was significantly shorter than those without Thebesian valves (9.4 ± 2.9 mm, P = 0.005). Similarly, the average craniocaudal dimension of the CS ostium in hearts with Thebesian valves (7.9 ± 2.7 mm) was also significantly shorter than those without Thebesian valves (9.3 ± 2.9 mm, P = 0.045). Conclusion Our study shows that some form of Thebesian valve is present in the majority of hearts (>70%). Of these, a significant minority (16%) had a valve morphology (covering >75% of the ostium, a fibrous, fibromuscular, or muscular composition, and devoid of fenestrations) that makes them a ‘potentially complicating’ structure interfering with the cannulation of the CS.

System and method for delivery of energy to tissue while compensating for collateral tissue

Abstract: A tissue ablation method for treating atrial fibrillation in a patient comprises locating an ostium of a pulmonary vein and positioning an interventional catheter adjacent the ostium. The interventional catheter has an energy source. Collateral tissue adjacent the ostium is located and tissue around the ostium is ablated with energy from the energy source so as to form a contiguous lesion circumscribing the ostium. The lesion blocks aberrant electrical pathways in the tissue so as to reduce or eliminate the atrial fibrillation. The ablating is modified so as to avoid ablating or otherwise damaging the collateral tissue.

Systems and Methods for Treating Sinuses

Abstract: Systems and methods for treating paranasal sinuses in a head of a patient include, for example, forming an opening through a canine fossa into a maxillary paranasal sinus and performing a procedure such as a balloon catheter dilation of the maxillary sinus ostium. In some embodiments, one or more procedures other than a balloon dilation procedure may be performed. In some embodiments, a combination of balloon dilation and one or more other procedures may be performed. Various approaches involve employing medical devices to accomplish alternative treatment modalities as well as taking alternative routes to the interventional site.

Catheter Selection for Coronary Angiography and Intervention in Anomalous Right Coronary Arteries

Abstract: Background: An anomalous origin of the right coronary artery (ARCA) from the left sinus of Valsalva (LSOV) has been reported in 6–27% of patients with coronary anomalies The unusual location and course of this anomaly poses a technical challenge for the interventionalist Appropriate guiding catheter selection is critical to ensure successful angiography and percutaneous intervention (PCI) We report our experience in 24 patients with an anomalous RCA originating from the LSOV Methods: Twenty-four angiograms of ARCA-LSOV were reviewed by two independent interventionalists with attention to the origin and take off of the RCA within the aortic root The origin was adjudicated with a scheme based on anatomical landmarks as described—A: origin from the aorta above the sinotubular plane; B: origin just below the ostium of the left coronary artery (LCA); C: origin below the sinotubular plane between the midline and the LCA; D: origin along the midline Results: The distribution of various takeoffs of the RCA was as follows: For type A (N = 4) the FL30 and FCL30 catheters were successful in three and one cases, respectively For type B (N = 5) the FCL30 or 35 was successful in four out of the five cases For type C (N = 9) the VL catheter was successful in eight (VL35 = 5:VL 30 = 3) cases The AL catheter was successful in five cases of type D (N = 6) RCAs (AL1 = 3:AL2 = 1:AL3 = 1) Conclusions: The classification method and catheter selection provide a useful framework to successfully engage ARCA-LSOV and may reduce contrast and radiation exposure

First-in-man (FIM) study of the Stentys™ bifurcation stent - 30 days results

Abstract: Aims: We report the acute and 30 day results of the OPEN I study, a multicentre prospective single arm study evaluating the safety and feasibility of the Stentys™ bifurcation stent Methods and results: The Stentys™ stent is a provisional, self-expanding nitinol drug eluting or bare metal stent with small interconnections that can be disconnected by balloon angioplasty to provide access to the side-branch and full ostium coverage Forty patients with de novo coronary bifurcation lesions were enrolled to be clinically followed-up over four years In addition to angiographic QCA evaluation, documentary IVUS and/or OCT were used in all cases to assess the stent’s deployment The patient population consisted of 85% males with an average age of 62 years Almost half had previous PCI, 31% previous MI and 5% previous CABG The majority of lesions (80%) involved the LAD-D, 42% of the patients had disease affecting the side-branch, with all three arms diseased in 24% of the cases The average lesion length in the main branch was 1295±363 mm with a bifurcation angle of 55° (range 30°-80°) Procedural success was achieved in 39/40 cases (955%) due to inability to track the stent in one patient with an extremely tortuous vessel In total 6 (15%) paclitaxel eluting and 33 (85%) BMS Stentys™ stents were successfully implanted, and simple disconnection of the stent mesh overlying the SB ostium was achieved in 37/39 cases (949%); in two cases, disconnection was not attempted The MACE at 30 days was 51% as a result of one non Q-wave MI following the procedure and one ischemia-driven revascularisation six days after the procedure Conclusions: This first-in-man (FIM) study demonstrates that the Stentys™ stent is safe and feasible resulting in an excellent procedural success rate and a low MACE rate The struts can be easily and safely disconnected to perform provisional stenting

Rare Case of an Unroofed Coronary Sinus Diagnosis by Multidetector Computed Tomography

Abstract: A 53-year-old man presented to our hospital with acute coronary syndrome and underwent uncomplicated cardiac catheterization with percutaneous coronary intervention. As part of an institutional research protocol for evaluation of the recently placed left circumflex stent, he underwent coronary CT angiography with ECG-gated, contrast-enhanced, 64-slice multidetector CT (Sensation Cardiac 64, Siemens Medical Solutions, Forchheim, Germany). An incidental note of an unroofed coronary sinus (CS) was made on the coronary CT angiogram (Figure 1A through 1D). The defect size measured by CT was 2.1×0.4 cm, and its distance from the CS ostium was 2.1 cm. In addition to its normal connection to the right atrium, the CS had a direct connection with the left atrium (LA) as noted by the contrast shunting from the LA into the CS and subsequently into the right atrium (Figure 1D). No other congenital anomalies, including persistent left superior vena cava (LSVC), were identified on the CT. Clinically, the patient had no prior history of strokes, hypoxia, or heart failure symptoms. His 12-lead surface ECG (Figure 2) showed normal sinus rhythm without evidence of chamber enlargement. The chest topogram from the CT …

Endoscopic endonasal transsphenoidal approach to the sellar region: results of endoscopic dissection on 30 cadavers.

Abstract: AIM: To recognize the endoscopic anatomy of the surgical corridor along the nasal cavity, sphenoidal sinus and the sellar area to delineate the pure endoscopic endonasal transsphenoidal approach (EETSA) to the region of the pituitary gland. MATERIAL and METHODS: The endoscopic anatomy of the nasal cavity, sphenoid sinus and the sellar region was studied in 30 fresh cadavers (mean age 42.1 / range 18-66) and dissections were performed in a stepwise manner to simulate EETSA to the sellar region. RESULTS: The sphenoid ostium, located 14.9 mm superior to the choana, was identified at the midpoint between the nasal septum and the superior turbinate in 23 specimens. The shape of the sphenoid ostium was linear (35%), fusiform (30%), oval(22%) or circular (13%). The mean width of the pituitary gland was 14.3 mm and the average minimum distance between the internal carotid arteries on both sides ranged between 13 to 22 mm. Following total hypophysectomy in 12 specimens, the width and length of diaphragma sellae was measured 10.83 and 5.83 mms respectively. CONCLUSION: This study documents that variations are common in nasal, sphenoidal and sellar phases of the trans-sphenoidal approach. Detailed knowledge of the basic anatomical relationships through the view of the endoscope and performing endoscopic dissections in large number of specimens will facilitate the endoscopic surgical procedures and decrease the rate of surgical complications.

Analysis of left main coronary artery bifurcation lesions treated with biolimus-eluting DEVAX AXXESS plus nitinol self-expanding stent: intravascular ultrasound results of the AXXENT trial.

Abstract: Objective: To assess the efficacy of the AXXESS stent on the treatment of left main coronary artery (LMCA) bifurcation lesions using IVUS. Background: The treatment of LMCA bifurcation lesions remains challenging even with the use of drug-eluting stents. The AXXESS system is a biolimus A9-eluting self-expanding stent, dedicated to the treatment of bifurcation lesions. Methods: Data were obtained from the AXXENT trial, a prospective, single-arm, multicenter study designed to evaluate the efficacy of the AXXESS stent on the treatment of LMCA bifurcation lesions. IVUS was available in 26 cases at 6-months follow-up. Volumetric and cross-sectional analyses within the AXXESS stent, and cross-sectional analyses at the ostia of left anterior descending (LAD) and left circumflex coronary arteries (LCX) were performed. Results: Within the AXXESS stent, percent neointimal volume obstruction was (3.0 ± 4.1)% with a minimal lumen area of 10.3 ± 2.6 mm2. AXXESS stent volume showed an 12.4% increase at follow-up compared with postprocedure (P = 0.04). Lumen area was significantly smaller in the LCX ostium compared with the LAD ostium at follow-up (3.6 ± 1.3 mm2 vs. 5.5 ± 2.0 mm2, P = 0.0112). There was greater neointimal formation in the LCX ostium compared with the LAD ostium (1.37 ± 1.20 mm2 vs. 0.30 ± 0.36 mm2, P = 0.0003). Conclusions: The AXXESS stent in the LMCA showed enlargement through 6-months follow-up and significant neointimal suppression. Greater neointimal formation and relatively inadequate stent expansion may contribute to luminal narrowing in the LCX ostium. © 2008 Wiley-Liss, Inc.

Real-time rotational ICE imaging of the relationship of the ablation catheter tip and the esophagus during atrial fibrillation ablation

Abstract: Introduction: Atrioesophageal fistula is a rare complication of atrial fibrillation (AF) ablation that should be avoided. We investigated whether rotational intracardiac echocardiography (ICE) can help to minimize ablation close to the esophagus. Methods and Results: We studied 41 patients referred for catheter ablation of refractory AF. A rotational ICE catheter was inserted into the (LA) to determine the location of the esophagus. The esophagus was identified to be either adjacent to the pulmonary vein (PV) ostium or to a cuff 2 cm outside the ostium. Circumferential ablation was performed at the PV ostium, with the exact ablation location determined by ICE. The relationship of the catheter tip to the esophagus was imaged during energy delivery, allowing interruption when respiration moved the tip closer to the esophagus. Out of 41 patients, the esophagus was seen near left-sided PVs in 32 and near right-sided PVs in three patients. The median distance from LA endocardium to esophagus was 2.2 mm (range, 1.4–6 mm). In 21 of 35 patients with a closely related esophagus, ablation over the esophagus was avoided by ablating either lateral or medial to the esophagus. In 14 patients, the esophagus could not be avoided, and risk was minimized by limiting lesion size. Significant movement (>10 mm) of the esophagus during the procedure occurred in 3/41 cases. Conclusion: Rotational ICE can accurately determine the distance of ablation sites from the esophagus. Real-time imaging of the relationship of the ablation catheter tip to the esophagus may reduce the incidence of esophageal injury.

Long-term outcomes of plaque debulking with rotational atherectomy in side-branch ostial lesions to treat bifurcation coronary disease.

Abstract: Background The prognosis after rotational atherectomy of a side-branch ostium to treat bifurcation coronary lesions is unknown. Methods This was a retrospective case-review study of 40 consecutive patients who underwent rotational atherectomy of the sidebranch ostium to treat symptomatic bifurcation coronary lesions meeting the Medina classification (1,1,1) at our institution between 2003 and 2007. Results Twenty-two (55.0%) patients underwent rotational atherectomy of the side-branch ostium alone and 18 (45.0%) underwent rotational atherectomy of the both the main vessel and the sidebranch ostium. Most of the patients (n = 37, 92.5%) had a drug-eluting stent placed in the main vessel after rotational atherectomy. Only 8 patients (20.0%) required side-branch stents, and 2 patients (5.0%) underwent a final kissing-balloon technique. No acute closure of the side branch or coronary perforation were observed. Major adverse cardiac events included cardiac death (n = 1; 2.5%), nonfatal myocardial infarction (n = 1; 2.5%), target vessel revascularization (n = 2; 5.0%) and target lesion revascularization (n = 0; 0.0%) during the mean follow-up period of 21.3 +/- 18.5 months. Conclusions The study demonstrated safety and feasibility of rotational atherectomy and provisional side-branch stenting to treat side-branch ostial lesions of true severe bifurcation coronary artery disease. The study results suggest that rotational atherectomy of a side-branch ostium prior to main-vessel stenting may be an option in selected patients undergoing complex bifurcation lesion angioplasty.

The changing face of paranasal sinus fungus balls.

Abstract: Objectives:We describe the clinical, radiographic, and histopathologic characteristics of fungus balls.Methods:We performed a retrospective review of 24 consecutive patients with the diagnosis of a paranasal sinus fungus ball (mycetoma) from 2001 to 2008.Results:We found that 18 of the 24 primarily involved sinuses had bony thickening, and 13 of the 24 had notable dilatation of the ostium. Eleven of the 24 patients were found to have some degree of immunocompromise (from organ transplantation, diabetes, etc). The patient's immune status correlated with the type of fungus involved. (Mucor-like fungi were more common in immunocompetent patients, and aspergillus-like fungi were more common in immunocompromised patients.) Also, there was a predilection for immunocompetent patients to have dilatated ostia, whereas immunocompromised patients were more likely to have a nondilatated ostium (p = 0.019).Conclusions:Our series of paranasal sinus fungus balls defines a group of patients heretofore poorly described in...

Vulnerable Carina Anatomy and Ostial Lesions in the left Anterior Descending Coronary Artery After Floating-Stent Treatment

Abstract: Introduction and objectives Percutaneous coronary intervention for ostial lesions of the left anterior descending coronary artery (LAD) remains a complex procedure. The aim of this study was to evaluate the usefulness of a method of treatment that we have termed the floatingstent approach. Methods The study involved 71 patients with ostial LAD lesions who underwent implantation of a drug-eluting stent in the LAD, which totally or partially covered the ostium of the circumflex artery. No further interventions were planned. Intravascular ultrasound was performed both at baseline and after treatment in 49 patients. All were followed up clinically (16 [12] months). Results Angiography of the LAD demonstrated an immediate success rate of 100%. However, significant focal damage was observed in the circumflex ostium in 7 (10%) patients, 3 of whom needed treatment. The mean protrusion of the stent over the origin of the circumflex artery was 2.48 (0.91) mm. The only predictor of circumflex ostial injury identified in the study was the carina having a spiky appearance on intravascular ultrasound, visible in the longitudinal view. We termed this feature the “eyebrow sign.” Carina displacement was responsible for the focal damage in 13 of the 14 patients with this feature. Overall, the major cardiac adverse event rate during follow-up was 4%. Conclusions Use of the floating-stent technique for treating LAD ostial lesions was straightforward and gave excellent medium-term results. Intravascular ultrasound showed that patients who had a carina with specific vulnerable anatomical features were predisposed to circumflex artery ostial injury.

Evaluation of aortic root and valve calcifications by multi-detector computed tomography

Abstract: BACKGROUND AND AIM OF THE STUDY In percutaneous aortic valve replacement (AVR), whilst calcifications are used as landmarks in fluoroscopic placement of the stent, they may also complicate stent placement. In response to this problem, the study aim was to examine severe aortic root calcification by using multi-detector computed tomography (MDCT), to better understand the pathology complicating percutaneous valve placement. METHODS In 33 patients with severe aortic stenosis and scheduled for surgery, the 'inner orifice' and 'outer fibrous' annulus diameter and area (with and without calcification) were measured, in addition to the distances of the calcifications and coronary ostia from the annulus, using by ECG-gated 64-slice MDCT. Aortic root calcification was evaluated as minimal (< 25% of total circumference), mild (25-50%), moderate (50-75%), and severe (75-100%). RESULTS The inner orifice annulus area was 5.9 +/- 1.9 cm2 (range: 1.4-10.1 cm2), while the outer fibrous area was 7.5 +/- 1.8 cm2 (range: 4.7-11.5 cm2). The proximal-to-distal extent of valve calcification from the annulus in the mid-center of leaflets was 0.8 +/- 0.26 cm. In 36% of patients, valvular calcification extended +/- 3 mm within the coronary-ostium level. The distance of the coronary ostia from the annulus was variable, with a mean of 1.3 +/- 0.35 cm (range: 0.6-2.4 cm) for the left coronary artery. In 42% of patients, a 'low coronary ostium' (< or = 1.1 cm), and in 6% a 'critical-low-coronary ostium' (< or = 8 mm) was identified. Annulus calcification was present in 100% of cases, but the severity varied widely (severe 50%, moderate 35%, mild 15%). In 36% of cases, the aortic annulus calcification extended caudally into the membranous part of the interventricular septum (and thus into the left ventricular outflow tract), and in 42% of cases (n = 14) into the anterior mitral valve leaflet. CONCLUSION The present results indicated that cardiac MDCT may qualify as a primary pre-procedural imaging modality to select patients for percutaneous AVR, based on the measurement and characterization of the aortic root and valve calcification. In comparison to echocardiography, CT will reduce--if not eliminate--difficulties in visualizing the aortic orifice area in heavily calcified valves. Furthermore, knowledge of the exact location of calcific deposits provides a distinct advantage to the fluroscopist for precise placement of the percutaneous aortic valve. Likewise, knowledge of the coronary arteries orifice in relation to the valve plane is critical to prevent inadvertent coronary artery occlusion, and would clearly be beneficial when planning future valve designs.

Electro-anatomical mapping of the left atrium before and after cryothermal balloon isolation of the pulmonary veins.

Abstract: The 28 mm cryoballoon catheter is a device used for pulmonary vein isolation (PVI). The aim of this study was to evaluate the extent of the ablation in the antral regions of the left atrium. Eighteen patients with drug refractory, symptomatic, paroxysmal AF were enrolled. A 3D electroanatomic reconstruction of the left atrium was made before and after successful PVI with the 28 mm cryoballoon. Markers were placed at the ostium. Sixteen patients were mapped. Fourteen patients had 4 veins each, and 2 patients had a common ostium of the left sided veins. All separate ostia were isolated in the antral region. The two common ostia showed ostial isolation. There was a significant difference in vein size between the common (29 and 31 mm) and the separate ostia (19 ± 4 mm) (p < 0.01). The performance of an additional segmental ablation if balloon PVI did not eliminate all electrical activity, did not influence the extent of the ablation. The earliest left atrial activation during sinus rhythm was located in the superior septal region before ablation in all patients. After ablation, two patients showed a substantial downward shift towards the middle and inferior septal region respectively (NS). Four patients demonstrated a slight downward shift of the first activation. In cryoballoon PVI, the majority of the veins undergo antral isolation. Veins with a diameter larger than the balloon, are isolated ostially. In individual cases, the left atrial activation sequence appears to be altered after ablation.

Vertebral artery ostial stent placement for atherosclerotic stenosis in 72 consecutive patients: clinical outcomes and follow-up results

Abstract: The study’s purpose is to report the technical and clinical outcomes of a patient cohort that underwent vertebral artery ostium stent placement for atherosclerotic stenosis. We retrospectively analyzed a prospectively collected database of neurointerventional procedures performed at a single center from 1999 to 2005. Outcome measures included recurrent transient neurological deficits (TNDs), stroke, and death. Kaplan–Meier analysis was used to estimate stroke- and/or death-free survival at 12 months. Cox proportional hazard was used to identify risk factors for recurrent vertebrobasilar ischemic events. Seventy-two patients with 77 treated vertebral ostial lesions were included. The 30-day stroke and/or death rate was 5.2% (n = 4), although no event was directly related to the vertebral ostium stent placement. Three procedure-related strokes were secondary to attempted stent placement at other sites (one carotid artery and two basilar arteries), and the one death was secondary to the presenting stroke severity. The mean clinical follow-up time available for 66 patients was 9 months. There were 14 TNDs (21%), two strokes (3%), and two deaths (3%) recorded in the follow-up. Recurrent vertebrobasilar ischemic events occurred in nine patients (seven TNDs and two strokes). No recurrent stroke and/or deaths were related to the treated vertebral ostium. Stroke- and/or death-free survival rate (including periprocedural stroke and/or death) was 89 ± 5% at 12 months. No vascular risk factor was significantly associated with recurrent vertebrobasilar ischemic events. Vertebral artery ostium stent placement can be safely and effectively performed with a low rate of recurrent stroke in the territory of the treated vessel. Patients who also underwent attempted treatment of a tandem intracranial stenosis appeared to be at highest risk for periprocedure stroke.

Open surgery versus endoscopic surgery in benign neoplasm involving the frontal sinus.

Abstract: The frontal sinus, because of its proper anatomic features, has a particular relation with nasal cavities. Indeed, its anatomic opening (ostium) is strictly related to a complex ethmoidal structure prechamber mainly composed of the frontal recess.This constitutional feature makes the endosco

Revision endoscopic sinus surgery in children: surgical causes of failure.

Abstract: Objectives/Hypothesis: Revision endoscopic sinus surgery (ESS) in children is uncommon. Causes of failure, however, are not very well delineated. The purpose of this study was to evaluate surgical causes of failure in children after ESS. Study Design: A retrospective review of children who had ESS at a tertiary children's referral center between 1993 and 2005 for chronic rhinosinusitis. Methods: ESS was performed on 243 children. Children with cystic fibrosis, immune deficiency/suppression, and ciliary abnormalities were excluded because the reasons of failure in those children are well known. Data were available on 176 children with at least one year of follow-up. Results: Twenty-three (13%) children required revision. The most common finding was adhesions in 57%, followed by maxillary sinus ostium stenosis or missed maxillary sinus ostium in 52% of the cases. In 39% of the cases, there was recurrent disease in the sinuses that were operated on initially. Interestingly, however, we found that in 26% surgery was needed because of disease that was present in nonoperated sinuses during the primary ESS. A deviated septum and a mucocele were the cause of failure in 17% and 13% of the patients, respectively. Presence of asthma and younger age contributed to the failure in some of these children. Conclusions: Adhesions and a scarred, narrow maxillary sinus ostium were the most common cause of failure in children after ESS. Steps taken during surgery may be required to help reduce the need for revision in particular for younger asthmatic children.

The improvement of middle ear ventilation by laser ablation of the epipharyngeal eustachian tube: a prospective study.

Abstract: A long-lasting dysfunction of the eustachian tube seems to be the etiologic origin for development of chronic otitis media (COM) with mesotympanic perforation, otitis media with effusion (OME), and chronic atelectasis of the middle ear. Surgical interventions in the middle ear generally treat the sequelae of the tube dysfunction but not the dysfunction itself. This prospective clinical study investigated how far fiber-guided laser ablation of the posterior half of the epipharyngeal tubal ostium led to better middle ear ventilation in the otologic disease patterns mentioned below. There were 38 adult patients included in the analysis. The patients in one group had a perforated tympanic membrane [COM before primary tympanoplasty (n = 14) or revision tympanoplasty (n = 5)]; the patients in a second group had an intact eardrum [OME resistant to therapy (n = 3), with an atelectasis of the middle ear (n = 2) or problems of pressure equalization with fast changes in ambient pressure (diving, flying) (n = 14)]. Laser ablation of the posterior half of the epipharyngeal tubal ostium was performed, generally with local anesthesia, if tubal function testing was pathologic (Valsalva maneuver, passive tube opening, tympanogram). In patients with COM the procedure was performed 8 weeks before the middle ear surgery. All patients were checked 8 weeks postoperatively and in the course of the following year. The intervention seemed to have had a positive effect on tube function in 68.4% of patients operated on (P = 0.001). In 26 of the 38 patients that had undergone operation, an improvement the results of tubal function tests could be seen in the postoperative follow-up. In the COM group the Valsalva maneuver improved in 14 of 19 patients (73.6%) (P = 0.001), and the passive tube opening improved in nine of 18 patients (50%). In the group with an intact eardrum the Valsalva maneuver improved in 13 of 18 patients (72.2%) (P = 0.001). The resulting condition remained stable after 1 year. None of the patients showed any complications as a result of the therapy. Minimally invasive shaping of the distal eustachian tube under topical anesthesia can be recommended for patients with the above-mentioned diagnoses who have pathologic middle ear ventilation. Especially prior to tympanoplasties, and especially in otologic revision procedures, where middle ear ventilation is a prerequisite for successful otologic surgery, the function of the eustachian tube can be optimized in 70% of the patients, particularly if there are pathological findings (tubal tonsil, narrow orifice of the tubal ostium, adenoids). The placement of permanent ear tubes in adults with recurrent OME can also be avoided by the procedure described. The resultant conditions remained stable for the next year. Patients with tympanic ventilation problems due to rapid pressure changes (flying, diving) can also benefit from this procedure.

Clinical experience with a single catheter for mapping and ablation of pulmonary vein ostium.

Abstract: Introduction: The aim of this single center study is to evaluate the safety and the efficacy of performing pulmonary vein isolation (PVI) using a single high-density mesh ablator (HDMA) catheter. Methods: A total of 17 consecutive patients with paroxysmal (10 patients) or persistent atrial fibrillation (7 patients) and no heart disease were enrolled. A single transseptal puncture was performed and the HDMA was placed at each PV ostium identified with anatomic and electrophysiological mapping. Pulsed radiofrequency (RF) energy was delivered at the targeted temperature of 58°C with maximum power of 80 watts. No other ablation system was utilized. The primary objective of the study was acute isolation of the targeted PV, and the secondary objective was clinical efficacy and safety of PVI with HDMA for atrial fibrillation (AF) prevention. Patients were followed at intervals of 1, 3, 6, and 12 months. Results: PVI was attempted with HDMA in 67/67 PVs. [Correction made after online publication October 27, 2008: PVs changed from 6/67 to 67/67] Acute success rate were: 100% (16/16) for left superior PV, 100% (16/16) for left inferior PV, 100% (17/17) for right superior PV, 100% (1/1) for left common trunk and 47% (8/17) for right inferior PV. Total procedure time was 200 ± 36 minutes (range 130–240 minutes) and total fluoroscopy time was 42 ± 18 minutes (range 23–75 minutes). During a mean follow-up of 11 ± 4 months, 64% of patients remained in sinus rhythm (8/10 paroxysmal AF and 3/7 for persistent AF). No complications occurred either acutely or at follow-up. Conclusions: PV isolation with HDMA is feasible and safe. The midterm efficacy in maintaining sinus rhythm is higher in paroxysmal than in persistent patients.

Novel self-expanding stent system for enhanced provisional bifurcation stenting: Examination by StentBoost and intravascular ultrasound.

Abstract: A 62-year-old man underwent percutaneous coronary intervention of a bifurcation lesion (Medina type 010) involving the mid-left anterior descending coronary artery and an important first diagonal branch with a novel stent specifically designed for bifurcations, the Stentys coronary bifurcation system. This is a self-expanding nitinol stent, with Z-shaped struts linked by interconnections that can be disconnected (in prespecified points every 1.5 mm all around the circumference and the length of the stent) at the level of the ostium of the side branch, simply by inflating an angioplasty balloon tracked to the ostium of the side branch, through the stent struts. The steps required for deployment of the stent and the final result obtained were evaluated by intravascular ultrasound examination and StentBoost Subtract, a specific X-ray stent-enhancing visualization technique. © 2009 Wiley-Liss, Inc.

Válvula nasal: anatomia e fisiologia

Abstract: The anterior portion of the nasal cavities, from the nostril to the nasal valve (NV), is the place of highest nasal resistance to airflow, paramount to nasal physiology. There are different terminologies for the same anatomic structures in the literature. AIM: The aim of this paper was to study the NV function and define clearly the structures of the anterior portion of the nasal cavities, mainly the region of the NV. CONCLUSION: Internum ostium is the anterior segment and isthmus nasi is the posterior segment of the NV region.

Assessment with optical coherence tomography of a new strategy for bifurcational lesion treatment: The Tryton Side‐Branch Stent

Abstract: The Tryton-Side Branch Stent™ (Tryton Medical, Inc., Newton, MA, USA) is a dedicated stent designed to provide complete carinal coverage of bifurcational lesions. After implantation of a 18 mm cobalt chromium Tryton stent from the left circumflex into the obtuse marginal branch, recrossing with an everolimus eluting Promus stent and final kissing balloon dilatation, optical coherence tomography (OCT) (LightLab Imaging Inc., Westford, MA, USA) was performed with a non-occlusive technique with motorized pullback (3 mm/s) during continuous pump injection of iso-osmolar contrast, in both LCx and OM1. OCT imaging showed good strut apposition at the level of the carina, with full coverage and no stent protrusion at the ostium of the side branch. Few malapposed struts were present in the proximal main vessel in the segment of stent superimposition, with a maximal separation from to the vessel wall of 160 μm. The implantation of the Tryton-Side Branch Stent™ allowed full coverage of the side branch ostium with uniform apposition of the stent struts at the level of the carina assessed by OCT. © 2008 Wiley-Liss, Inc.