תוצאת חיפוש

איתי ויזר, יהודה אדלר

המכון לשיקום הלב, מרכז רפואי תל-השומר והפקולטה לרפואה סאקלר, אוניברסיטת תל-אביב

מסתם וותין מסויד ומוצר (calcific aortic-valve stenosis) הוא מימצא ששכיחותו עולה עם הגיל והוא מהווה את הסיבה הנפוצה ביותר להחלפת מסתם הוותין (aortic valve). הסתיידות מסתם הוותין דווחה לראשונה בשנת 1904 על ידי Monkeburg ומאז, הועלו מספר תיאוריות להסברת תהליך ההסתיידות (calcification). התיאוריה המכאנית מציגה במרכז את תהליך השחיקה הכרוני של המסתם (wear and tear), הפוגע בקולאגן ומוביל להסתיידות. לדוגמה: זרימת דם לא תקינה דרך מסתם ותין דו-צניפי (bicuspid aortic valve) נקשרת לשחיקה מוגברת של המסתם, מה שמהווה גורם סיכון להסתיידותו. למרות שמקובל לחשוב, כי שלושה עלים המווסתים את העומס על המסתם טובים יותר משני עלים, שלושה עלי מסתם ותין תקינים אנטומית יעולים גם הם להפוך למסוידים ומוצרים. תיאוריית ההתאבנות (petrification) מציגה את הסברה, כי הזדקנות ומוות תאים במישלב עם התאבנות תוצרי-לוואי של פירוקם גורמים להסתיידות של עלי המסתם. האם הסתיידות מסתם הוותין היא רק חלק מתהליך ההזדקנות? ראיות חדשות מצביעות, כי תהליך הסתיידות המסתם אינו תהליך סביל, ומעורב בו תהליך דלקתי בדומה לזה המתרחש בטרשת עורקים.

Treatment of Traumatic False Aneurysm of the Thoracic Aorta with Stent Graft

R. Avrahami, M. Noyman-Levine, M. Haddad, A. Koren, J. Dahan, G. Sivak, A. Zelikovski,

Department of Vascular Surgery, Rabin Medical Center, Beilinson Campus, Petah Tikva

and Sackler School of Medicine, Tel-Aviv University, Israel

The treatment of traumatic false aneurysm of the thoracic aorta by endovascular stent graft may have advantages over conventional surgery. This is a case study of two women suffering from false aneurysm of the thoracic aorta caused in one by a knife injury and in the other by a car accident. After the patients became hemodynamically stable, a commercially available endothelial stent graft (Talent, Gor) was deployed. Recovery was rapid in the first patient. The second patient required emergency laparotomy for venous bleeding one day after stent placement; she died two weeks later, mainly from organ failure.

Conclusions: Endovascular techniques can be used in selected cases to treat thoracic false aneurysms thereby avoiding the complexity and morbidity of conventional surgery.

Balloon Angioplasty of Native Coarctation of the Aorta

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, Petah Tikva, and Sackler School of Medicine, Tel Aviv University

The use of balloon dilatation to treat native coarctation of the aorta is gaining acceptance among interventional pediatric cardiologists, but is still controversial. We describe our experience with this procedure in 21 children, mean age 5.6 years and mean weight 21.1 kg. Most had an additional congenital heart defect, most commonly a bicuspid aortic valve. 17 were asymptomatic, 3 had tachypnea and 1 infant had severe congestive heart failure and was ventilated. The mean systolic blood pressure was 129.7 mm Hg.

Balloon dilatation was successful in 90% (19), decreasing the mean maximal systolic gradient from 35.3 to 9 mm Hg (p<0.001), and increasing the narrowest area from 3.9 to 8.2 mm (p<0.001), with a mean balloon-to-coarctation width-ratio of 2.8. There were no complications. Of 15 who underwent repeat cardiac catheterization at a mean interval of 10.6 months, 2 had a maximal systolic gradient of more than 20 mm Hg. 1 of these underwent successful repeat angioplasty and the other, who also had a small aneurysm, underwent surgical repair successfully. 2 others had small aneurysms and they are being followed clinically.

All patients were seen again after a mean interval of 31 months. The mean systolic blood pressure was 104 mm Hg, significantly lower than before intervention (p<0.002). 1 had an increased pressure gradient between right arm and leg of 35 mm Hg at later follow-up, and repeat cardiac catheterization demonstrated a good result 13 months after the initial procedure. She is awaiting a third catheterization. Overall, 90% had good mid-term results.

Based on our experience and recent reports, balloon angioplasty is safe and effective in most children older than 7 months and should be considered a viable alternative to operation for discrete aortic coarctation. Further long-term evaluation is needed.

Percutaneous Closure of Patent Arterial Ducts with Occluding Spring Coils

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, Petah Tikva and Sackler School of Medicine, Tel Aviv University

In recent years percutaneous closure of small and medium- sized patent arterial ducts has been achieved using occluding spring coils. We describe our experience in 93 patients with this tec, using a snare to facilitate the procedure in most. All patients had a clinically apparenpatent arterial duct and had undergone attempts at transcatheter closure at a mean age of 6.8 years. In 1, the duct was a residual lesion following surgical ligation, and in 5 it was a residual following attempted closure with the Rashkind double-umbrella. The mean narrowest diameter of the ducts was 2.1 mm.

In our 93 patients implantation was successful in 92 (99%), using 1 coil (82 patients), or 2 (10 patients), and in 1 by a combination of a double-umbrella device and an occluding spring coil.

The mean fluoroscopic screening time for the whole group was 22.8 minutes, which decreased to 16.8 minutes in the last 50 patients. The coil embolized in 7 patients, but was retrieved in 6 and the ducts were subsequently occluded with another coil. In 1 patient the coil was left in a distal small branch of the left pulmonary artery and the duct was successfully occluded with a double-umbrella.

Color-Doppler echocardiogram performed the morning after placement of the coils showed residual leaks in 18%. At mean follow-up of 24.6 months repeat imaging showed residual leaks in only 3 of these patients (3%).

We conclude that occlusion of small to medium-sized ducts using coils appears to be effective and is the treatment of choice. The use of a snare to hold and manipulate the coil as it is delivered improves control of the coil, the accuracy of its placement, as well as giving complete occlusion of the ducts.

Traumatic Aortocaval Fistula

Gad Shaked, Arie Arisch, David Czeiger

Surgery Dept., Soroka University Hospital, Beer Sheba

Arterio-venous fistula is a relatively rare form of vascular injury. A cof an unusual fistula between aorta and inferior vena cava is presented. Occasionally this type of is difficult to diagnose early. Life-threatening conditions may mandate prompt treatment and the use of damage control strategy. It is also important to diagnose and treat this injury in order to prevent complications. Sudden hemorrhage and congestive heart failure are the major disturbances that result from aortocaval fistula.