Rupture of sinus of Valsalva

Catheterization and Cardiovascular Interventions 2014;84:1184-89.

Li Zhong et al.

Transcatheter closure of ruptured sinus of Valsalva aneurysm.

n=22

From...To:

Non-coronary sinus to RA 11

Non-coronary sinus to RVinflow 1

Right coronary sinus to RVOT 8

Right coronary sinus to RA 2

Devices used: 

Amplatzer duct occluder 19

Amplatzer muscular VSD device 1

Outcome:

Successful in 20.

No residual shunt in 18, Small residual shunt in 2.

Complications:

Two patient needed urgent AVR because of procedure-related aortic valve regurgitation.

Diabolo Stent - Fontan Fenestration Creation, Creation of Dumbell shape

Catheter Cardiovasc Interv. 2010 Nov 15;76(6):860-4.
Novel technique to reduce the size of a Fontan Diabolo stent fenestration.
Anderson B, Bhole V, Desai T, Mehta C, Stumper O.
Source
The Birmingham Children's Hospital, Birmingham, United Kingdom.

Abstract
OBJECTIVES:
To develop an effective catheter technique to reduce the size of a Diabolo stent fenestration in the failing Fontan circulation.

BACKGROUND:
Diabolo stent fenestration is employed by many centers in the treatment of the failing Fontan patient. With subsequent recovery, exercise tolerance may be impaired by significant desaturation secondary to the right to left shunt across the fenestration. Complete fenestration closure carries the risk of recurrence of the initial symptoms and, hence, reduction of the size of fenestration should be the preferred technique.

METHODS:
Twenty-eight patients with failing Fontan circulations (16 early and 12 late) underwent Diabolo stent fenestration for relief of symptoms. Five of these patients remained very limited by severe desaturation even at rest, after complete recovery from symptoms. Further cardiac catheterization with crimping/reduction of the size of the waist of the stent was carried out using a technique whereby a snare catheter was placed over the waist of the stent aided by an arterio-venous guidewire loop and a balloon catheter placed within the stent.

RESULTS:
All 5 patients had successful stent reduction with improvement in saturations, whilst still maintaining a small residual fenestration. No complications were encountered.

ONCLUSION:
This novel technique of reduction of a diabolo stent fenestration, in a failing Fontan circulation, offers the advantages of avoidance of implanting further devices in the circulation and the ability to redilate the stent should symptoms recur.

Copyright © 2010 Wiley-Liss, Inc.

Bifurcation stenting - RVOT. Branch PA, Coarctation

Catheter Cardiovasc Interv. 2011 Sep 1;78(3):419-24. doi: 10.1002/ccd.23025. Epub 2011 Mar 30.
A novel technique for stenting pulmonary artery and conduit bifurcation stenosis.
Stumper O, Bhole V, Anderson B, Reinhardt Z, Noonan P, Mehta C.
SourceHeart Unit, Birmingham Children's Hospital, United Kingdom. oliver.stumper@bch.nhs.uk

Abstract
BACKGROUND: Distal conduit obstruction is a recognized complication after surgery for congenital heart disease requiring implantation of a conduit from the right ventricle to the pulmonary arteries. Endovascular stenting of distal conduit obstruction can be challenging due to the proximity to the pulmonary artery bifurcation.

OBJECTIVE: A technique is described, whereby a single stent is mounted onto two balloon angioplasty catheters in tandem. This ensemble was delivered to the distal conduit/pulmonary artery via a large Mullins sheath on two guidewires, one placed in each of the branch pulmonary arteries. The aim was to assess safety and efficacy of this novel technique.

MATERIALS AND RESULTS: Seven patients (mean age 13.4 (6.7-23.4) years, mean weight 44.2 (23-69) kg were treated with this method. The pressure gradient was reduced from 36 (26-52) mm Hg to 11 (8-15) mm Hg [P< 0.05]. RV/LV pressure ratio decreased from 0.85 (0.6-0.95) to 0.42 (0.35-0.5) [P < 0.05]. There were no significant complications. During follow-up over a median of 2.6 (0.3-6.7) years no patient required re-intervention or surgery.

CONCLUSION: This novel technique appears to be safe and effective for stenting stenoses just proximal to pulmonary artery bifurcation.

Copyright © 2011 Wiley-Liss, Inc.



Catheter Cardiovasc Interv. 2011 Sep 1;78(3):425-7.



Dual wire technique for aortic coarctation stent placement.
Lampropoulos K, Budts W, Gewillig M.
SourceCongenital, University Hospitals Leuven, Belgium.

Abstract
A young adult presented for percutaneous treatment of a narrow aortic coarctation. A very large left subclavian artery originated immediately proximal to the coarctation. In order not to exclude or jail the left subclavian artery with a stent, a double wire technique was used. From a femoral approach, two guide wires were positioned, one in the aortic arch and another in the subclavian artery. A stent crimped over a 16-mm balloon and a 4-Fr catheter was advanced over the two wires within a 14-Fr long introducer sheath. The stent was successfully deployed and molded within the bifurcation by a kissing balloon technique, relieving the obstruction and leaving a guaranteed passage to the subclavian artery. The double wire technique is an elegant way to deliver a stent safely across a narrowing with guaranteed access to important side branches.

Copyright © 2010 Wiley-Liss, Inc.

Figure-8 stitch - For Hemostasis of femoral vein access

Catheter Cardiovasc Interv. 2011 Jul 1;78(1):155-60.

Technique of temporary subcutaneous "Figure-of-Eight" sutures to achieve hemostasis after removal of large-caliber femoral venous sheaths.

Cilingiroglu M, Salinger M, Zhao D, Feldman T.
SourceNorthShore University HealthSystem, Evanston, Illinois, USA.

Abstract
Over the last decade, significant advances have been made in percutaneous treatment of structural heart diseases. Many of these interventions require insertion of large caliber sheaths in the femoral veins. Manual compression, compression devices, and various closure devices have been used for removal of large-sized venous sheaths. Here, we describe the use of a temporary subcutaneous "Figure-of-Eight" suture technique for venous access site closure after removal of large-caliber sheaths.

Copyright © 2011 Wiley-Liss, Inc.

Cath: Melody Valve in Contegra Graft - Animal Study

Circulation. 2010;122:A19333

Abstract 19333: Transcatheter Delivery of Melody Valves (MelV) Larger Than Contegra Conduit (CC)

Core 3. Genetics, Genomics and Congenital CV Disorders Session Title: Cardiac Catheterization and Electrophysiology in the Young

Prakul Chanthong; Luis Quinonez; Patty Boylen; Jon Timinsky; James Y Coe

UNIVERSITY ALBERTA HOSPITAL, Edmonton, Canada; Medtronic Canada, Missisauga, Canada; UNIVERSITY ALBERTA HOSPITAL, Edmonton, Canada

Transcatheter replacement of pulmonary valves is used in failed right ventricular to pulmonary artery (RV-PA) homografts (H) or prosthetic valves (PV). The former calcify and the latter have metal rings ± struts, both providing secure landing spots for MelV. The MelV expansion is limited by the H or PV size, and H may rupture if expanded beyond its original diameter. CCs often do not calcify, yet may become aneurysmal with increased intraluminal pressure. We tested the hypothesis that transcatheter MelV replacement is possible in a hypertensive, supported CC. Under general anesthesia, supported 18 mm CCs were placed as descending aortic jump grafts via a left thoracotomy in sheep (n=6). After a recovery period, 22 mm MelVs (n=4) were delivered via a carotid artery into the CCs. 56-82 (mean 72) days after aortic placement, the 18 mm CC dilated to 36-37 mm under systemic pressure, while the ring diameter remained at 18 mm. Deploying the MelV at 22 mm expanded the CC rings to 22 mm. without CC rupture. Transcatheter Melody valve replacement into the Contegra conduits is feasible. The Melody valve will expand the rings of the Contegra conduit to the largest valve diameter.

Author Disclosures: P. Chanthong, None; L. Quinonez, None; P. Boylen, Medtronic, Modest, Employment; J. Timinsky, None; J.Y. Coe, Medtronic, Modest, Consultant/Advisory Board; NuMed, Modest,Consultant/Advisory Board.

Radiation Exposure during Radial Access (Right vs. Left)

CIRCINTERVENTIONS.111.961185

Published online before print May 17, 2011

Referenced here, more to highlight the methodology of the adult study and for actual reports of measurement dose, etc. This adult study compares right and left radial access. Radiation exposures were similar between right and left radial approached. Slightly increased exposure to the wrist in right radial approach compared to left radial approach.

Operator Radiation Exposure During Percutaneous Coronary Procedures Through the Left or Right Radial Approach

The TALENT Dosimetric Substudy

1. Alessandro Sciahbasi, MD at al.


Background—Transradial percutaneous coronary procedures may be effectively performed through the right radial approach (RRA) or the left radial approach (LRA), but data on radiation dose absorbed by operators comparing the two approaches are lacking. The aim of the present study was to evaluate radiation dose absorbed by operators during coronary procedures through the RRA and LRA.

Methods and Results—Three operators were equipped with 5 different dosimeters (left wrist, shoulder, thorax outside the lead apron, thorax under the lead apron, and thyroid) during RRA or LRA for coronary procedures. Each month, the dosimeters were analyzed to determine the radiation dose absorbed. From February to December 2009, 390 patients were randomly assigned to the RRA (185 patients; age, 66±11 years) or the LRA (185 patients; age, 66±11 years). There were no significant differences in fluoroscopy time (for RRA, 369 seconds; interquartile range, 134 to 857 seconds; for LRA, 362 seconds; interquartile range, 142 to 885 seconds; P=0.58) between the 2 groups. There were no significant differences in monthly radiation dose at the thorax (0.85±0.46 mSv for RRA and 1.12±0.78 mSv for LRA, P=0.33), at the thyroid (0.36±0.2 mSv for RRA and 0.34±0.3 mSv for LRA, P=0.87), and at the shoulder (0.73±0.44 mSv for RRA and 0.94±0.42 mSv for LRA, P=0.27). The dose at the wrist was significantly higher for the RRA (2.44±1.12 mSv) compared with the LRA (1±0.8 mSv, P=0.002). In both radial approaches, the thoracic radiation dose under the lead apron was undetectable.

Conclusions—Compared with RRA, LRA for coronary procedures is associated with similar radiation dose for operators at the body, shoulder, or thyroid level, with a possible significant advantage at the wrist. The cumulative radiation dose for both approaches is well under to the annual dose-equivalent limit.

Clinical Trial Registration—URL: http://www.clinicaltrials.gov/. Unique identifier: NCT00282646.

Cath: Novelties. Fusing MRI with X-ray

Published ahead of print. Accessed on 5/2/2011
Circulation: Cardiovascular Imaging

X-ray Magnetic Resonance Fusion to Internal Markers and Utility in Congenital Heart Disease Catheterization

Yoav Dori1*, et al.
The Children's Hospital of Philadelphia, Philadelphia, PA & Siemens Healthcare, Malvern, PA
Corresponding author; email: doriy@email.chop.edu

Abstract
Background—X-ray magnetic resonance fusion (XMRF) allows for utilization of 3D data during cardiac catheterization. However, to date, technical requirements have limited the use of this modality in clinical practice. Here we report on a new internal marker XMRF method that we have developed and describe how we used XMRF during cardiac catheterization in congenital heart disease.

Methods and Results—XMRF was performed in a phantom and in 23 patients presenting for cardiac catheterization who also needed cardiac MRI for clinical reasons. The registration process was performed in less than 5 minutes per patient with minimal radiation (0.004 - 0.024 mSv) and without contrast. Registration error was calculated in a phantom and in 8 patients using the maximum distance between angiographic and 3D model boundaries. In the phantom the measured error in the AP projection had a mean of 1.15 mm (standard deviation 0.73). The measured error in patients had a median of 2.15 mm (IQR 1.65 - 2.56 mm). Internal markers included bones, airway, image artifact, calcifications, and the heart and vessel borders. The MRI data was used for road mapping in 17/23 (74%) cases and camera angle selection in 11/23 (48%) cases.

Conclusions—Internal markers based registration can be performed quickly, with minimal radiation, without the need for contrast, and with clinically acceptable accuracy using commercially available software. We have also demonstrated several potential uses for XMRF in routine clinical practice. This modality has the potential to reduce radiation exposure and improve catheterization outcomes.

Two video links:
http://circimaging.ahajournals.org/content/suppl/2011/04/29/CIRCIMAGING.111.963868.DC1/Video1.mov

Video showing MRI fusion with fluoro guiding cath procedure:
http://circimaging.ahajournals.org/content/suppl/2011/04/29/CIRCIMAGING.111.963868.DC1/Video2.mov

Balloon Pulmonary Angioplasty - Adverse reactions (C3PO group)

Balloon Angioplasty and Stenting of Branch Pulmonary Arteries
Adverse Events and Procedural Characteristics: Results of a Multi-Institutional Registry
Ralf J. Holzer, et al.
Circ Cardiovasc Interv Apr 26, 2011 (Pub ahead of print)

Background—Pulmonary artery (PA) balloon angioplasty and/or stenting (PA rehabilitation) is one of the most common procedures performed in the cardiac catheterization laboratory, but comprehensive and consistently reported data on procedure-related adverse events (AE) are scarce.

Methods and Results—Data were prospectively collected using a multicenter registry (Congenital Cardiac Catheterization Project on Outcomes). All cases that included balloon angioplasty and/or stent implantation in a proximal or lobar PA position were included. Multivariate analysis was used to evaluate for independent predictors of AE and need for early reintervention. Between February 2007 and December 2009, 8 institutions submitted details on 1315 procedures with a PA intervention. An AE was documented in 22% with a high severity (level 3 to 5) AE in 10% of cases. Types of AE included vascular/cardiac trauma (19%), technical AE (15%), arrhythmias (15%), hemodynamic AE (14%), bleeding via endotracheal tube/reperfusion injury (12%), and other AE (24%). AE were classified as not preventable in 50%, possibly preventable in 41%, and preventable in 9%. By multivariate analysis, independent risk factors for level 3 to 5 AE were presence of ≥2 indicators of hemodynamic vulnerability, age below 1 month, use of cutting balloons, and operator experience of <10 years. Reintervention during the study period occurred in 22% of patients undergoing PA rehabilitation.

Conclusions—PA rehabilitation is associated with a 10% incidence of high-level severity AE. Hemodynamic vulnerability, young age, use of cutting balloons, and lower operator experience were significant independent risk factors for procedure-related AE.

Link to article

Innovation: Robotic Coronary Angioplasty

J Am Coll Cardiol Intv, 2011; 4:460-465,

First-in-Human Evaluation of a Novel Robotic-Assisted Coronary Angioplasty System

Juan F. Granada, MD*,,*, Juan A. Delgado, MD, Maria Paola Uribe, MSCE, Andres Fernandez, MD, Guillermo Blanco, MD, Martin B. Leon, MD, Giora Weisz, MD
* Skirball Center for Cardiovascular Research, Cardiovascular Research Foundation, New York, New York Corbic Research Institute, Envigado, Colombia Corbic Medical Center, Envigado, Columbia New York Presbyterian Hospital, Columbia University Medical Center, New York, New York (Email: jgranada@crf.org)

Background: A remote-control, robotic-assisted angioplasty system is under development to address some of the procedural challenges and occupational hazards associated with traditional PCI.

Methods:

CorPath 200 robotic system (Corindus, Inc., Natick, Massachusetts) consists of a remote cockpit & a multicomponent bedside unit that enables the operator to advance, retract, and rotate guidewires and rapid exchange catheters. The primary endpoint was device clinical success (30% residual stenosis) without in-hospital major adverse cardiac events.

Technical success was defined as the ability of the system to complete all the planned angioplasty steps on the basis of procedural segments. Patients were followed up to 30 days after angioplasty procedure.

Results: A total of 8 patients were enrolled in the study. The primary endpoint was achieved in all patients (100%). The technical success of the robotic system was 97.9% in completing 47 of 48 planned steps. There were no device- or procedure-related complications and no in-hospital or 30-day major adverse cardiac events. The operators rated the robotic system performances as equal to or better than manual procedures in 97.5% of the cases. The operator radiation exposure was 97% lower than the levels found at the standard table position.

Conclusions: Early clinical experience with a robotic-assisted angioplasty system demonstrated feasibility, safety, and procedural effectiveness comparable to manual operation. In addition, the total operator exposure to radiation was significantly low. A larger study is warranted to verify the safety and effectiveness of robotic-assisted percutaneous coronary intervention.

Risk Categories in Cath Procedures

Circulation: Cardiovascular Interventions.
2011; 4: 188-194

Procedure-Type Risk Categories for Pediatric and Congenital Cardiac Catheterization

Lisa Bergersen, MD, MPH, Kimberlee Gauvreau, ScD, Audrey Marshall, MD, Jacqueline Kreutzer, MD, Robert Beekman, MD, Russel Hirsch, MD, Susan Foerster, MD, David Balzer, MD, Julie Vincent, MD, William Hellenbrand, MD, Ralf Holzer, MD, John Cheatham, MD, John Moore, MD, James Lock, MD and Kathy Jenkins, MD, MPH

Abstract

Background— The Congenital Cardiac Catheterization Project on Outcomes (C3PO) was established to develop outcome assessment methods for pediatric catheterization.

Methods and Results— Six sites have been recording demographic, procedural and immediate outcome data on all cases, using a web-based system since February 2007. A sample of data was independently audited for validity and data completeness. In 2006, participants categorized 84 procedure types into 6 categories by anticipated risk of an adverse event (AE). Consensus and empirical methods were used to determine final procedure risk categories, based on the outcomes: any AE (level 1 to 5); AE level 3, 4, or 5; and death or life-threatening event (level 4 or 5). The final models were then evaluated for validity in a prospectively collected data set between May 2008 and December 31, 2009. Between February 2007 and April 2008, 3756 cases were recorded, 558 (14.9%) with any AE; 226 (6.0%) level 3, 4, or 5; and 73 (1.9%) level 4 or 5. General estimating equations models using 6 consensus-based risk categories were moderately predictive of AE occurrence (c-statistics: 0.644, 0.664, and 0.707). The participant panel made adjustments based on the collected empirical data supported by clinical judgment. These decisions yielded 4 procedure risk categories; the final models had improved discrimination, with c-statistics of 0.699, 0.725, and 0.765. Similar discrimination was observed in the performance data set (n=7043), with c-statistics of 0.672, 0.708, and 0.721.

Conclusions— Procedure-type risk categories are associated with different complication rates in our data set and could be an important variable in risk adjustment models for pediatric catheterization.

Hybrid Procedure: Intraop. VSD closure

Catheterization and Cardiovascular Interventions 2011;77:557-563

A novel method of hybrid intraoperative catheter-based closure of ventricular septal defects using the Amplatzer® PDA occluder†
Christian Neukamm MD, et al.

Oslo, Norway & Kiel, Germany

Background: In five patients, an apical muscular septal defect was closed in a hybrid approach using the Amplatzer® duct occluder during open heart surgery, whereas concomitant defects were treated surgically. In addition to their different heart defects that needed surgery, all had a muscular ventricular septal defect in the apex of the heart, poorly accessible for traditional, surgical approach. We describe the method and outcome in these patients.

Methods: The tip of a forceps was advanced from the left into the right ventricle through the ventricular septal defect. The delivery sheath was caught under visual control in the right ventricle and pulled back into the left ventricle. The disc was developed and pulled back until it was felt tugging at the septum. Then the core was developed. The end of the device was visible in the right ventricle and was secured with a Prolene® suture.

Results: The procedures were event-free. During early follow-up there were either no or only insignificant shunts in the region of the prior trabecular defects in four patients. The unsatisfactory result in the last patient was caused by inaccurate preoperative assessment.

Conclusion: The method seems valuable in patients in need of other intracardiac surgery.

© 2010 Wiley-Liss, Inc.

Tricuspid Valve Implantation in Fontan Patient

Circulation: Cardiovascular Interventions. 2011;4:112-3.
Images in Cardiology























History:
Tricuspid Atresia - type 1c
(Tricuspid atresia, Normally-related Great Arteries, VSD, no PS)

14 yrs: Fontan-Bjork Operation (RA-RV Hancock Prosthesis, Closure of ASD and VSD)

24 yrs: Obstruction of Hancock prosthesis. Therefore, replaced with 23 mm Aortic Homograft

38 yrs: Complete Heart Block - Dual Chamber pacemaker (RV lead via homograft)

45 yrs: PLE, failure of medical therapy, Severe TR

47 yrs: Melody Valve in Tricuspid position (inside Aortic Homograft). Resolution of PLE

14 mo follow-up: No recurrence of PLE.

Cath Lab: Percutaneous Pulmonary Valve Implantation - Early and Late Functional Outcome

J Am Coll Cardiol, 2011; 57:724-731

Early Versus Late Functional Outcome After Successful Percutaneous Pulmonary Valve Implantation. Are the Acute Effects of Altered Right Ventricular Loading All We Can Expect?

Philipp Lurz, MD*,,,*, Johannes Nordmeyer, MD*,,, Alessandro Giardini, MD, PhD, Sachin Khambadkone, MD, Vivek Muthurangu, MD*, Silvia Schievano, PhD*, Jean-Benoit Thambo, MD,, Fiona Walker¶, Seamus Cullen¶, Graham Derrick, Andrew M. Taylor, MD*, and Philipp Bonhoeffer, MD*

Objectives: The purpose of this study was to assess the potential of late positive functional remodeling after percutaneous pulmonary valve implantation (PPVI) in right ventricular outflow tract dysfunction.

Background: PPVI has been shown to impact acutely on biventricular function and exercise performance, but the potential for further late functional remodeling remains unknown.
Methods: Sixty-five patients with sustained hemodynamic effects of PPVI at 1 year were included. Patients were divided into 2 subgroups based on pre-procedural predominant pulmonary stenosis (PS) (n = 35) or predominant pulmonary regurgitation (PR) (n = 30). Data from magnetic resonance imaging and cardiopulmonary exercise testing were compared at 3 time points: before PPVI, within 1 month (early) and at 12 months (late) after PPVI.

Results: There was a significant decrease in right ventricle end-diastolic volume early after PPVI in both subgroups of patients. Right ventricle ejection fraction improved early only in the PS group (51 ± 11% vs. 58 ± 11% and 51 ± 12% vs. 50 ± 11%, p < 0.001 for PS, p = 0.13 for PR). Late after intervention, there were no further changes in magnetic resonance parameters in either group (right ventricle ejection fraction, 58 ± 11% in the PS group and 52 ± 11% in the PR group, p = 1.00 and p = 0.13, respectively). In the PS group at cardiopulmonary exercise testing, there was a significant improvement in peak oxygen uptake early (24 ± 8 ml/kg/min vs. 27 ± 9 ml/kg/min, p = 0.008), with no further significant change late (27 ± 9 ml/kg/min, p = 1.00). In the PR group, no significant changes in peak oxygen uptake from early to late could be demonstrated (25 ± 8 ml/kg/min vs. 25 ± 8 ml/kg/min vs. 26 ± 9 ml/kg/min, p = 0.48).

Conclusions: In patients with a sustained hemodynamic result 1 year after PPVI, a prolonged phase of maintained cardiac function is observed. However, there is no evidence for further positive functional remodeling beyond the acute effects of PPVI

Cath lab: Retinal Emboli after Cardiac Cath (Adult)

Clinical significance of retinal emboli during diagnostic and therapeutic cardiac catheterization in patient with coronary artery disease

Javad Kojuri , Morteza Mehdizadeh , Hamed Rostami and Danial Shahidian

BMC Cardiovascular Disorders 2011, 11:5doi:10.1186/1471-2261-11-5

Published:	21 January 2011

Abstract (provisional)

Background

Cardiac catheterization may cause retinal embolization, a risk factor for cerebrovascular emboli and stroke. We describe the incidence of clinically silent and apparent retinal emboli following diagnostic and interventional coronary catheterization and associated risk factors.

Methods

Three hundred selected patients attending a tertiary referral center for diagnostic and therapeutic cardiac catheterization were studied. Direct retinal examination and examination of the visual field and acuity were done before and after catheterization by a retinal specialist.

Results

There was 5 case of retinal embolus before catheterization, and 19 patients (incidence 6.3%) developed new retinal arteriolar emboli after catheterization. Only 1 patient developed clinically apparent changes in vision. Two conventional risk factors (age and hypertension) were significantly associated with new retinal emboli. The risk of retinal emboli was also significantly associated with operator expertise.

Conclusions

Retinal embolism was found after coronary catheterization in 6.3% of our patients. This finding indicates that the retinal, and possibly the cerebral circulation, may be compromised more frequently than is clinically apparent as a complication of coronary catheterization. Age and hypertension are independent predictors of retinal embolism (clinical trial registrationNCT01157338)

Cath lab: Outcome of ASD created by Transseptal puncture

The Incidence and Long-Term Clinical Outcome of Iatrogenic Atrial Septal Defects Secondary to Transseptal Catheterization with a 12Fr Transseptal Sheath

1. Sheldon M. Singh1*,
2. Pamela S. Douglas2 and
3. Vivek Y. Reddy1

1. ¹ Mount Sinai School of Medicine, New York, NY;
2. ² Duke Clinical Research Institute, Durham,

Abstract

Background—Studies assessing the presence of a residual iatrogenic atrial septal defect (iASD) after transseptal catheterization with 8Fr transseptal sheaths have suggested that the majority of these iASD close within 6 months. However, these studies have been limited by small patient numbers and short follow-up. Additionally, there are a number of novel catheter procedures in interventional cardiology and electrophysiology that employ larger transseptal sheaths. The objective of this study was to assess the incidence of and complications associated with iASD in a large cohort of patients undergoing transseptal catheterization with a 12Fr transseptal sheath.

Methods and Results—253 patients without a pre-existing inter-atrial shunt undergoing WATCHMAN implantation as part of the PROTECT AF study were included in this current study. Patients underwent transesophageal echocardiography (TEE) with echo-contrast immediately post-procedure, 45-days, 6 months, and 12 months. 87% of patients had an iASD immediately post-procedure, the majority of which sealed by 6 months (incidence of iASD - 34% at 45 days, 11% at 6 months, 7% at 12 months). While the majority of iASDs were >3mm in diameter immediately post-procedure, the minority of iASD were >3mm during the follow-up period. Additionally, inter-atrial shunting was predominantly left-to-right when an iASD was present. There was no significant difference in the rate of stroke and/or systemic embolism during the follow up period in patients with or without iASD.

Conclusions—Transseptal catheterization procedures with a large diameter transseptal sheath have a high spontaneous closure rate of iASD, and is not associated with an increased rate of stroke / systemic embolization during long-term follow-up.

• Received July 29, 2010.
• Accepted December 20, 2010.

Cath Lab: Transcatheter techniques to repair Mitral Valve

Review article by Chiam & Ruiz JACC Intrv 2011;4:1-13.
Some current and some futuristic ideas.

Fetal AS with MR

Pathophysiology, Fetal intervention and Outcome

JACC 2011;57:348-355

Closure of ASD in adults

Benefit of Atrial Septal Defect Closure in Adults: Impact of Age
Humenberger M, Rosenhek R, Gabriel, et al.
Eur Heart J 2010;Oct 12:[Epub ahead of print].

Comments (3)Study Question:
What is the effect of age on the clinical benefit of atrial septal defect (ASD) closure in adults?
Methods:
A cohort of 236 patients undergoing transcatheter ASD closure at a single center was studied. Patients were divided into three groups based on age.
Group A included patients younger than age 40 (n = 78),
Group B included patients ages 40-60 (n = 84), and
Group C included patients older than 60 years (n = 74).
Pulmonary pressures, right ventricular size, and symptoms were assessed before and after device closure.

Results:
The mean age for the entire cohort was 49 ± 18 years. There was no difference in defect size (median 22 mm; interquartile range, 19-26 mm) or shunt ratio (Qp:Qs 2.2; interquartile range, 1.7-2.9). Pulmonary pressure and right ventricular size were significantly related to age. Right ventricular size (by two-dimensional echocardiogram measures) decreased in all groups. Post-procedure, the systolic pulmonary artery pressure (PAP) decreased from 31 ± 7 to 26 ± 5 mm Hg in group A, 37 ± 10 to 30 ± 6 mm Hg in group B, and 53 ± 17 to 43 ± 14 mm Hg in group C (p < 0.0001). Absolute changes in right ventricular size and PAP did not differ between the groups. Symptoms were present in 13%, 49%, and 83% of patients prior to the procedure, and 3%, 11%, and 34% of patients after the procedure in groups A, B, and C, respectively. Functional status was related to PAP.
Conclusions:
At any age, ASD closure is followed by symptomatic improvement, and decrease in right ventricular size and PAP.

Perspective:
Closure of ASD in adults of advancing age has long been an area of controversy in congenital cardiology. Most studies comparing defect closure with conservative management were done in the era of surgical closure and did not convincingly demonstrate a survival benefit. Most studies, including this one, demonstrate significant improvement in symptoms after closure of ASD. The impact on atrial arrhythmias is less clear. The minimal mortality and overall low complication rate of device closure make it an attractive option for older adults who may have multiple comorbidities. This study supports closure of ASDs in older adults, particularly for symptomatic relief. As patients with long-standing ASD may not appreciate their level of symptomatology, all patients with significant ASD should be strongly considered for device closure.
Author(s):
Timothy B. Cotts, M.D., F.A.C.C.

How much is too much?!

A Heart With 67 Stents
Rami N. Khouzam, MD, Rajvir Dahiya, MD and Richard Schwartz, MD
Winthrop University Hospital, Mineola, New York

JACC 2010;56:1605

A 56-year-old male with coronary artery disease presented with angina, nonspecific electrocardiographic changes, and elevated troponins. Coronary angiography revealed total occlusion of a stent in the circumflex artery, where another was deployed—his 67th stent. The patient had 28 catheterizations over 10 years, with stents placed in his native coronary arteries as well as in 3 bypass grafts. All stents were placed to relieve his angina, refractory to maximal medical treatment and transmyocardial laser revascularization. Stents can be a great tool to help revascularization and relieve symptoms; unfortunately, they are prone to thrombosis and restenosis. If they fail while medical management is maximized unsuccessfully, alternative tools are lacking. This case raises many questions: "How much is too much?" "Are there guidelines?" and "What else can be offered for symptom relief?" More studies are needed to evaluate impact on quality of life versus risks in this multistent population. LAD = left anterior descending coronary artery; LCX = left circumflex coronary artery; OM = obtuse marginal branch of the circumflex coronary artery; RCA = right coronary artery.

CoreValve - Malposition and Correction

Publish ahead of print: Accessed Nov 10, 2010.
http://circinterventions.ahajournals.org/content/early/2010/11/09/CIRCINTERVENTIONS.110.944983.abstract?papetoc

Incidence and Management of CoreValve Dislocation During Transcatheter Aortic Valve Implantation

Sarah Geisbüsch, MD, Sabine Bleiziffer, MD, Domenico Mazzitelli, MD, Hendrik Ruge, MD, Robert Bauernschmitt, MD, PhD and Rüdiger Lange, MD, PhD

From the Clinic for Cardiovascular Surgery, German Heart Center Munich, Munich, Germany.

Background—Transcatheter aortic valve implantation is a highly specialized technique offering a new therapeutic option to patients at high risk for conventional surgery. Complications associated with this catheter procedure differ from complications after surgical aortic valve replacement. This is to report incidence, management, and impact on morbidity and mortality of CoreValve dislocation during catheter valve implantation.

Methods and Results—Between June 2007 and September 2009, the self-expandable CoreValve prosthesis (Medtronic Inc, Minneapolis, Minn) was implanted in 212 patients through a transarterial (femoral or subclavian) access. Patients with severe aortic stenosis who were at high risk for conventional surgery were included. We observed dislocation of the prosthesis during CoreValve implantation in 21 patients. In 16 cases, the CoreValve could be implanted in the correct annular position after retrieving it and reloading the catheter. In 4 patients, the completely deployed prosthesis had to be placed in the ascending or abdominal aorta before implanting a second one. One patient underwent open surgery. Overall 30-day mortality was 11.0%, 21.5% in the dislocation group and 9.9% in patients without dislocation (P=0.024). Coronary ischemia, stroke, and renal failure occurred more frequently in patients with dislocation, whereas pacemaker dependency did not differ significantly between the groups.

Conclusions—CoreValve dislocation during transcatheter aortic valve implantation occurred in 10% of the cases and significantly increases perioperative risk for severe complications or death. It requires individual specific management and can be managed either interventionally or, rarely, results in open surgery.