Paravalvular leak closure under intracardiac echocardiographic guidance.

OBJECTIVES: The objective of this study was to determine the safety and efficacy of intracardiac echocardiography (ICE) to guide percutaneous paravalvular leak (PVL) closure. BACKGROUND: PVL following surgical valve replacement occurs in 2%-15% of patients. Percutaneous treatment is an accepted management strategy in patients deemed to be too high risk for redo surgery. This is most commonly performed with transesophageal (TOE) guidance requiring general anesthesia that both potentially further increase the risk of intervention. ICE can be used to guide intervention, facilitating procedures to be performed under local anesthesia without esophageal intubation potentially making procedures shorter and safer and further enabling the treatment of patients that may have been turned down for intervention. METHODS: All patients that underwent ICE-guided percutaneous transcatheter PVL closure between 2006 and 2016 at the John Radcliffe Hospital, Oxford, United Kingdom were retrospectively analyzed. RESULTS: Twenty-one procedures were performed in 18 patients during the study period. Fourteen patients (77.8%) underwent successful ICE guided PVL closure. There were no ICE-related complications. Eleven patients (78.6%) reported symptomatic improvement of at least one New York Heart Association (NYHA) Class and the remaining 3 patients had no change. No patient demonstrated objective evidence of persistent hemolysis following successful closure. There was one death within 30 days of the procedure and 1 year survival was 71.4%. CONCLUSIONS: Percutaneous paravalvular leak closure guided by ICE without the requirement of general anesthesia is feasible, safe, and associated with acceptable procedural success rates.

Initial use of the new GORE(®) septal occluder in patent foramen ovale closure: implantation and preliminary results.

BACKGROUND: A number of devices are available for percutaneous closure of a clinically significant patent foramen ovale (PFO). The new GORE(®) septal occluder (GSO) is a nonself-centering device consisting of an expanded polytetrafluoroethylene tube supported by a frame of nitinol wire conforming into a double disk. This study reports the first clinical GSO implantation experience. METHODS: GSO implantation in 20 consecutive patients is reported. Inclusion criteria were all patients referred with a significant PFO implicated in paradoxical embolism or transient right to left shunting causing desaturation. Procedures were performed under local anaesthesia and intracardiac echocardiography (ICE) in addition to fluoroscopy. Procedural data, acute and early closure rates were examined. RESULTS: All patients underwent successful day-case device implantation. Eleven patients had previous stroke, five had transient ischemic attacks, two had a history suspicious of PFO-related desaturation, and two had a history suspicious of PFO-related peripheral thromboembolism. Acute closure rates on IVC injection bubble testing were 100% at implant and 100% (14/14) at 1 month. Average PFO balloon size was 8.0 ± 3.6(range 2.0-16.7) mm, mean fluoroscopic implantation time 3.0 ± 1.7(range 0.7-6.3) min, radiation dose 283 ± 340 (range 6-1,431) µGym(2), and total procedural time 34.8 ± 8.0 (range 22-53) min. 5 × 20 mm(2), 7 × 25 m(2), 8 × 30 mm(2) GSO devices were implanted, aiming for device size at least twice balloon PFO size. Cases included aneurysmal septums with up to 30 mm deviation and tunnels up to 12 mm long. Removal and repositioning of two devices was performed on two occasions after uncertainty about device locking. At 1 month follow-up, two patients had brief self-terminating episodes of suspected atrial fibrillation, all had normal resting ECGs. No thromboembolic/neurological events were reported. CONCLUSIONS: The GSO can be implanted under local anaesthesia and ICE with low procedural and fluoroscopy times with high procedural success as a day case. No residual shunts were seen. This initial experience suggests that it is a safe and effective device for PFO closure.

Intracardiac echocardiography off piste? Closure of the left atrial appendage using ICE and local anesthesia.

Left atrial appendage (LAA) occlusion is increasingly accepted to reduce the risk of stroke in patients with atrial arrhythmia who are unsuitable for routine anticoagulation. It is generally performed under general anesthesia, guided by transoesophageal echocardiography with accurate imaging being essential for correct deployment of the device. We present a case where LAA occlusion was done under local anesthesia in a high-anesthetic risk patient, using novel placement of an intracardiac echo probe via a Mullins sheath in the right ventricular outflow tract and pulmonary artery. This allowed accurate visualization of device deployment in the LAA. This technique may increase the spectrum of patients who may benefit from the procedure and decrease procedure time, fluoroscopy, and procedure-related morbidity.

Prominence of the Eustachian valve in paradoxical embolism.

AIMS: to investigate the relationship between Eustachian valve (EV) length and degree of atrial septal movement in patients with patent foramen ovale (PFO) and presumed paradoxical cerebral embolism. PFO is a well-established risk factor for cryptogenic stroke. However, due to the high prevalence of PFO, many of these are bystanders rather than true pathological entities. Other studies have sought to define which patients with PFO are particularly at risk of cryptogenic stroke by measuring various parameters of right atrial anatomy. We investigated the relationship between EV length and atrial septal movement. METHODS AND RESULTS: measurements of EV length and atrial septal movement were made prospectively from 72 consecutive patients referred to our centre for PFO closure following presumed cryptogenic stroke, by intracardiac phased array echocardiography. The most significant finding from this study was that patients with fewer than 10 mm atrial septal movement had significantly longer EVs than those in whom there was >10 mm septal movement (P = 0.003). The mean EV length with >10 mm septal movement is 6.35 mm, and 13.33 mm with fewer than 10 mm movement. The prevalence of septal movement beyond 10 mm was significantly less in our series than in previously published papers. CONCLUSION: we propose that while a large degree of atrial septal movement significantly increases propensity to cerebral embolism in patients with PFO, its absence does not negate this risk. We have shown that long EV may function independently from atrial septal movement to potentiate paradoxical embolism.

Stent-graft repair of coronary vein graft aneurysm.

The authors describe treating a 6-cm right coronary artery bypass graft aneurysm that was causing recurrent angina. With use of the combined skills of interventional radiologists and cardiologists, the aneurysm was successfully occluded by using a stent-graft typically used to treat aneurysms in the peripheral circulation. One month after the procedure, the aneurysm had sealed at follow-up computed tomographic angiography.

Mammoth interatrial septal aneurysm in the ICE age.

BACKGROUND: Intracardiac echocardiography (ICE) is a useful imaging modality that is now being used more widely to assist in the percutaneous closure of atrial septal defects (ASD) and patent foramen ovales (PFO). CASE PRESENTATION: A 42 year old lady with a history of transient ischaemic attacks and migraine underwent percutaneous closure of an ASD. Intraprocedural ICE demonstrated a mammoth billowing multiperforated interatrial septal aneurysm in association with a secondum ASD. CONCLUSION: ICE provides excellent adjuvant imaging during percutaneous closure of intracardiac shunts, in this case demonstrating a 'mammoth' interatrial septal aneurysm.

What is the role of balloon dilatation for severe aortic stenosis during pregnancy?

BACKGROUND AND AIM OF THE STUDY: Severe aortic stenosis in pregnancy creates several challenges for the physician. In recent years, balloon valvuloplasty has become more widely used, though the indications for its use in this setting are unclear. A review of the available evidence is presented, and a suggested management strategy illustrated. METHODS AND RESULTS: Available literature on the subject was reviewed via Medline search and reference lists from the identified articles. Particular attention was paid to prediction of risk, management options and outcome. The data suggest the importance of early symptoms in determining management, as there is a high risk of complications if left untreated. This group should be considered for valvuloplasty, whereas asymptomatic patients are at low risk, and can be managed expectantly. This is illustrated with two contrasting cases from the authors' practice: the symptomatic patient underwent aortic balloon valvuloplasty as a palliative procedure, using transesophageal and minimal fluoroscopic guidance, with good medium-term results. Both patients required aortic valve replacement in the medium to long-term. CONCLUSION: The use of aortic balloon valvuloplasty in pregnancy is useful as a palliative procedure, allowing deferral of valve replacement until after birth. Echocardiographic features alone are not enough to decide on management, and symptoms play a vital role in determining risk. The use of transesophageal echocardiography during the procedure significantly reduces fluoroscopy time.

Native valve endocarditis due to Streptococcus vestibularis and Streptococcus oralis.

Viridans streptococci are the commonest cause of native valve infective endocarditis (IE). The taxonomy of this group is evolving allowing new disease associations to be made. Streptococcus vestibularis is a recently described member of the viridans group, first isolated from the vestibular mucosa of the human oral cavity. It has rarely been associated with human disease. Streptococcus oralis, another member of the viridans group resident in the human oral cavity is a well known cause of IE and bacteraemia in neutropenic patients. We report the first case of native mitral valve endocarditis due to S. vestibularis in a patient with co-existing S. oralis endocarditis.

Echocardiographic assessment and percutaneous closure of multiple atrial septal defects.

Atrial septal defect closure is now routinely performed using a percutaneous approach under echocardiographic guidance. Centrally located, secundum defects are ideal for device closure but there is considerable morphological variation in size and location of the defects. A small proportion of atrial septal defects may have multiple fenestrations and these are often considered unsuitable for device closure. We report three cases of multiple atrial septal defects successfully closed with two Amplatzer septal occluders.

Percutaneous retrieval of an embolized pacemaker lead from the pulmonary artery.

Migration of retained fractured pacemaker electrodes to the pulmonary artery is a rare but recognised complication. It is imperative that if this occurs the electrode is removed from this position due to the increased risk of associated infection and thrombus formation. Historically open surgery has been required to manage this potentially serious complication, however as illustrated by this case, a percutaneous approach can be employed successfully.

Acute worsening in migraine symptoms following PFO closure: a matter of fact?

There is currently conjecture in the literature as to whether percutaneous closure of patent foramen ovales (PFO) leads to an improvement in migraine symptoms. The present study reports the migraine status at 30 days, of 57 consecutive patients who underwent closure PFO closures for cryptogenic stroke at our institution. Our findings suggest a significant change in migraine character following PFO closure with the majority of these patients reporting a worsening in migraine severity. Those patients with more severe migraine prior to the procedure were more likely to experience deterioration. Patients should be counselled about the possibility of changing or worsening migraine prior to percutaneous closure for cryptogenic stroke.