Feasibility of intentional bioprosthetic valve fracture in the tricuspid position.

BACKGROUND: Transcatheter tricuspid valve-in-valve (ViV) replacement has yielded good hemodynamic outcomes in the treatment of dysfunctional bioprosthetic valves (BPVs). Intentional fracture of certain rigid BPV frames, if feasible, allows a larger implanted valve when compared with implant into an unfractured BPV. There remains limited data on the feasibility of tricuspid valve frame fracture. AIMS: Evaluate the feasibility of transcatheter tricuspid ViV replatement with fracture of the underlying BPV ring. METHODS: An international multicenter registry of tricuspid ViV replacement with intentional tricuspid valve frame fracture was created. Demographic data along with procedural characteristics, outcomes, and follow-up data were collected. Comparison was made to the pre- and post-ViV replacement with fracture of the tricuspid valve frame conditions. RESULTS: Ten patients from six centers were included with a median age and weight of 29 years and 67.3 kg respectively. Tricuspid valve frame fracture was performed using a median balloon diameter 3 mm (IQR 3-5) larger than the true inner diameter (ID). The final ID was a mean of 1.5 mm (95% CI: 0.35, 2.64: p < 0.05), and median 1.1 mm (0.5, 2.1) larger than the reported true ID of the surgical BPV after ViV replacement. The mean tricuspid inflow gradient by echocardiogram decreased by 6.65 mmHg (95% CI: 4.14, 9.15: p < 0.001). All procedures were without complication, specifically there was no heart block, pericardial effusion, or right coronary disruption. CONCLUSION: Intentional tricuspid valve frame fracture with tricuspid ViV replacement is feasible and can increase the valve orifice potentially reducing the risk of ViV patient prosthesis mismatch and is not associated with significant complications.

Balloon Pulmonary Angioplasty for the Treatment of Chronic Thromboembolic Pulmonary Hypertension.

Chronic thromboembolic pulmonary hypertension is a rare form of pulmonary hypertension in patients who have evidence of chronic thromboembolic occlusion of the pulmonary vasculature. Historically, surgical pulmonary thromboendarterectomy has been the treatment of choice. However, with up to 40% of patients deemed inoperable, balloon pulmonary angioplasty has emerged as an additional treatment strategy. Balloon pulmonary angioplasty is a complementary strategy alongside surgical pulmonary thromboendarterectomy and offers the opportunity for pulmonary revascularization in patients who have more distal disease, higher comorbidities, or residual obstruction following operative intervention. This review examines the history of balloon pulmonary angioplasty, highlights its effectiveness, discusses important complications and risk reduction strategies, and emphasizes the importance of centers forming a multidisciplinary team of providers to manage the complexity of patients with chronic thromboembolic pulmonary hypertension.

Impact of Social Determinants of Health on Outcomes for Patients with Adult Congenital Heart Disease.

PURPOSE OF REVIEW: The study of adults with congenital heart disease (ACHD) is a rapidly growing field; however, more research is needed on the disparities affecting outcomes. With advances in medicine, a high percentage of patients with congenital heart disease (CHD) are advancing to adulthood, leading to an increase in the number of ACHD. This creates a pressing need to evaluate the factors, specifically the social determinants of health (SDOH) contributing to the outcomes for ACHD. RECENT FINDINGS: A myriad of factors, including, but not limited to, race, education, and socioeconomic status, have been shown to affect ACHD outcomes. Existing data from hospitalizations, mortality and morbidity, advanced care planning, patient and physician awareness, financial factors, and education alongside race and socioeconomic status present differences in ACHD outcomes. With SDOH having a significant impact on ACHD subspecialty care outcomes, ACHD centers need to be constantly adapting and innovating, incorporating SDOH into patient management, and providing additional healthcare resources to manage the care of ACHD.

Tough Crossing: A Challenging Case of Valve-in-Valve Transcatheter Tricuspid Valve Replacement.

Transcatheter tricuspid valve replacement is a feasible treatment alternative in high-risk patients with degenerated tricuspid prosthesis. Either transjugular or transfemoral approaches are feasible, with the latter being used more commonly. We describe a challenging case of valve-in-valve transcatheter tricuspid valve replacement where we used a long sheath positioned in the right ventricular outflow tract to deliver the transcatheter heart valve.

Single-Center Experience With Aortic Coarctation Stenting in Adult Patients.

OBJECTIVE: Endovascular repair of aortic coarctation (CoA) has become an important tool in the treatment of an expanding patient population. In this study, we present our 10-year experience with endovascular repair of CoA. METHODS: Between January 2012 and January 2022, a total of 15 patients were treated at our Institution for CoA with catheter-based techniques. Demographics, intraprocedural data, and follow-up data were retrospectively collected from institutional databases and analyzed. The primary endpoint was technical success and secondary endpoints were intraoperative complications and short-, mid-, and long-term follow-up. RESULTS: Mean age was 44.87 ± 15.52 years (range, 15-64) and 12 patients (80%) were male. Fourteen patients (93.3%) were hypertensive, and 4 patients (26.7%) had a bicuspid aortic valve. Three patients (20%) had undergone open repair in the pediatric age. Fourteen patients (93.3%) received stenting of CoA and 1 patient (6.7%) received thoracic endovascular aortic repair and left subclavian artery stenting for proximal pseudoaneurysmatic dilation and symptomatic restenosis. Mean pretreatment trans-stenotic gradient was 23.25 ± 11.16 mm Hg and posttreatment trans-stenotic gradient was 1.3 ± 1.33 mm Hg. Primary technical success was achieved in 15 cases (100%). One right inguinal hematoma (6.7%) was observed. One patient (6.7%) had an aortic rupture at the left subclavian artery origin after poststent dilation. Mean follow-up time was 34.75 ± 34.38 months. A total of 2 patients had an increased trans-stenotic gradient at long-term follow-up, and 1 reintervention (6.7%) for somatic growth was performed. CONCLUSIONS: Endovascular repair of CoA is effective and safe, with excellent mid-term and long-term success rates.

PFO Closure after Pulmonary Valve Intervention in Patients with Hypoxemia Due to Right-to-Left Intracardiac Shunt.

Four patients with pulmonary valve (PV) disease and patent foramen ovale (PFO) presented with dyspnea on exertion. Work-up revealed hypoxemia secondary to right-to-left intracardiac shunt. We demonstrate that correction of the primary culprit right heart overload lesion via PV replacement enabled safe PFO repair and resolution of hypoxemia.

Multimodality Image-Guided Embolization of Bronchial Artery Pseudoaneurysm in a Patient With Aortopathy.

A 59-year-old man received an incidental diagnosis of a 5-cm right para-aortic mass that was initially thought to be of venous origin. Multimodality imaging revealed a right bronchial artery pseudoaneurysm that was treated with endovascular embolization. Bronchial artery pseudoaneurysms are extremely rare and can be fatal if ruptured. (Level of Difficulty: Advanced.).

Automated catheter tip repositioning for intra-cardiac echocardiography.

PURPOSE: Intra-Cardiac Echocardiography (ICE) is a powerful imaging modality for guiding cardiac electrophysiology and structural heart interventions. ICE provides real-time observation of anatomy and devices, while enabling direct monitoring of potential complications. In single operator settings, the physician needs to switch back-and-forth between the ICE catheter and therapy device, making continuous ICE support impossible. Two operator setups are sometimes implemented, but increase procedural costs and room occupation. METHODS: ICE catheter robotic control system is developed with automated catheter tip repositioning (i.e., view recovery) method, which can reproduce important views previously navigated to and saved by the user. The performance of the proposed method is demonstrated and evaluated in a combination of heart phantom and animal experiments. RESULTS: Automated ICE view recovery achieved catheter tip position accuracy of [Formula: see text] mm and catheter image orientation accuracy of [Formula: see text] in animal studies, and [Formula: see text]mm and [Formula: see text] in heart phantom studies, respectively. Our proposed method is also successfully used during transseptal puncture in animals without complications, showing the possibility for fluoro-less transseptal puncture with ICE catheter robot. CONCLUSION: Robotic ICE imaging has the potential to provide precise and reproducible anatomical views, which can reduce overall execution time, labor burden of procedures, and X-ray usage for a range of cardiac procedures.

CT-Guided Endovascular Exclusion of Pseudoaneurysmal Subclavian Bypass After Early-Age Surgical Correction of Complex Aortic Coarctation.

We describe a 64-year-old woman with subclavian pseudoaneurysm after aortic coarctation repair, treated using a hybrid approach involving true three-dimensional analysis and image fusion-guided placement of thoracic endovascular aortic repair stents. This case illustrates the potential complications of coarctation repair and need for lifelong surveillance in these patients. (Level of Difficulty: Advanced.).

Ventricular Fibrillation Arrest and Pulmonary Homograft Rupture During Transcatheter Pulmonary Valve: Successful Rescue by Heart Team.

We describe a 31-year-old woman with pulmonary homograft rupture and ventricular fibrillation arrest complicating a transcatheter pulmonary valve (TPV) procedure. She underwent extracorporeal membrane oxygenation (ECMO) with immediate surgical repair including bioprosthetic pulmonary valve replacement. She had difficulty weaning off ECMO due to hyperacute failure of the valve and ultimately underwent successful hybrid TPV with complete recovery. This case illustrates the importance of the heart team approach during catheter and surgical interventions in adult congenital heart disease.

Successful coil embolization of a large right coronary artery-coronary sinus fistula causing a significant left-to-right shunt: a case report.

BACKGROUND: This case reviews a challenging but successful transcatheter coil embolization of a large congenital coronary artery fistula (CAF) causing a significant left-to-right shunt. CASE SUMMARY: A 51-year-old female with no significant prior history presented with symptoms of dyspnoea and chest discomfort. Extensive evaluation revealed a large CAF between a tortuous right coronary artery (RCA) and the coronary sinus (CS) composed of three aneurysmal pseudochambers. Closure of the RCA-CS fistula was attempted through coil deployment into the fistula neck. However, due to the brisk flow through the fistula, both coils embolized into the fistula sac. An alternative location was subsequently identified on three-dimensional rendering of a computed tomography angiography scan, which revealed a sharp bend in the RCA prior to the fistula neck and distal to the posterior descending artery (PDA) takeoff. Repeat attempt at embolization was accomplished using a telescoping system to reach and occlude the targeted bend. The coil mass remained stable and angiography demonstrated reduced flow through the fistula and preserved patency of the PDA. The decreased residual flow through the fistula secondary to the initial embolization attempt likely aided the successful deployment of coils in the second and final attempt. At 1 year, the patient was doing well with resolution of her symptoms and no clinical symptoms of coronary ischaemia. DISCUSSION: We suggest that an initial unsuccessful attempt at transcatheter embolization of a CAF should not preclude subsequent attempts for closure when there exists an appropriate indication.

CT-Fluoroscopy Image-Fusion Guidance for Embolization of Aortopulmonary Collaterals.

BACKGROUND: In adults with congenital heart disease, anatomically complex culprit collateral vessels may cause life-threatening hemoptysis and require catheter-based embolization. Techniques using conventional 2-dimensional (2D) fluoroscopy can be challenging. TECHNIQUE: We describe a technique using 2D/3-dimensional (3D) image fusion for intraprocedural guidance to embolize aortopulmonary collaterals. Two fluoroscopic images of the thorax at least 30° apart with pigtail catheter in the ascending aorta were used for image fusion with preprocedural computed tomography (CT) angiography using the spine and pigtail catheter as landmarks. 3D planning information was overlaid on 2D fluoroscopy for cannulation and embolization. RESULTS: Between November 2018 and June 2019, a total of 6 sessions of aortopulmonary collateral embolization using CT-fluoroscopy image-fusion guidance were conducted in 3 patients with adult congenital heart disease. In 3/6 sessions, the indication for embolization was hemoptysis. Common target vessels were left and right bronchial arteries (4 and 3 sessions, respectively). The spine and a pigtail catheter in the aorta were frequently used as landmarks for image fusion (67%). Particle embolization was used in 100% of cases. Mean procedure and fluoroscopy times were 3 hours, 23 minutes and 1 hour, 3 minutes, respectively. On average, 169 mL (350 mg iodine/mL) of contrast material was used in each session and total skin dose of radiation exposure was 1538 mGy. Successful collateral embolization was confirmed by postprocedure angiography that showed negligible or no flow through culprit collaterals. CONCLUSION: Use of CT-fluoroscopy image-fusion guidance can aid in embolization of aortopulmonary collaterals with complex anatomy in 3D space.

Transitioning From Room to Zoom: The 2020 Cardiovascular Fellows' Boot Camp in the COVID-19 Era.

For 10 years, the annual Houston Methodist Cardiovascular Fellows' Boot Camp hosted hundreds of cardiovascular trainees in Houston for a concise yet comprehensive 3-day training program for new fellows. The cornerstone of the program was the hands-on Skills Academy, which included a variety of timed learning stations that taught surgical techniques, dissection skills, and suturing techniques as well as echocardiography and cardiac catheterization using simulators. This was followed by 2 days of didactics covering essential topics in each specialty. However, that model was upended in 2020 by the COVID-19 pandemic. The pandemic forced the digitization of medical education and posed significant challenges as we transitioned Boot Camp to a virtual format. In this editorial, we review our experience designing and implementing a virtual cardiology track of the Houston Methodist Cardiovascular Fellows' Boot Camp and highlight challenges and proposed solutions in the era of virtual education.