Percutaneous closure of multiple atrial septal defects in a child utilizing three Occlutech Figulla septal occluders: A bailout.

We describe a unique report of percutaneous closure of multiple secundum atrial septal defects in a child utilizing three Occlutech Figulla septal occluders deployed sequentially. The procedure was performed under live three-dimensional transesophageal echocardiography guidance.

Paravalvular Leak Closure After Transcatheter Tricuspid Valve-in-Ring Implantation: A Case Report.

Transcatheter tricuspid valve intervention (TTVI) has emerged as a promising alternative for patients with severe tricuspid regurgitation who are deemed high-risk for surgery. With advancements in device design and delivery systems, TTVI has shown promising outcomes in reducing tricuspid regurgitation severity and improving symptoms in selected patients. Paravalvular leaks (PVLs) are one of the most common complications faced, which can significantly contribute to patients' morbidity and mortality. Percutaneous PVL closure represents a minimally invasive approach to address this issue, but its efficacy and safety in the context of transcatheter tricuspid valve-in-ring implantation require further elucidation. We describe the case of a 44-year-old lady with a history of rheumatic valve disease status post-tricuspid valve annuloplasty with an incomplete ring who presented to cardiology clinics with symptomatic torrential tricuspid regurgitation. Due to the high risk of surgical reintervention secondary to severe right ventricular (RV) failure, she was denied surgical intervention. Therefore, she underwent transcatheter tricuspid valve-in-ring (TVIR) implantation with a 26 mm MyVal (Meril Life Sciences Pvt Ltd., Vapi, GJ, IND), which was complicated by a residual severe tricuspid paravalvular regurgitation. The defect was subsequently closed by a dedicated Occlutech PVL device (Occlutech, Helsingborg, SWE) measuring 18 mm x 10 mm. Post which, the patient had trivial tricuspid regurgitation and significant improvement in signs and symptoms with subsequent follow-up.

Short-Term Clinical Outcomes of Transcatheter Aortic Valve Replacement in a Developing Country.

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) is an effective alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis in all surgical risk groups. Reports of clinical outcomes post-TAVR in developing countries are scarce. We aimed to address the clinical outcomes and safety profile of TAVR in a developing country. METHODS: We conducted a single-center, retrospective study on patients undergoing TAVR at the American University of Beirut Medical Center (AUBMC) from January 2016 to April 2023. We included a total of 399 patients. Our primary endpoint was to assess the rate of TAVR in-hospital and 30-day mortality, neurologic events, and new permanent pacemaker implantation (PPI) in patients, stratified by the Society of Thoracic Surgeons (STS) risk of mortality score. RESULTS: Survival rates were 98.7% (394) at discharge vs. 97.5% (389) at 30 days post-procedure. The technical success rate was 95% (379) at the end of the procedure. Device success and early safety rates were 93.5% (373) and 83% (331), respectively at 30 days post-procedure. The all-cause mortality rate increased from 1.3% (5) at discharge to 2.5% (10) at 30-day intervals. The rate of ischemic stroke was 1.3% (five) at discharge and increased to 2% (eight) at 30 days post-procedure. PPI was needed in 5.8% (23) of patients at discharge with an increase to 7% (28) at one-month interval. Overall, the rates of TAVR outcomes among the three risk groups were comparable including neurologic events, valve-related complications, bleeding problems, vascular and access-related complications, and myocardial infarction. CONCLUSION: This study at AUBMC highlights the successful implementation of the TAVR program in a developing country, showcasing its efficacy and safety within 30 days post-operation, despite challenges such as financial constraints and limited access to specialized training. Larger cohorts and longer follow-up periods are needed to accurately represent clinical outcomes in developing countries.

Safety of Amulet Left Atrial Appendage Occluder and Watchman Device for Left Atrial Appendage Closure in Patients With Atrial Fibrillation.

BACKGROUND: Left atrial appendage (LAA) closure is an alternative to chronic anticoagulation for stroke prevention in patients with nonvalvular atrial fibrillation. Multiple devices were used for LAA closure, with the Amplatzer Amulet LAA Occluder (Abbott, Chicago, IL, USA) and Watchman device (Boston Scientific, Marlborough, MA, USA) being the most commonly used in clinical practice. In August 2021, the FDA approved the use of the Amplatzer Amulet LAA Occluder. There is still a knowledge gap in the safety profile of the Amplatzer Amulet LAA Occluder device in comparison to the Watchman device. OBJECTIVE: The aim of this study was to assess and compare the safety profile peri-procedure and post-procedure between the Amplatzer Amulet LAA Occluder and Watchman devices. METHODS: Patients who underwent LAA closure using Watchman or Amulet devices from July 2015 to August 2020 at the American University of Beirut Medical Center were included in the analysis. Primary endpoints included peri-operative and post-procedural complications (thromboembolic events, bleeding complications, vascular access complications, pericardial effusion/tamponade, device positional complications and in-hospital death). RESULTS: The study included 37 patients (21 had Watchman devices, 16 had Amplatzer Amulet LAA Occluder devices, and 28 were men, mean age 76.57 ± 9.3 years). Seven patients developed post-procedural iatrogenic atrial septal defects (four in the Watchman group vs three in the Amulet group, p-value=0.982). Three patients developed pericardial effusion (one in the Watchman vs two in the Amulet group, p-value=0.394). Only one patient developed peri-device leak (one in the Watchman group vs none in the Amulet group, p-value=0.283). One device could not be deployed (one in the Amulet group vs none in the Watchman group, p-value=0.191). None of the patients developed in-hospital death, cardiac tamponade, device embolism, device thrombosis, stroke/transient ischemic attack (TIA), cranial bleeding, or arrhythmias after the procedure. The rate of peri-operative complications was similar between both groups. Both groups displayed low rates of adverse events in the peri-operative and post-operative periods. CONCLUSION: There was no significant difference in the safety profile of Amplatzer Amulet LAA Occluders and Watchman devices. There was a low incidence of peri-operative and post-operative adverse events with the implanted devices.

Percutaneous Coronary Intervention with Procedural Unfractionated Heparin without Activated Clotting Time Guidance: A Unique Opportunity to Assess Thrombotic and Bleeding Events.

Background: Rates of major bleeding and intraprocedural thrombotic events (IPTE) in the setting of percutaneous coronary intervention (PCI) using weight-adjusted unfractionated heparin (UFH) without activated clotting time (ACT) monitoring are not known. Methods: We reviewed 2,748 consecutive patients who underwent coronary angiography at our tertiary care university hospital between January 2017 and December 2020. All patients who underwent PCI with weight-adjusted UFH without ACT guidance were considered for further analysis. Major bleeding complications occurring within 48 hours of PCI were collected from patients' medical records. IPTE were collected independently by two interventional cardiologists after review of coronary angiograms. Results: There were 718 patients included in the analysis (65.4 ± 12.2 years old; 81.3% male). In total, 45 patients (7.8%) experienced a major bleed or IPTE. The most common IPTE were slow/no reflow (1.5%) and coronary artery dissection with decreased flow (1.1%). Other IPTE occurred in <1% of cases. Major bleeding occurred in 11 patients (1.5%), of whom 8 required blood transfusion and 3 required vascular intervention. Bleeding complications were more common with femoral compared with radial access (6.6% vs. 0.2%, P < 0.001). Conclusion: Weight-adjusted UFH use during PCI without ACT monitoring was related to low rates of major bleeding or IPTE.

Post-TAVR conduction abnormalities leading to permanent pacemaker implantation: Risk factors, prevention, and management.

Transcatheter aortic valve replacement (TAVR) often leads to conduction abnormalities, necessitating pacemaker implantation. This review of 38 meta-analyses identified preexisting right bundle branch block (RBBB), LAHB, and new-onset left bundle branch block as key risk factors, with a higher PPM risk in male and older patients. Procedural factors like transfemoral access and self-expandable valves also increase this risk. Prevention focuses on tailoring TAVR to individual electrophysiological and anatomical profiles. However, there's a lack of consensus in managing these conduction disturbances post-TAVR, highlighting the need for further research and standardized treatment strategies.

Case report: acute myocardial infarction in the setting of acute transcatheter aortic valve thrombus.

We describe a case of valve thrombosis and a subsequent thromboembolic event within only 10 days of transcatheter aortic valve implantation (TAVI). Postprocedural anticoagulants are not standard of care medications post-TAVI in patients without atrial fibrillation. Valve thrombosis is an indication to initiate anticoagulation to resolve and prevent further thrombus.

Aortic Annulus S-Curve: Implications for Transcatheter Aortic Valve Replacement and Related Procedures, Part 1.

Most transcatheter aortic valve replacement-related procedures (eg, transcatheter aortic valve replacement implantation depth, commissural alignment, coronary access, bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction, paravalvular leak closure) require an optimal fluoroscopic viewing angle located somewhere along the aortic annulus S-curve. Chamber views, coronary cusp and coronary anatomy, can be understood along the aortic annulus S-curve. A better understanding of the optimal fluoroscopic viewing angles along the S-curve may translate into increased operator confidence and improved safety and efficacy while reducing procedural time, radiation dose, contrast volume, and complication rates.

Post trans-catheter aortic valve replacement shock: Back to the basics.

Transcatheter aortic valve replacement (TAVR) is indicated for the treatment of patients with severe aortic stenosis (AS) at low, intermediate, and high risk. Immediate complications post-TAVR that lead to hemodynamic compromise include: retroperitoneal bleeding, aortic dissection or rupture, pericardial tamponade, coronary ostial obstruction, acute severe central or paravalvular regurgitation, heart block, and suicide left ventricle. The presence of significant paravalvular leak (PVL) after TAVR is now an uncommon complication with newer generation devices. We present a case of an 82-year-old frail female patient who presented to our clinic with dyspnea upon minimal exertion and orthopnea. She was found to have severe AS that was treated with TAVR. The procedure was complicated by hemodynamic compromise due to severe PVL and left ventricular outflow tract (LVOT) obstruction which was underestimated by transthoracic echocardiography. The PVL was eventually treated with a vascular plug device and the LVOT obstruction was treated with alcohol septal ablation. This case highlights the vital role of early and aggressive work up in unstable patients post-TAVR and the importance of transesophageal echocardiography in patients with unexplained hypotension post-TAVR to unmask the severe PVL and dynamic LVOT obstruction. .

Transcatheter occlusion of a hepatic vein-to-left atrium fistula: Should we close venovenous collateral vessels following Fontan operation?

Right-to-left shunt due to abnormal systemic venous drainage to the left heart is among the causes of hypoxemia following Fontan operation. There are conflicting data regarding the closure of the venovenous collaterals (VVCs) post-Fontan, showing decreased survival in older patients. In a child with visceral heterotaxy, we describe a rare fistula draining a right-sided hepatic vein into hepatic venous plexus and a right-sided pulmonary venous atrium. The patient presented with severe hypoxemia post-Fontan and underwent fistula occlusion with AMPLATZER™ Vascular Plug II, successfully improving hemodynamic status with resolution of the hypoxemia. Younger patients with cyanosis due to VVCs may benefit from percutaneous occlusion post-Fontan.

Imaging Modalities Employed in the TAVR Procedure With a Focus on CTA: What the Radiologist Needs to Know.

RATIONALE AND OBJECTIVES: Aortic stenosis (AS) is one of the most common valvular heart disease. Symptomatic AS is associated with a high mortality rate which prompts fast intervention. The introduction of transcatheter aortic valve replacement (TAVR) has drastically improved the outcome of high surgical risk for mortality patients with severe AS. However, this procedure requires the employment of multimodality imaging in the pre-procedural planning, intra-procedural optimization, and post-procedural follow-up stages. This also requires an accurate understanding of the indications, measurements, strength, and limitations of each imaging modality during the different TAVR stages. CONCLUSION: In this review, we aim to outline to radiologists the evidence-based approach and indications of different imaging modalities through the pre, peri, and post TAVR stages.

Endovascular Stent Repair of Aortic Coarctation in a Developing Country: A Single-Center Experience.

BACKGROUND/PURPOSE: CoA remains one of the most common congenital heart diseases and is associated with significant morbidity and mortality and if untreated. We aim to evaluate the safety, feasibility, and outcomes of endovascular stenting of Coarctation of the aorta (CoA) in a developing country with limited resources and compare it to available benchmarks. MATERIALS/METHODS: A retrospectively review of all patients who underwent endovascular stent repair of aortic coarctation at our tertiary center since 2009 was done. RESULTS: 18 patients were identified, sixteen had native CoA, while two had recurrent CoA. mean age at the time of procedure was 21.2 ± 9.8 years (range 10-45 years), and 12(66%) patients were males. The mean follow-up duration was 4 ± 2.8 years. Post stenting, the average ascending-to-descending aorta systolic gradient decreased by 42.9 ± 20.4 mmHg (p < 0.001). After the intervention, 13(72.2%) patients achieved normal BP while 5(27.8%) had residual hypertension. Fourteen patients received bare-metal stents, and four had covered stents. Attempted stent implantation was successful in all patients. Our procedural success rate was 94%. On follow-up, no dissections or aneurysmal changes were detected, four patients underwent re-expansion of the stent, one patient with suboptimal stenting result required surgery 6 months after stenting, and two patients had minor post-operative complications. CONCLUSIONS: Endovascular stenting for de-novo or recurrent CoA in children and adults at a tertiary center in a developing country is feasible and safe with outcomes comparable to developed countries. A multidisciplinary team approach is paramount in achieving good results and low complication rates in limited-resource settings.

Structural valve deterioration of the Labcor Dokimos aortic prosthesis: a single-centre experience.

OBJECTIVES: The goal of this study was to assess the performance and incidence of the deterioration of the Labcor Dokimos bioprosthetic aortic valve. METHODS: We performed a retrospective medical chart review of 116 patients who underwent surgical aortic valve replacement with the Labcor Dokimos aortic valve between 2010 and 2018. Abstracted data included patient demographic and echocardiographic data. Patients were divided into 2 groups: patients with structural valve deterioration (SVD) and patients without SVD. RESULTS: Among the patients with complete follow-up (n = 95), 10 patients were excluded because they died within a year; 85 patients were included in the final analysis. Of the 85 patients, 32 (38%) developed SVD; 22 (26%) had severe SVD, 15 (18%) of whom underwent reintervention. The most common aetiology of SVD was severe central aortic regurgitation, which was detected in 91% of the patients who had severe SVD. The average time from operation to severe SVD was 4.7 years with a minimum of 1.5 years and a maximum of 7.9 years. CONCLUSIONS: Bioprosthetic aortic valve deterioration due to severe aortic regurgitation is common and occurs early with the Labcor Dokimos valve. This occurrence needs to be furthered investigated in larger registries.

Intravascular Lithotripsy-Assisted Transfemoral TAVI: The Copenhagen Experience and Literature Review.

Transcatheter aortic valve implantation (TAVI) is currently an established therapy for elderly patients with symptomatic severe aortic valve stenosis across all surgical risk categories. Access is an important aspect when planning for and performing TAVI. The superiority of a transfemoral (TF) approach compared to a transthoracic (transapical, direct aortic) approach has been demonstrated in several studies. Recently, the introduction of intravascular lithotripsy (IVL) has made it possible to treat patients with calcified iliofemoral disease by TF approach. This article aimed to provide a comprehensive overview on the following aspects: (1) preprocedural planning for IVL-assisted TF-TAVI; (2) procedural aspects in IVL-assisted TF-TAVI; (3) outcomes of IVL-assisted TF-TAVI in an experienced TAVI center; and (4) literature review and discussion of this new emerging approach.