Redo MitraClip for Late Recurrent Severe Mitral Regurgitation: Case Report and Literature Review.

Transcatheter mitral valve repair using the MitraClip (Abbott Vascular, Santa Clara, CA) is a reasonable option for the treatment of patients with severe symptomatic degenerative mitral regurgitation (MR) who are at prohibitive surgical risk. The occurrence of recurrent severe MR after initial successful MitraClip repair is uncommon. Data are sparse on the management of recurrent severe MR after initial successful repair using the MitraClip. We describe a successful case of redo MitraClip repair for late recurrent severe MR secondary to progressive degenerative mitral valve disease after a successful initial MitraClip procedure and review the literature.

La réparation transcathéter de la valve mitrale au moyen d'un dispositif MitraClip (Abbott Vascular, Santa Clara, CA) constitue une bonne option pour le traitement de l'insuffisance mitrale (IM) dégénérative symptomatique grave lorsque la chirurgie représente un risque prohibitif pour le patient. Il est rare qu'une IM grave récurrente survienne après l'implantation réussie d'un dispositif MitraClip. On dispose de très peu de données sur la prise en charge de l'IM grave récurrente après une première réparation au moyen d'un dispositif MitraClip. Nous présentons le cas d'une seconde réparation au moyen d'un dispositif MitraClip pour remédier à une IM grave récurrente tardive secondaire à une atteinte dégénérative évolutive de la valve mitrale survenue après une première intervention efficace au moyen d'un dispositif MitraClip, et nous passons en revue les publications portant sur cette question.

Echocardiographic Derived Parameters Association With Long-Term Outcomes After Transcatheter Valve Replacement.

BACKGROUND: Transaortic flow, maximum velocity (V max), mean gradient (MG), left ventricular ejection fraction (LVEF), Aortic valve area (AVA) and dimensional index (DI) are important determinants of prognosis in patients with severe aortic stenosis. The specific role of these echocardiography-derived values in predicting prognosis of severe aortic stenosis patients undergoing Transcatheter aortic valve replacement (TAVR) is less defined. METHODS: We identified all severe AS patients who underwent TAVR between 01/2012 and 6/2016. Baseline characteristics, clinical, procedural and one year follow-up data were obtained. Hierarchical logistic regression was used to assess predictors of 1-year mortality after TAVR. Normal flow (NF) was defined as having stroke volume index (SVI) of ≥35 ml/m2; while low Flow (LF) was defined as SVI < 35 ml/m2. High gradient (HG) was defined as mean gradient of ≥40 mmHg; while low gradient (LG) was defined as <40 mmHg. RESULTS: A total of 399 patients were analyzed. There were no significant differences in baseline characteristics. LVEF less than 35% was associated with higher rate of 1-year mortality (17.6% LVEF <35% vs. 8.9% LVEF≥35%; RR = 2.19; CI 1.05 to 4.54; P = 0.03). There was no difference in 1-year mortality outcomes after TAVR in relation to: Mean Gradient MG, transaortic flow/Stroke Volume Index SVI, DI, V max or AVA. CONCLUSION: Low LVEF <35% remains the strongest parameter associated with 1 year mortality after TAVR.

Transcatheter Mitral Valve Therapy With Novel Supra-Annular AltaValve: First Experience in the United States.

This case demonstrates the feasibility and procedural success of a novel supra-annular transcatheter mitral valve, the AltaValve via transapical approach in a patient with severe symptomatic mitral regurgitation who was a prohibitive surgical risk candidate. (Level of Difficulty: Advanced.).

Simultaneous transcatheter transfemoral aortic and transeptal mitral valve replacement using Edward SAPIEN S3.

Patients with concomitant severe aortic stenosis (AS) and severe mitral stenosis (MS) with mitral annular calcification (MAC) constitute an elderly high-risk population with multiple baseline comorbidities that coexist even before they develop severe valvular dysfunction. Transcatheter mitral valve replacements (TMVR) offer an alternative option for high-risk patient with severe MS with MAC. A simultaneous transfemoral Transcatheter aortic valve replacement (TAVR) and transseptal TMVR is feasible and offers the least invasive approach of management. We are reporting a case of an 83-year-old man with very symptomatic severe AS and severe native MS with associated severe MAC and moderate mitral regurgitation with high STS score who underwent a simultaneous transfemoral TAVR and transseptal TMVR with good results and great improvement in symptoms that was maintained on 10 months follow-up.

Endovascular repair of complex Juxtarenal aortic aneurysm using a combined fenestrated endograft and chimney technique.

Chimney EVAR (CHEVAR) and Fenestrated EVAR (FEVAR) are two options for management of very complex abdominal aortic aneurysm (AAA). While some anatomical factors may favor one strategy over the other, there are some cases where the anatomical challenges may require using a hybrid approach. We are reporting the case of an 84-year-old male with a 6.8×5.7cm infrarenal abdominal aortic aneurysm that arises immediately below the level of the renal arteries and extends down to just above the iliac bifurcation with occluded celiac and inferior mesenteric arteries and severe bilateral renal artery stenosis with caudally oriented right renal and cranially oriented left renal artery. This case shows that a combined strategy with fenestrated graft and Chimney stenting is feasible for aortic aneurysm repair and may offer a reasonable option for patients with very complex aortic anatomy.

Transcatheter aortic valve replacement through transcaval aortic access in a patient with duplicated inferior vena cava and poor iliofemoral anatomy.

Transthoracic (transapical and transaortic) access is inferior compared with femoral artery access. Percutaneous transcaval aortic access is a reasonable alternative approach that is being used in transcatheter aortic valve replacement (TAVR) in patients with poor iliofemoral anatomy. Duplicated Inferior vena cava (DIVC) is an uncommon abnormality. We report the case of 76-year-old lady with history of severe peripheral vascular disease, morbid obesity, diabetes, hypertension, hyperlipidemia and duplicated IVC that had severe symptomatic aortic stenosis. The patient had diffuse bilateral iliac disease precluding the arterial access required for TAVR. Other comorbidities made transthoracic access less desirable. We report the first successful Transcaval TAVR in a patient with DIVC.

Percutaneous thoracic aortic aneurysm repair through transcaval aortic access.

Transcaval aortic access has been used for deployment of transcatheter aortic valves in patients in whom conventional arterial approaches are not feasible. This access can be vital in other situation when large bore access is needed. We described a case of 65-year-old man who had large thoracic descending aortic aneurysm with diffuse bilateral iliac disease precluding the arterial access required for the procedure. The patient underwent successful transcaval access with placement of 22-Fr balloon expandable sheath followed with successful deployments of 32 mm × 32 mm × 150 mm Valiant stent graft (Medtronic, Minneapolis, MN). The aorto-vena cava tract was closed successfully using 12 × 10 PDA occluder device with no residual flow at the end of the case, which was confirmed on repeated CT next day.

Comparison of the boomerang wire vascular access management system versus manual compression alone during percutaneous diagnostic and interventional cardiovascular procedures: The boomerang™ wire vascular access management trial II.

OBJECTIVES: To evaluate the use of the Boomerang™ Wire as an adjunct to manual compression (MC) in patients requiring diagnostic (Dx) or interventional (Ix) percutaneous procedures. BACKGROUND: MC remains the standard of care for closure of femoral artery access sites. Adjunctive use of a device to facilitate closure, reduce time to hemostasis (TTH) and ambulation (TTA) without increasing complication rates could reduce costs and hospital resource demands. METHODS: The Boomerang™ Trial was a prospective, multicenter, randomized, controlled trial comparing use of the Boomerang™ wire, (Cardiva Medical, Sunnyvale, CA) in conjunction with MC versus MC alone to achieve hemostasis in Dx and Ix patients undergoing percutaneous procedures requiring femoral artery access. Endpoints included TTH, TTA, major, and minor access-site related complications. Subjects were randomized 3:1, Boomerang versus MC. RESULTS: No minor or major device-related adverse events were reported. Nondevice related complication rates were 3 (0.9%) in the Boomerang arm (n = 327) and 1 (0.8%) in MC arm (n = 123). Mean TTH for Boomerang vs. MC was 11.2 ± 4.3 vs. 23.2 ± 11 min for Dx (P < 0.0001) and 13.9 ± 5.4 vs. 38.4 ± 57.3 min for Ix patients (P < 0.0001). Mean TTA for Boomerang vs. MC was 3.3 ± 3.0 vs. 4.5 ± 2.0 hr (P < 0.0001)for Dx and 5.4 ± 3.3 vs. 6.8 ± 3.2 hr (P < 0.0001) for Ix patients. CONCLUSIONS: Boomerang™ use, in conjunction with MC, was associated with low rates of complications and demonstrated that Boomerang™ as an adjunct to MC can significantly decrease TTH and TTA after both Dx and Ix procedures. © 2015 Wiley Periodicals, Inc.

Endovascular management of splenic artery aneurysms: case series using telescoping guide and cage/coil technique.

Splenic artery aneurysms are rare, but still the third most common abdominal aneurysm. Rupture is associated with significant morbidity and mortality. Traditionally, cardiologists have rarely been involved in the management of this entity. We present a series of four patients managed percutaneously by interventional cardiology using a combined telescoping guide and cage/coil technique.

Impact of an integrated intervention program on atorvastatin adherence: a randomized controlled trial.

BACKGROUND: This trial evaluated the effectiveness of an integrated intervention program that included a 3-to-5-minute nurse counseling session, copay relief cards, and a monthly newsletter on adherence to atorvastatin treatment. METHODS AND RESULTS: A prospective, integrated (composed of nurse counseling, adherence tip sheet, copay relief card, opportunity to enroll in 12-week cholesterol management program) randomized interventional study was designed involving patients >21 years of age who were prescribed atorvastatin at a large single-specialty cardiovascular physician practice in Illinois from March 2010 to May 2011. Data from the practice's electronic medical record were matched/merged to IMS Health's longitudinal data. A total of 500 patients were enrolled (125 in the control arm; 375 in the intervention arm). After data linkage, 53 control patients and 155 intervention patients were included in the analysis. RESULTS: Mean age was 67.8 years (control) and 69.5 years (intervention); 67.9% and 58.7%, respectively, were male. The mean 6-month adherence rate was 0.82 in both arms. The mean proportion of days covered for both the new-user control and intervention groups was the same, averaging 0.70 day (standard deviation [SD], 0.27 day); for continuing users, the proportion of days covered for the control group was 0.83 (SD, 0.24) and for the intervention group was 0.84 (SD, 0.22). For continuing users, the control group had mean persistent days of 151.6 (SD, 50.2) compared with 150.9 days (SD, 50.9) for the intervention group. New users had fewer persistent days (control 111.4 days, SD, 69.6 days; intervention 112.0 days, SD, 58.8 days) compared with continuing users. The Cox proportional hazards model of the risk of discontinuation with index therapy was not significantly different between the intervention and control groups (hazard ratio 0.83, P = 0.55). CONCLUSION: The integrated intervention program did not significantly improve atorvastatin adherence relative to usual care in the studied patient population.

Renal nerves in the maintenance of hypertension: a potential therapeutic target.

Renal sympathetic efferent and afferent nerves, which lie within and immediately adjacent to the wall of the renal arteries, contribute to the maintenance of hypertension. Because the causative factors of hypertension change over time, denervation of both efferent and afferent renal nerves should result in long-term attenuation of hypertension. The importance of the renal nerves in hypertensive patients can now be defined with the novel development of percutaneous, minimally invasive renal denervation from within the renal artery using radiofrequency energy as a therapeutic strategy. Studies thus far show that catheter-based renal denervation in patients with resistant essential hypertension lowers systolic blood pressure 27 mm Hg by 12 months, with the estimated glomerular filtration rate remaining stable. The decrease in arterial pressure after renal denervation is associated with decreased peripheral sympathetic nervous system activity, suggesting that the kidney is a source of significant central sympathetic outflow via afferent renal nerve activity.

Long-term outcomes of drug-eluting stents versus bare-metal stents in saphenous vein graft disease: results from the Prairie "Real World" Stent Registry.

OBJECTIVES: This study was designed to compare long-term clinical outcomes of drug-eluting stents (DES) versus bare metal stents (BMS) in patients with saphenous vein graft (SVG) disease in the "real world." BACKGROUND: The safety and efficacy of DES versus BMS in SVG remains uncertain due to contradictory reports of either lower revascularization rates with DES; or clinical equivalence to BMS; or even an excess of clinical events associated with DES use. METHODS: We identified consecutive patients who underwent stent placement within a de novo SVG lesion between May 1, 2003 and July 31, 2007. Follow-up was obtained at regular intervals. The Kaplan-Meier method was used to produce actuarial survival estimates. Cox regression analysis was used to predict the risk associated with stent type, and propensity scores were generated to risk-adjust the results. RESULTS: The study group included 379 stent recipients (284 DES; 95 BMS) with 410 stented lesions. BMS were placed more frequently in current smokers, acute myocardial infarctions, larger vessels, and longer lesions. In-hospital mortality was higher in BMS recipients than in their DES counterparts (3.2% vs. 0, respectively; P = 0.015). At 3 years, there was no significant difference in clinical adverse event rates between DES and BMS recipients, even after risk adjustment. CONCLUSIONS: Three-year adverse event rates are similar among patients treated with DES or BMS in SVG lesions. Therefore, while DES are safe, they do not appear to offer an advantage in terms of long-term graft patency.

Proliferation and beta-tubulin for human aortic endothelial cells within gas-plasma scaffolds.

PURPOSE: We determined if human aortic endothelial cells (HAEC) enhanced proliferative and angiogenic phenotypes within gas-plasma treated bioresorbable D,L-polylactic acid (D,L-PLA) three-dimensional scaffolds. METHOD: 6 x 10(3) HAEC (N=120) were incubated for 6, 12 or 18 days within either non-treated control or treated scaffolds. Before removing media, unstained wells were observed for apparent cell densities. Quantitative colorimetric WST-1 mitochondrial assays were determined for pooled conditioned media from both HAEC attached to wells and their respective HAEC-containing scaffolds. Fixed HAEC in scaffolds were examined using non-quantitative laser confocal microcopy with FITC-conjugated consensus, Types-I/II or Type-III beta-tubulin. RESULTS: WST-1 indicated that significantly (p<0.05) less mitochondria were on cell culture plates than inside scaffolds but for different reasons. For example, a 12-18 days comparison between WST-1 and beta-tubulin indicated that wells decreased because of overgrowth apotosis; whereas, mitochondrial activity inside treated scaffolds decreased with increased tubulogenesis. Observed with consensus and Type-I/II beta-tubulin, HAEC-treated scaffolds exhibited increased cell-cell interconnections and angiogenic cords undergoing tubulogenesis to form vessels with central lumens as well as increased Type-III beta-tubulin, predominantly in cells of smaller surface areas. Moreover, beta-tubulin inside HAEC-treated scaffolds appeared in discrete cytoskeletal and podial regions; yet, beta-tubulin for HAEC-control scaffolds was located in more diffuse cytoplasmic regions especially at 18 days. CONCLUSIONS: HAEC-treated scaffolds undergo increased migration, proliferation, beta-tubulin expression and quiescent cord formation. HAEC in scaffolds represent a potential model to study mechanisms for vascular cord progression into tubes. WST-1 does not represent accurate cell densities in three-dimensional scaffold matrices.

An unusual presentation of congenital heart disease.

We describe an unusual presentation of congenital heart disease mimicking preeclampsia in a young, gravid girl. The diagnosis of Shone's complex was confirmed by echocardiography. This complex is manifested by multiple levels of obstruction involving the left side of the heart and the systemic circulation. It is extremely rare, especially in pregnant adolescents. We briefly describe the patient's clinical history, physical examination, and treatment, as well as our clinical decisions regarding her case. The discussion focuses on the spectrum of findings in Shone's complex and the physiologic impact of therapy on this patient.

Localization of a coronary artery fistula using contrast transesophageal echocardiography.

With the increasing use of transesophageal and other cardiac imaging, coronary fistulas are being discovered more often. The clinical significance of these communications is unclear. Microbubble echo-contrast has been used to enhance endocardial definition, myocardial perfusion, and augment Doppler signals. This case describes the use of microbubbles to enhance the color Doppler signals to better define location and extent of a coronary artery fistula communicating with the left ventricle.