Transcatheter Edge-to-Edge Repair in Complex Cyanotic Congenital Heart Disease With a Common Atrioventricular Valve.

A 21-year-old patient with complex cyanotic congenital heart disease and highly symptomatic severe common atrioventricular valve regurgitation was deemed too high risk for surgical intervention or transplantation. She successfully underwent transcatheter edge-to-edge repair with resulting considerable improvement in her symptoms, renal function, and quality of life.

Effectiveness of a new 3D printed simulator for mitral transcatheter edge-to-edge repair in enhancing the confidence and procedural skills of the operator.

BACKGROUND: . Mitral transcatheter edge-to-edge repair (m-TEER) is a minimally invasive procedure for treating mitral regurgitation (MR). m-TEER is a highly technical procedure, and a steep learning curve needs to be overcome for operators to ensure optimal patient outcomes and minimise procedural complications. Training via online simulation and observation of procedures is not sufficient to establish operator confidence; thus, advanced hands-on training modalities need to be explored and developed. METHODS: . In this study, a novel anatomical simulator for m-TEER training was evaluated in comparison to a standard model. The proposed simulator resembled the anatomical features of the right and left atrium, left ventricle and mitral valve apparatus. Participants in the questionnaire (n = 18) were recruited across 4 centres in London with (n = 8) and without (n = 10) prior experience in m-TEER. Participants were asked to simulate procedures on both an idealised, routinely used simulator and the newly proposed anatomical model. The questionnaire was designed to assess (i) participants' confidence before and after training and (ii) the realism of the model in the context of the m-TEER procedure. The results of the questionnaires were collected, and statistical analysis (t-test) was performed. RESULTS: . Both models were equally beneficial in increasing operator confidence before and after the simulation of the intervention (P = 0.43). However, increased confidence after training with the anatomical model was recorded (P = 0.02). Participants with prior experience with m-TEER therapy were significantly more confident about the procedure after training with the anatomical model than participants who had no prior experience (P = 0.002). On average, all participants thought that the anatomical model was effective as a training simulator (P = 0.013) and should be integrated into routine training (P = 0.015)). Participants with experience thought that the anatomical model was more effective at reproducing the m-TEER procedure than the idealised model (P = 0.03). CONCLUSIONS: . This study showed how a more realistic simulator can be used to improve the effectiveness of m-TEER procedural training. Such pilot results suggest planning future and large investigations to evaluate improvements in clinical practice.

Predictors of post-TAVI conduction abnormalities in patients with bicuspid aortic valves.

OBJECTIVES: This study evaluates predictors of conduction abnormalities (CA) following transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valves (BAV). BACKGROUND: TAVI is associated with CA that commonly necessitate a permanent pacemaker. Predictors of CA are well established among patients with tricuspid aortic valves but not in those with BAV. METHODS: This is a single-centre, retrospective, observational study of patients with BAV treated with TAVI. Pre-TAVI ECG and CT scans and procedural characteristics were evaluated in 58 patients with BAV. CA were defined as a composite of high-degree atrioventricular block, new left bundle branch block with a QRS >150 ms or PR >240 ms and right bundle branch block with new PR prolongation or change in axis. Predictors of CA were identified using regression analysis and optimum cut-off values determined using area under the receiver operating characteristic curve analysis. RESULTS: CA occurred in 35% of patients. Bioprosthesis implantation depth, the difference between membranous septum (MS) length and implantation depth (δMSID) and device landing zone (DLZ) calcification adjacent to the MS were identified as univariate predictors of CA. The optimum cut-off for δMSID was 1.25 mm. Using this cut-off, low δMSID and DLZ calcification adjacent to MS predicted CA, adjusted OR 8.79, 95% CI 1.88 to 41.00; p=0.01. Eccentricity of the aortic valve annulus, type of BAV and valve calcium quantity and distribution did not predict CA. CONCLUSIONS: In BAV patients undergoing TAVI, short δMSID and DLZ calcification adjacent to MS are associated with an increased risk of CA.

Demonstration of Use of a Novel 3D Printed Simulator for Mitral Valve Transcatheter Edge-to-Edge Repair (TEER).

Mitral regurgitation is a common valvular disorder. Transcatheter edge-to-edge repair (TEER) is a minimally invasive technique which involves holding together the middle segments of the mitral valve leaflets, thereby reducing regurgitation. To date, MitraClip™ is the only Food and Drug Administration (FDA)-approved device for TEER. The MitraClip procedure is technically challenging, characterised by a steep learning curve. Training is generally performed on simplified models, which do not emphasise anatomical features, realistic materials, or procedural scenarios. The aim of this study is to propose a novel, 3D printed simulator, with a major focus on reproducing the anatomy and plasticity of all areas of the heart involved and specifically the ones of the mitral valve apparatus. A three-dimensional digital model of a heart was generated by segmenting computed tomography (CT). The model was subsequently modified for: (i) adding anatomical features not fully visible with CT; (ii) adapting the model to interact with the MitraClip procedural equipment; and (iii) ensuring modularity of the system. The model was manufactured with a Polyjet technology printer, with a differentiated material assignment among its portions. Polypropylene threads were stitched to replicate chordae tendineae. The proposed system was successfully tested with MitraClip equipment. The simulator was assessed to be feasible to practice in a realistic fashion, different procedural aspects including access, navigation, catheter steering, and leaflets grasping. In addition, the model was found to be compatible with clinical procedural imaging fluoroscopy equipment. Future studies will assess the effect of the proposed training system on improving TEER training.