Single-Operator Left atrial appendage Occlusion utilizing Conscious sedation TEE, Lack of Outpatient pre-imaging, and Same-day Expedited discharge (SOLO-CLOSE): A comparison with conventional approach.

BACKGROUND: Left atrial appendage occlusion (LAAO) with WATCHMAN currently requires preprocedural imaging, general anesthesia, and inpatient overnight admission. We sought to facilitate simplification of LAAO. AIMS: We describe and compare SOLO-CLOSE (single-operator LAA occlusion utilizing conscious sedation TEE, lack of outpatient pre-imaging, and same-day expedited discharge) with the conventional approach (CA). METHODS: A single-center retrospective analysis of 163 patients undergoing LAAO between January 2017 and April 2022 was conducted. The SOLO-CLOSE protocol was enacted on December 1, 2020. Before this date, we utilized the CA. The primary efficacy endpoint was defined as successful LAAO with ≤5 mm peri-device leak at time of closure. The primary safety endpoint was the composite incidence of all-cause deaths, any cerebrovascular accident (CVA), device embolization, pericardial effusion, or major postprocedure bleeding within 7 days of the index procedure. Procedure times, 7-day readmission rates, and cost analytics were collected as well. RESULTS: Baseline characteristics were similar in both cohorts. Congestive heart failure (37.5% vs. 11.1%) and malignancy (28.8% vs. 12.5%) were higher in SOLO-CLOSE. Median CHA2D2SVASc score was 5 in both cohorts. The primary efficacy endpoint was met 100% in both cohorts. Primary safety endpoint was similar between cohorts (p = 0.078). Mean procedure time was 30 min shorter in SOLO-CLOSE (p < 0.01). Seven-day readmissions for SOLO-CLOSE was zero. After SOLO-CLOSE implementation, there was a 188% increase in positive contribution margin per case. CONCLUSIONS: The SOLO-CLOSE methodology offers similar efficacy and safety when compared to the CA, while improving clinical efficiency, reducing procedural times, and increasing economic benefit.

A grand mimicker of pulmonary malignancy: The massive mediastinal intercostal nerve tumour.

Mediastinal mass-like manifestations often cause alarm and instigate a myriad of investigative testing to rule out insidious malignant processes. However, a unique and benign finding, the schwannoma can present either incidentally or while in pursuit of a symptomatic presentation. Given its rarity, limited literature exists on these neurogenic tumours with less than three dozen reported cases. No specific guidelines exist regarding the extent of required advanced imaging or degree of invasive evaluation. Therefore, practitioners confronted with these intrathoracic tumours may find management challenging or delayed. We present a case discussing a large benign tumour causing symptomatic burden, the investigative methods implored and treatment modality. We add to the literature another unique presentation of an intercostal nerve sheath tumour with schwannoma pathology.

A Novel Percutaneous Snare-Assisted Manipulation and Repositioning of a ProtekDuo Cannula in a COVID-19 Acute Respiratory Distress Syndrome.

Venovenous extracorporeal membrane oxygenation [VV-ECMO] has gained increasing notoriety during the COVID-19 pandemic as a salvation therapy for fulminant respiratory failure. Various configurations can present unique challenges in management. For instance, the ProtekDuo cannula is a 29Fr to 31Fr dual-lumen cannula inserted by way of the right internal jugular vein that allows for right atrium to pulmonary artery bypass with an attached oxygenator, essentially resulting in VV-ECMO. Understanding that these different configurations inevitably dictate the types of complications that can arise during the circuit implantation and management is imperative. However, in a hemodynamically unstable patient, time or resources may not permit standard maneuvers for management. In conclusion, we present an innovative, percutaneous approach which allowed the restoration of flow and oxygenation in a decompensating ProtekDuo patient without having to explant/disconnect the circuit or implant a new VV-ECMO circuit.