Atrial Fibrillation Ablation-induced Pulmonary Venous Occlusion Requiring Pneumonectomy.

A 71-year-old woman with a history of atrial fibrillation underwent a catheter-based ablation procedure. Months later, she presented with dyspnea and a left-sided pleural effusion. Diagnostic evaluation revealed left-sided pulmonary venous occlusion, with essentially absent left lung perfusion. The patient underwent left pneumonectomy, with left atrial appendage occlusion. Although lobectomy for pulmonary venous occlusion of a single vein after pulmonary vein isolation has been described, this appears to be a novel report of occluded pulmonary venous drainage of an entire lung necessitating pneumonectomy.

Early Usage of Extracorporeal Membrane Oxygenation in the Absence of Invasive Mechanical Ventilation to Treat COVID-19-related Hypoxemic Respiratory Failure.

A subset of patients with coronavirus disease 2019 (COVID-19) develop profound respiratory failure and are treated via invasive mechanical ventilation (IMV). Of these, a smaller subset has severe gas exchange abnormalities that are refractory to maximal levels of IMV support. Extracorporeal membrane oxygenation (ECMO) has been used successfully in these circumstances. However, using ECMO only after failure of IMV exposes patients to the risks of ventilator-induced lung injury. We report a successful outcome using ECMO in the setting of COVID-19 in the absence of IMV failure in an awake, nonintubated patient. This approach may be beneficial for selected patients with COVID-19.

Trans-ventricular catheter device-based closure of postmyocardial infarction ventricular septal defect following coronary artery bypass grafting: A staged hybrid approach.

A 66-year-old woman with a history of hypertension, ischemic stroke, and rheumatoid arthritis presented to the hospital with severe angina pectoris and dyspnea and was diagnosed with myocardial infarction (MI). Coronary angiography revealed multisystem coronary artery occlusive disease. Due to refractory myocardial ischemia/evolving MI, emergency coronary artery bypass grafting (CABG) was undertaken. Intraoperative transesophageal echocardiography additionally revealed an apical muscular ventricular septal defect (VSD). Concomitant VSD repair was deferred due to the absence of surface evidence of transmural MI for left ventriculotomy, in the setting of pre-existing severe left ventricular dysfunction. An initial totally percutaneous attempt to close the VSD postoperatively failed. A hybrid surgical/catheter-based VSD closure was performed on postoperative day 4, with a successful outcome. The patient did well postoperatively and currently is alive in good condition. To the best of our knowledge, this is the first report of a staged (post-CABG) and hybrid surgical/catheter-based technique without the utilization of cardiopulmonary bypass.

Clinically Important Misclassification of Aortic Valve Stenosis Severity Using Non-Invasive Techniques: Simultaneous Echocardiography and Cardiac Catheterization During Transcatheter Aortic Valve Implantation in Awake Patients.

BACKGROUND: Suitability for transcatheter aortic valve (AV) implantation (TAVI) is determined by using transthoracic echocardiography (TTE), although left-sided cardiac catheterization (LCC) provides directly measured pressure data. TAVI in awake patients permits simultaneous comparison of TTE and LCC under physiologically relevant left ventricular loading conditions. We hypothesized that clinically important discrepancies between TTE and LCC would be identified. METHODS AND RESULTS: TAVI was performed in 108 awake patients undergoing intra-procedural TTE and LCC between January 1, 2016 and December 31, 2016, based upon pre-procedure TTE data. Intra-procedural assessments simultaneously were performed before and after prosthesis implantation. Based upon mean trans-AV systolic ejection pressure gradient (MSEPG), AS was graded as: mild (<20 mm Hg; grade 1), moderate (20 - <40 mm Hg; grade 2), or severe (≥40 mm Hg; grade 3). In 79 of the 108 (73.1%) patients, intra-procedural TTE and LCC assessments were concordant. In 2 of the 108 (1.9%) patients, TTE overestimated AS severity by ≥1 grade. In 27 of the 108 (25.0%) patients, TTE underestimated AS severity by ≥1 grade. In total, AS severity reclassification occurred in 29 (26.9%) patients. Overall, TTE underestimated MSEPG by 8.9 ± 1.2 mm Hg (TTE MSEPG versus LCC MSEPG; P < .001). CONCLUSION: Current TTE criteria appear to frequently and importantly underestimate AS severity. Because decision-making regarding TAVI often exclusively is based upon TTE data, these findings suggest either a continued role for LCC in the diagnostic assessment of AS in patients who do not meet standard TTE criteria or lowering TTE cutoffs for TAVI.

Outcomes of Patients Undergoing Transcatheter Aortic Valve Implantation With Incidentally Discovered Masses on Computed Tomography.

Routine preprocedural chest and abdomen computed tomography is done prior to transcatheter aortic valve implantation (TAVI), which, in turn, have led to the discovery of radiographic potentially malignant incidental masses (pMIM). It is largely unknown whether pMIM impact the outcomes of patients undergoing TAVI. In this retrospective cohort study from a single center, 1,081 patients underwent TAVI from 2012 to 2016, who had available computed tomographies, survived the index hospitalization, and also had 1 year follow-up data for review. Machine learning (backward propagation neural network)-augmented multivariable regression for mortality by pMIM was conducted. In this cohort of 1,081 patients, the mean age was 79.1 (± 9.0), 48.8% were females, 16.8% had a history of prior malignancy, and 21.1% had pMIM. One-year mortality for the entire cohort was 12.6%. The most common prior malignancies were prostate, breast, and lymphoma and the most common pMIM were present in the lung, kidneys, and thyroid. In a fully adjusted regression analysis, neither prior malignancy nor pMIM increased mortality odds. However, having both was associated with a higher 1-year mortality (odds ratio 4.02, 95% confidence interval 1.50 to 10.73, p = 0.006). In conclusion, presence of pMIM alone was not associated with an increased 1-year mortality among patients undergoing TAVI. However, the presence of pMIM and a history of prior malignancy was associated with a significant increase in 1-year mortality.

Advanced Pulmonary and Cardiac Support of COVID-19 Patients: Emerging Recommendations From ASAIO-a Living Working Document.

The severe acute respiratory syndrome-CoV-2 is an emerging viral pathogen responsible for the global coronavirus disease 2019 pandemic resulting in significant human morbidity and mortality. Based on preliminary clinical reports, hypoxic respiratory failure complicated by acute respiratory distress syndrome is the leading cause of death. Further, septic shock, late-onset cardiac dysfunction, and multiorgan system failure are also described as contributors to overall mortality. Although extracorporeal membrane oxygenation and other modalities of mechanical cardiopulmonary support are increasingly being utilized in the treatment of respiratory and circulatory failure refractory to conventional management, their role and efficacy as support modalities in the present pandemic are unclear. We review the rapidly changing epidemiology, pathophysiology, emerging therapy, and clinical outcomes of coronavirus disease 2019; and based on these data and previous experience with artificial cardiopulmonary support strategies, particularly in the setting of infectious diseases, provide consensus recommendations from American Society for Artificial Internal Organs. Of note, this is a living document, which will be updated periodically, as additional information and understanding emerges.

Advanced Pulmonary and Cardiac Support of COVID-19 Patients: Emerging Recommendations From ASAIO-A "Living Working Document".

The severe acute respiratory syndrome (SARS)-CoV-2 is an emerging viral pathogen responsible for the global coronavirus disease 2019 (COVID)-19 pandemic resulting in significant human morbidity and mortality. Based on preliminary clinical reports, hypoxic respiratory failure complicated by acute respiratory distress syndrome is the leading cause of death. Further, septic shock, late-onset cardiac dysfunction, and multiorgan system failure are also described as contributors to overall mortality. Although extracorporeal membrane oxygenation and other modalities of mechanical cardiopulmonary support are increasingly being utilized in the treatment of respiratory and circulatory failure refractory to conventional management, their role and efficacy as support modalities in the present pandemic are unclear. We review the rapidly changing epidemiology, pathophysiology, emerging therapy, and clinical outcomes of COVID-19; and based on these data and previous experience with artificial cardiopulmonary support strategies, particularly in the setting of infectious diseases, provide consensus recommendations from ASAIO. Of note, this is a "living document," which will be updated periodically, as additional information and understanding emerges.

Balloon-expandable transcatheter aortic valve replacement outcomes by procedure location: Catheterization laboratory versus operating room.

BACKGROUND: The impact of procedure location on clinical outcomes after TAVR remains unclear. We aimed to compare short-term outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) in the catheterization laboratory (CATH) versus surgical operating room (OR). METHODS: A retrospective review of 63,581 trans-femoral TAVR patients using balloon-expandable valves from 2015 to 2018 were captured utilizing the TVT Registry. Propensity score matching was performed using 24 covariates resulting in 2 risk-adjusted groups. Patients were further stratified by STS Risk Score with outcomes compared. RESULTS: Propensity score matching resulted in 24,160 risk-matched CATH and OR patient pairs. Short-term clinical outcomes including all-cause mortality, stroke, major vascular complications, life-threatening bleeding, and new dialysis were similar between CATH and OR (p = all ns). There was no difference in conversion to open heart surgery between CATH and OR with both occurring at a very low rate (0.4% vs. 0.5%, p = 0.07). Moreover, the 30-day survival post-conversion was similar whether TAVR was performed in CATH versus OR (43.3% and 49.7%, p = 0.28). When stratified by STS Risk Score, there was no difference in conversion to surgery or 30-day mortality in low and intermediate risk patients between CATH and OR. For high risk patients, however, conversion to surgery was lower in CATH vs. OR (0.2% vs. 0.4%, p = 0.04) with no difference in 30-day survival (46% vs. 43%, p = 0.94). CONCLUSIONS: Procedure location has minimal impact on TAVR procedural and 30-day outcomes with a very low conversion to open surgery rate between CATH versus OR for low, intermediate, and high-risk patients.

Direct Transcatheter Valve Deployment via Sternotomy for Complex Aortic Valve Reoperation.

Reoperative aortic valve replacement is associated with increased morbidity. Valve-in-valve transcatheter aortic valve replacement offers a less invasive alternative to traditional reoperation. However, cases of valve failure after valve-in-valve transcatheter aortic valve replacement represent a complex surgical challenge. We present a case requiring a complex reoperative aortic valve replacement due to structural valve deterioration after multiple previous valve-in-valve transcatheter aortic valve replacements. We performed removal of 3 previous valve-in-valve transcatheter aortic valves, bioprosthetic leaflet excision, and intentional bioprosthetic fracture under direct vision for annular enlargement. This facilitated direct insertion of a new transcatheter aortic valve for expedient and successful management of recurrent aortic stenosis in a very high-risk patient. Creative use of leaflet excision, intentional bioprosthetic fracture, and insertion of a new transcatheter aortic valve under direct vision, proved efficient and successful in a high-risk patient with few surgical options.

Bioprosthetic valve fracture: Technical insights from a multicenter study.

OBJECTIVE: Valve-in-valve transcatheter aortic valve replacement (VIV TAVR) can result in high residual gradients that are associated with increased mortality. Bioprosthetic valve fracture (BVF) has been shown to improve residual gradients following VIV TAVR; however, factors influencing the results of BVF have not been studied. METHODS: BVF was performed in 75 patients at 21 centers. Hierarchical multiple linear regression was performed to identify variables that were associated with lower final transvalvular gradient. RESULTS: Surgical valves with a median true internal diameter of 18.5 mm (interquartile range, 17.0-20.5 mm) were treated with VIV TAVR in conjunction with BVF using balloon-expandable (n = 43) or self-expanding (n = 32) transcatheter heart valves with a median size of 23 mm (interquartile range, 23-23 mm). There were no aortic root disruptions, coronary occlusions, or new pacemakers; in-hospital or 30-day mortality was 2.6% (2 out of 75). Final mean transvalvular gradient was 9.2 ± 6.3 mm Hg, but was significantly lower when BVF was performed after VIV TAVR compared with BVF first (8.1 ± 4.8 mm Hg vs 16.9 ± 10.1 mm Hg; P < .001). After adjusting for timing of BVF (ie, before or after VIV TAVR), transcatheter heart valve size/type, surgical valve mode of failure, true internal diameter, and baseline gradient and BVF balloon size, performing BVF after VIV TAVR (P < .001) and using a larger BVF balloon (P = .038) were the only independent predictors of lower final mean gradient. CONCLUSIONS: BVF can be performed safely and results in reduced residual transvalvular gradients. Performing BVF after VIV TAVR and using larger balloon appears to achieve the best hemodynamic results.

Regional, Artery-Specific Thresholds of Quantitative Myocardial Perfusion by PET Associated with Reduced Myocardial Infarction and Death After Revascularization in Stable Coronary Artery Disease.

Because randomized coronary revascularization trials in stable coronary artery disease (CAD) have shown no reduced myocardial infarction (MI) or mortality, the threshold of quantitative myocardial perfusion severity was analyzed for association with reduced death, MI, or stroke after revascularization within 90 d after PET. Methods: In a prospective long-term cohort of stable CAD, regional, artery-specific, quantitative myocardial perfusion by PET, coronary revascularization within 90 d after PET, and all-cause death, MI, and stroke (DMS) at 9-y follow-up (mean ± SD, 3.0 ± 2.3 y) were analyzed by multivariate Cox regression models and propensity analysis. Results: For 3,774 sequential rest-stress PET scans, regional, artery-specific, severely reduced coronary flow capacity (CFC) (coronary flow reserve ≤ 1.27 and stress perfusion ≤ 0.83 cc/min/g) associated with 60% increased hazard ratio for major adverse cardiovascular events and 30% increased hazard of DMS that was significantly reduced by 54% associated with revascularization within 90 d after PET (P = 0.0369), compared with moderate or mild CFC, coronary flow reserve, other PET metrics or medical treatment alone. Depending on severity threshold for statistical certainty, up to 19% of this clinical cohort had CFC severity associated with reduced DMS after revascularization. Conclusion: CFC by PET provides objective, regional, artery-specific, size-severity physiologic quantification of CAD severity associated with high risk of DMS that is significantly reduced after revascularization within 90 d after PET, an association not seen for moderate to mild perfusion abnormalities or medical treatment alone.

Surgical pulmonary embolectomy and catheter-based therapies for acute pulmonary embolism: A contemporary systematic review.

OBJECTIVES: Mortality in acute pulmonary embolism (PE) is believed to be principally due to the subgroup of PEs that are massive. Systemic thrombolysis is the therapeutic mainstay for acute massive PE, despite evidence suggesting limited survival benefits. Both catheter-based therapies (CBT) and surgical pulmonary embolectomy (SE) are well-accepted alternatives to treat acute PE. However, the comparative effectiveness of these approaches is difficult to study. We conducted a systematic review of CBT and SE for acute PE. METHODS: The PubMed database was queried for CBT- and SE-related publications between January 1998 and June 2017. A minimum of 10 patients undergoing intervention(s) was required for inclusion, and studies must not have excluded patients with massive PE. End points examined included hospital mortality, and additionally for CBT, procedural success rate. RESULTS: A total of 75 studies (41 of CBT, 34 of SE) were identified, with 1650 patients undergoing CBT and 1101 undergoing SE. Patients undergoing SE were more critically ill than those undergoing CBT (massive PE, 545 out of 975 [55.9%] for SE vs 742 out of 1553 [47.8%] for CBT). Cardiopulmonary resuscitation (CPR) was required in 217 out of 1015 patients undergoing SE (21.4%) versus 38 out of 983 patients undergoing CBT (4.0%). The hospital mortality of SE was 14.0%, versus 5.6% for CBT, in the entire patient group. However, the hospital mortality of SE in patients with pre-SE CPR was 46.3%, whereas it was 6.8% in those patients without pre-SE CPR. Although CPR was associated with an increased risk of mortality both for CBT and SE, it accounted for all of the mortality effect on SE (the adjusted odds ratio for CPR in a random effects model with treatment considered was 9.79 (95% confidence interval, 4.98-19.17; P < .0001). The adjusted odds ratio for mortality for SE relative to CBT was 1.36 (95% confidence interval, 0.80-2.32; P = .84). Moreover, CBT was associated with a procedural failure rate of 8.3%. CONCLUSIONS: Both CBT and SE were associated with satisfactory published outcomes. SE is associated with greater absolute postprocedure mortality than CBT, but has been undertaken in more critically ill populations. The markedly higher incidence of CPR in SE accounts for the differential mortality between the patients undergoing SE and those undergoing CBT. Decision making with respect to best therapy must take into account potential needs for periprocedure artificial mechanical right ventricle and lung support, institutional experience and outcomes, anticipated therapeutic efficacy and benefit, and approach-specific risks.