Positioning of self-expanding transcatheter valve prostheses.

The anatomic interplay between aortic valve, ascending aorta, left ventricular outflow tract and peripheral vasculature play a major role in determining device related outcomes in transcatheter aortic valve replacement. Factors such as the alignment angle (prosthesis-ascending aorta), pre-dilatation, operating team experience and chronic kidney disease may play a role in valve displacement. Careful analysis of all imaging modalities while sizing and selecting a valve type, and attention to newer deployment techniques may improve outcomes.

Transcatheter valves are a viable option for degenerative surgical mitral bioprostheses.

Repeat surgery is the ideal choice for degenerated bioprosthetic mitral valves. Percutaneous valve-in-valve (ViV) replacement for the treatment of degenerated bioprostheses has emerged as an alternative to open surgery in patients who are at high risk of surgical complications. Joseph et al have described the feasibility and long-term outcomes of Melody ViV Implantation for bioprosthetic mitral valve dysfunction in high-risk population.

Redefining landmarks to improve #safefemoral outcomes.

Retroperitoneal hemorrhage (RPH) and other femoral artery access site complications are associated with "high" arterial punctures. Using the nadir of inferior epigastric artery (IEA) as the landmark for identifying the inguinal ligament and high punctures can reduce access site complications. Traditional teaching of aiming for the middle of the femoral head while obtaining femoral access can result in higher than desired puncture site more frequently than aiming for the lower quarter. Enhanced understanding of anatomical landmarks, use of imaging guidance and strict adherence to safe access practices can help improve outcomes.

Transcatheter valve-in-valve for failing bioprosthetic aortic valve: Usually a good idea.

Use of bioprosthetic implants for surgical aortic valve replacements (SAVR) has been increasing in the recent years Surgical redo AVRs for failed surgical aortic bioprostheses have been traditionally considered the standard practice; however, in patients with higher surgical risk scores, transcatheter valve-in-valve aortic valve replacements are being commonly performed There is scarcity of data comparing these two approaches in this complex patient cohort Available data suggest that transcatheter ViV aortic valve replacement is generally a safe approach once some caveats are accounted for.

Coronary chronic total occlusions: How to dilate the tough ones.

Several chronic total occlusions (CTOs) may be undilatable despite successful wire passage; several techniques can be used for lesion preparation, such as high-pressure balloon inflations, rotational atherectomy laser, cutting balloon, and scoring balloons. Presence of moderate to severe calcification and lesion length over 40 mm in association with comorbidities, such as diabetes mellitus and reduced ejection fraction, may contribute to making a CTO lesion undilatable. Still, appropriate therapy selection for a patient with CTO should be individualized and procedure safety attended to.

The quest for a "diabetic" stent.

Patients with diabetes mellitus and extensive coronary artery disease generally had worse outcomes with early generation drug eluting stents (DES) as compared to coronary artery bypass grafting. Initial results with Amphilimus eluting coronary stent in patients with diabetes have been promising in small studies The data from Sardella et al. should be used, in conjunction with previous clinical studies with this DES type, as hypothesis generating for a large multicenter randomized trial to aid in our quest to find the "new diabetic stent."

Overlapping bio-absorbable scaffolds: Aim for D2D technique?

The results of overlapping metallic stents have been concerning but this practice is often unavoidable in the setting of long or tortuous lesions, diameter discrepancy of proximal and distal vessel, and for residual dissections. Theoretically, bio-absorbable scaffolds may carry an advantage over metallic stents due to the progressive resorption of the scaffold theoretically rendering the overlap a non-issue; this has not been clinically evident. Since stent/scaffold overlap cannot be entirely avoided, improved stent delivery/deployment and scaffold design modification may reduce complications in this complex patient subset.

Continuous invasive hemodynamic monitoring using steerable guide catheter to optimize mitraclip transcatheter mitral valve repair: A multicenter, proof-of-concept study.

OBJECTIVES: We report our multicenter experience on continuous hemodynamic monitoring using exclusively the steerable guide catheter (SGC) during MitraClip repair. BACKGROUND: Left atrial pressure (LAP) and V-wave are useful to evaluate MitraClip repair but no simple method of continuous monitoring exists. METHODS: From 11/2016 to 8/2017, 74 patients from four centers with symptomatic moderate-severe to severe mitral regurgitation (MR), underwent MitraClip NT repair with continuous hemodynamic monitoring via the SGC. Real-time LAP/V-wave changes were compared with transesophageal echocardiography (TEE). When mitral stenosis was suspected, transmitral gradients were verified by invasive hemodynamics. Clinical and echocardiographic outcomes were determined. RESULTS: Mean age was 78 ± 10 years and STS score 9.1 ± 11.0%. Pathology included leaflet prolapse/flail (45%), restriction (35%), and mixed (20%). Number of clips averaged 1.7 ± 0.7 per case. There was a significant reduction in LAP (21 ± 10 to 15 ± 7 mmHg, P < 0.0001) and V-wave(37 ± 19 to 24 ± 10 mmHg, P < 0.0001) post MitraClip, but the decrease was less in patients with atrial fibrillation (P < 0.05). Transmitral gradient significantly increased from 2.0 ± 1.2 to 4.0 ± 1.7 mmHg (P < 0.0001). Paradoxical increases in LAP and V-wave despite MR reduction were observed in three cases requiring MitraClip repositioning or retrieval to avoid stenosis. Follow-up averaged 5.0 ± 2.9 months and was 100% complete. KCCQ improvement was significant and MR reduction to <1+ was 67% and <2+ was 93% at 30 days. CONCLUSIONS: Continuous hemodynamic monitoring using the SGC complements TEE to assess and optimize MitraClip repair in real-time. Further validation is necessary but this feature may be part of future MitraClip and other transcatheter mitral repair systems.

Reverse Takotsubo Cardiomyopathy with Severe Dengue: Case Report from Pakistan.

Takotsubo Cardiomyopathy is an established transient cardiomyopathy found predominately in females with intense emotional and physical strain. It has four notable variants: Apical, Mid-Ventricular, Basal and Focal. Mid Ventricular variant is also referred to as Reverse Takotsubo Cardiomyopathy. Dengue is a viral arthopod-borne tropical disease endemic to Pakistan, with multiple reports of cardiovascular involvement. We report an atypical presentation of a 17 year old male, suffering from Dengue Fever, who presented to a tertiary care hospital with Reverse Takotsubo Cardiomyopathy.

Rota Ablation - When There is No Other Option. A Complex Case of 86 Years Old Male with Multiple Comorbids Presenting With Stemi.

The aim of this report is to explore the direct and long-term outcome in a high risk patient who was treated with rotational atherectomy (RA) to assist the placement of drug eluting stents in heavily calcified lesions. The patient presented with acute STEMI and had severely calcified Left main stem (LMS) disease, requiring plaque modification before coronary angioplasty and stent implantation. As the patient was elderly, with multiple comorbids including a number of coronary interventions, a decision of conservative management was made. Patient then re-presented with typical chest pain and pulmonary edema. A Heart Team meeting was called and high risk decision of RA to LMS was taken. His percutaneous transluminal coronary angioplasty (PTCA) to LM and LAD was planned. LMS to LAD was rotablated with 1.75 burr and PTCA with 3.5 NC at 20 Atm. During the procedure, patient developed flash pulmonary edema. In post-operative care, his renal functions deteriorated and nephrology was taken on board. After multiple sessions of hemodialysis, patient was clinically improved and stabilized. The report highlights the expertise required in RA of a complex LMS disease and judicious post-procedure care which resulted in significant reduction of morbidity, mortality and frequent hospitalizations of the patient.

Novel Anatomic Predictors of New Persistent Left Bundle Branch Block After Evolut Transcatheter Aortic Valve Implantation.

New persistent left bundle branch block (NP-LBBB) has been associated with adverse outcomes after TAVI but few predictors thus far reported. We sought to identify predictors of NP-LBBB after TAVI with EvolutR/PRO (ER/EP). From 1/2016 to 4/2019, 544 patients from 2 centers underwent TAVI with Evolut (54% ER, 46% EP) for severe native aortic stenosis. Patients with previous LBBB and pacemaker were excluded. Aortic root analysis was performed using 3Mensio Valves Software and membranous septal length (MSL) was determined using the standard coronal view. Clinical, anatomic and procedural characteristics of 396 Evolut were analyzed and predictors of NP-LBBB were identified. Valve Academic Research Consortium-2 outcomes were reported. At discharge, NP-LBBB was seen in 76(19.2%) patients. NP-LBBB in Evolut was associated with implant depth at left coronary cusp (p = 0.004) and 34 mm ER (p = 0.026). Independent predictors of NP-LBBB in Evolut were shorter MSL (odds ratio [OR] = 0.82 per mm septum, 95% confidence interval [CI] = 0.68 to 0.98,p = 0.030), left ventricular outflow tract (LVOT) eccentricity (OR = 1.04 per %, 95% CI = 1.01 to 1.06,p = 0.002), implant depth at noncoronary cusp (NCC) (OR = 1.28 per mm ventricular, 95% CI = 1.11 to 1.48,p = 0.001) and annular perimeter oversizing ≥20% (OR = 2.38, 95% CI = 1.20 to 4.72, p = 0.013). On ROC curve analysis, MSL ≤6.5 mm, NCC depth ≥3 mm and LVOT eccentricity ≥35% were optimal threshold values to predict NP-LBBB. In Conclusion, shorter MSL, LVOT eccentricity, annular oversizing and deeper implant depth are novel predictors of NP-LBBB in Evolut TAVI. Preprocedural CT assessment of aortic root anatomy may help identify patients at risk for NP-LBBB. In such patients, modifying procedural factors such as higher implant and less annular oversizing may reduce the risk of NP-LBBB. Further evaluation of our hypothesis is warranted.

The impact of perioperative inotropes on the incidence of pancreatic leak following pancreaticoduodenectomy.

BACKGROUNDS/AIMS: Pancreatic leak and fistula formation following pancreatic resection is a dreaded complication associated with significant morbidity and mortality. The perioperative use of inotropes has been implicated in anastomotic dehiscence in other types of gastrointestinal surgery but their impact in pancreatic surgery remains unclear and a potentially modifiable risk factor for pancreatic leak. This study aims to assess the impact of perioperative inotrope infusion on the incidence of pancreatic leak following pancreaticoduodenectomy. METHODS: Retrospective data analysis of all patients undergoing pancreaticoduodenectomy at a tertiary HPB institute. Multivariate analysis and regression models assessed the impact of inotrope use against other known risk factors such as pancreatic duct size and gland texture. Pancreatic fistulae were graded as per ISGPF as Grade A (biochemical leak), Grade B and Grade C fistula. RESULTS: One-hundred and twenty-three (123) patients were included. A total of 52 patients (42%) developed a leak (29 grade A, 15 grade B, and 8 Grade C). In the fistula group, 28 patients (55%) received perioperative inotropes compared to 26 (35%) in the no fistula group. On univariate analysis, patients receiving inotropes (p=0.04) and patients with a soft pancreatic texture (p=0.003) had a statistically higher incidence of developing a pancreatic fistula of any grade. On multivariate analysis, only inotrope use was associated with an increased risk of developing a pancreatic fistula of any grade (OR 2.46, p=0.026), independent of pancreatic texture and pancreatic duct size. CONCLUSIONS: Perioperative inotrope use is associated with an increase incidence of pancreatic leak following pancreaticoduodenectomy and should therefore be used judiciously.

Impaired right ventricular reserve predicts adverse cardiac outcomes in adults with congenital right heart disease.

OBJECTIVE: The prevalence of heart failure (HF) among adult patients with congenital heart disease (ACHD) is rising. Right ventricle (RV) exercise reserve and its relationship to outcomes have not been characterised. We aim to evaluate the prognostic impact of impaired RV reserve in an ACHD population referred for cardiopulmonary exercise testing (CPET). METHODS: This retrospective study evaluates patients with ACHD who underwent CPET (n=147) with first-pass radionuclide ventriculography at a single tertiary care centre. RV reserve was categorised as normal, mild to moderately or severely impaired. The primary composite clinical outcome included clinical right HF, arrhythmia, transplantation or death. RESULTS: Patients were median age 41±13 years, 50% were female and median follow-up was 1.1 (IQR: 0.7-2.0) years. Exercise RV reserve was impaired in 103 patients (70%), of whom 32% were asymptomatic. Resting RV systolic function poorly predicted RV reserve, with 52% of patients with severe impairment having a qualitatively normal echocardiographic assessment. The severely impaired reserve group had lower peak oxygen consumption (VO2)(17.2 vs 22.5 mL/kg/min, p<0.0001) compared with the normal reserve group, and was more likely to develop the composite outcome (48% vs 9%, log-rank p<0.001). Severely impaired RV reserve predicted event-free survival after adjusting for peak VO2, age, sex, RV pathology, QRS duration, New York Heart Association class, resting RV ejection fraction and RV dilation by echocardiography or MRI (HR 3.7, 95% CI 1.1 to 13.0, p=0.039). CONCLUSION: Impaired RV reserve, occurred in asymptomatic patients, was not well predicted by resting systolic function assessment, and strongly predicted adverse cardiovascular outcomes.

Cardiac Imaging In Athletes.

Athletic heart syndrome refers to the physiological and morphological changes that occur in a human heart after repetitive strenuous physical exercise. Examples of exercise-induced changes in the heart include increases in heart cavity dimensions, augmentation of cardiac output, and increases in heart muscle mass. These cardiac adaptations vary based on the type of exercise performed and are often referred to as sport-specific cardiac remodeling. The hemodynamic effects of endurance and strength training exercise lead to these adaptations. Any abnormalities in chamber dilatation and left ventricular function usually normalize with cessation of exercise. Athletic heart syndrome is rare and should be differentiated from pathologic conditions such as hypertrophic cardiomyopathy, left ventricular noncompaction, and arrhythmogenic right ventricular dysplasia when assessing a patient for athletic heart syndrome. This paper describes specific adaptations that occur in athletic heart syndrome and tools to distinguish between healthy alterations versus underlying pathology.

Emergent unilateral renal artery stenting for treatment of flash pulmonary edema: fact or fiction?

Flash pulmonary edema is characteristically sudden in onset with rapid resolution once appropriate therapy has been instituted (Messerli et al., 2011). Acute increase of left ventricular (LV) end diastolic pressure is the usual cause of sudden decompensated cardiac failure in this patient population. Presence of bilateral renal artery stenosis or unilateral stenosis in combination with a single functional kidney in the susceptible cohort is usually blamed for this condition. We describe a patient who presented with flash pulmonary edema in the setting of normal coronary arteries. Our case is distinct as our patient developed flash pulmonary edema secondary to unilateral renal artery stenosis in the presence of bilateral functioning kidneys. Percutaneous stent implantation in the affected renal artery resulted in rapid resolution of pulmonary edema.