Pulmonary vascular disease and optical coherence tomography imaging in patients with Fontan palliation.

INTRODUCTION: The Fontan procedure is the palliative procedure of choice for patients with single ventricle physiology. Pulmonary vascular disease (PVD) is an important contributor to Fontan circulatory failure. AREAS COVERED: We review the pathophysiology of PVD in patients with Fontan palliation and share our initial experience with optical coherence tomography (OCT) in supplementing standard hemodynamics in characterizing Fontan-associated PVD. In the absence of a sub-pulmonary ventricle, low pulmonary vascular resistance (PVR; ≤2 WU/m2) is required to sustain optimal pulmonary blood flow. PVD is associated with adverse pulmonary artery (PA) remodeling resulting from the non-pulsatile low-shear low-flow circulation. Predisposing factors to PVD include impaired PA growth, endothelial dysfunction, hypercoagulable state, and increased ventricular end-diastolic pressure. OCT parameters that show promise in characterizing Fontan-associated PVD include the PA intima-to-media ratio and wall area ratio (i.e. difference between the whole-vessel area and the luminal area divided by the whole-vessel area). EXPERT OPINION: OCT carries potential in characterizing PVD in patients with Fontan palliation. PA remodeling is marked by intimal hyperplasia, with medial regression. Further studies are required to determine the role of OCT in informing management decisions and assessing therapeutic responses.

Growth Differentiation Factor-15 as a Predictor of Functional Capacity, Frailty, and Ventricular Dysfunction in Patients With Aortic Stenosis and Preserved Left Ventricular Ejection Fraction.

In aortic stenosis (AS), left ventricular (LV) remodeling often occurs before symptom onset, and early intervention may be beneficial. Risk stratification remains challenging and identification of biomarkers may be useful. We evaluated the association between growth differentiation factor-15 (GDF-15) and soluble suppression of tumorigenicity 2 (sST2) and known markers of poor prognosis in AS. Baseline plasma GDF-15 and sST2 levels were measured in 70 patients with moderate-severe AS (aortic valve area <1.5 cm2) and preserved LV ejection fraction (>45%). Patients were categorized into "low GDF-15" versus "high GDF-15" and "low sST2" versus "high sST2" groups. Groups were compared for differences in cardiovascular risk factors, 6-minute walk test, 5 m gait speed, cognitive function (Montreal Cognitive Assessment), and echocardiographic parameters. Overall, 44% of patients were deemed asymptomatic by New York Heart Association class, 61% had severe AS (aortic valve area <1 cm2) and all patients had preserved LV ejection fraction. GDF-15 levels were not predictive of AS severity. However, high GDF-15 (>1,050 pg/ml) was associated with LV dysfunction as shown by lower indexed stroke volume (p <0.01), worse LV global longitudinal strain (p = 0.04), greater mean E/e' (p = 0.02) and indexed left atrial volume (p <0.01). It was also associated with decreased functional capacity with shorter 6-minute walk test (p = 0.01) and slower 5 m gait speed (p = 0.02). Associations between sST2 levels and markers of poor prognosis were less compelling. In this study of patients with moderate to severe AS, elevated GDF-15 levels are associated with impaired functional capacity, poorer performance on fragility testing, and LV dysfunction. In conclusion, GDF-15 may integrate these markers of adverse outcomes into a single biomarker of poor prognosis.

Canadian Spontaneous Coronary Artery Dissection Cohort Study: 3-Year Outcomes.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in young to middle-aged women. OBJECTIVES: We aim to define the long-term natural history of SCAD. METHODS: We performed a multicenter, prospective, observational study of patients with nonatherosclerotic SCAD presenting acutely from 22 North American centers. We recorded baseline demographics, in-hospital characteristics, precipitating and predisposing conditions, angiographic features (adjudicated), in-hospital and 3-year major adverse cardiovascular events (MACE). Cox regression multivariable analysis was performed. RESULTS: We prospectively enrolled 750 consecutive patients with SCAD from June 2014 to June 2018. Mean age was 51.7 ± 10.5 years, 88.5% were women (55.0% postmenopausal); 31.3% presented with ST-segment elevation myocardial infarction, and 68.3% with non-ST-segment elevation myocardial infarction. Precipitating emotional stressor was reported in 50.3%, and physical stressor in 28.9%. Predisposing conditions included fibromuscular dysplasia in 42.9% (56.4% in those with complete screening), peripartum state 4.5%, and genetic disorders 1.6%. Most patients were treated conservatively (84.3%); 14.1% underwent percutaneous coronary intervention (PCI), 0.7% coronary artery bypass graft. At 3.0-year median follow-up, mortality was 0.8%, recurrent MI 9.9% (extension of previous SCAD 3.5%, de novo recurrent SCAD 2.4%, iatrogenic dissection 1.9%), with overall MACE 14.0%. Presence of genetic disorders, peripartum SCAD, and extracoronary fibromuscular dysplasia were independent predictors of 3-year MACE. Patients who underwent PCI at index hospitalization had similar postdischarge MACE compared with no PCI. At 3 years, 80.0% remained on aspirin and 73.5% on beta-blockade. CONCLUSIONS: Long-term mortality and de novo recurrent SCAD was low in our contemporary large SCAD cohort that included low revascularization rate and high use of beta-blockade and aspirin. Genetic disorders, extracoronary fibromuscular dysplasia, and peripartum SCAD were independent predictors of long-term MACE.

Indications, Limitations, and Development of Tricuspid Valve Interventions in Adults.

Tricuspid regurgitation is associated with excessive mortality and poor outcomes regardless of the cause and associated comorbidities. Despite this clear association with mortality, tricuspid valve diseases remain undertreated. Tricuspid valve surgery, either repair or replacement, has shown little detectable survival benefit. Transcatheter tricuspid valve interventions have emerged as a less invasive approach to tricuspid valve diseases. They can be categorised into coaptation devices, annuloplasty devices, transcatheter tricuspid valve replacement, heterotopic caval valve implantation, and tricuspid valve-in-valve. Despite the late referral and the patient's profile, results remain fairly acceptable at least in the short term, with good procedural device success, excellent safety profile, and sustained reduction of tricuspid regurgitation for up to 1 year. Because results are limited to the mid-term, transcatheter tricuspid valve intervention durability will need to be established before broader adoption of these technologies.

Bicuspid Aortic Valve Stenosis: From Pathophysiological Mechanism, Imaging Diagnosis, to Clinical Treatment Methods.

Bicuspid aortic valve (BAV) is the most frequent congenital anomaly and has a natural evolution toward aortic regurgitation or stenosis due to the asymmetrical valve function associated with an evolutive ascending aortopathy. Several BAV classifications exist describing the presence and number of raphe, amount and location of calcium, and the symmetry of the functional cusps. The impact of BAV morphology on transcatheter aortic valve implantation (TAVI) outcomes still remains little investigated. Pivotal randomized trials comparing TAVI with surgery have excluded BAV until yet. However, data from registries and observational studies including highly selected patients have shown promising results of TAVI in BAV. With this review, we aimed at describing anatomical and pathophysiological characteristics of BAV, discussing the main aspects to assess diagnostic imaging modalities, and giving an overview of TAVI outcomes and technical considerations specific to BAV morphology.

Value of FEops HEARTguide patient-specific computational simulations in the planning of left atrial appendage closure with the Amplatzer Amulet closure device: rationale and design of the PREDICT-LAA study.

BACKGROUND: Optimal preprocedural planning is essential to ensure successful device closure of the left atrial appendage (LAA). DESIGN: The PREDICT-LAA study is a prospective, international, multicentre, randomised controlled trial (ClinicalTrials.gov NCT04180605). Two hundred patients eligible for LAA closure with an Amplatzer Amulet device (Abbott, USA) will be enrolled in the study. Patients will be allocated to a computational simulation arm (experimental) or standard treatment arm (control) using a 1:1 randomisation. For patients randomised to the computational simulation arm, preprocedural planning will be based on the analysis of cardiac computed tomography (CCT)-based patient-specific computational simulations (FEops HEARTguide, Ghent, Belgium) in order to predict optimal device size and position. For patients in the control arm, preprocedural planning will be based on local practice including CCT analysis. The LAA closure procedure and postprocedural antithrombotic therapy will follow local practice in both arms. The primary endpoint of the study is incomplete LAA closure and device-related thrombus as assessed at 3 months postprocedural CCT. Secondary endpoints encompass procedural efficiency (number of devices used, number of repositioning, procedural time, radiation exposure, contrast dye), procedure-related complications within 7 days postprocedure and a composite of all-cause death and thromboembolic events at 12 months. CONCLUSION: The objective of the PREDICT-LAA study is to test the hypothesis that a preprocedural planning for LAA closure with the Amplatzer Amulet device based on patient-specific computational simulations can result in a more efficient procedure, optimised procedural outcomes and better clinical outcomes as compared with a standard preprocedural planning. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04180605).

Lead Extraction With Baffle Stenting in Adults With Transposition of the Great Arteries.

OBJECTIVES: This study sought to assess the feasibility, safety, and outcomes of a stepwise combined percutaneous approach that includes transvenous lead extraction (TLE) followed by baffle stenting and device reimplantation in patients with D-transposition of the great arteries (D-TGA) and atrial baffle dysfunction. BACKGROUND: Management of baffle leak or stenosis in patients with D-TGA and atrial switch surgery is challenging in the presence of transvenous cardiac implantable electronic devices. Baffle complications hinder device-related interventions and addressing baffle dysfunction often requires TLE. METHODS: All consecutive patients with D-TGA and TLE followed by a percutaneous baffle intervention at the Montreal Heart Institute between 2009 and 2018 were enrolled. RESULTS: Ten patients, median 38.6 years of age (range 15.2 to 50.6 years), 5 males (50.0%) were included. Procedures were performed for a device-related indication in 5 patients (50.0%) and for baffle dysfunction in 5 patients (50.0%). A total of 19 leads (17 pacing, 2 defibrillation) were targeted, with a median time from implantation of 8.7 (range 4.3 to 22.1) years. A laser sheath was most frequently required for successful TLE, which was achieved in all patients. Immediate baffle stenting was performed in 9 patients (90.0%) and immediate device reimplantation in 6 (60.0%). During a median follow-up of 3.0 (range 0.1 to 8.2) years, the only complication was subpulmonary atrioventricular valve damage requiring surgery in 1 patient, 8 months after the procedure. CONCLUSIONS: A combined approach with TLE followed by baffle stenting and reimplantation appears to be safe and feasible in D-TGA patients with atrial switch, baffle dysfunction, and transvenous leads.

Canadian spontaneous coronary artery dissection cohort study: in-hospital and 30-day outcomes.

AIMS: Spontaneous coronary artery dissection (SCAD) was underdiagnosed and poorly understood for decades. It is increasingly recognized as an important cause of myocardial infarction (MI) in women. We aimed to assess the natural history of SCAD, which has not been adequately explored. METHODS AND RESULTS: We performed a multicentre, prospective, observational study of patients with non-atherosclerotic SCAD presenting acutely from 22 centres in North America. Institutional ethics approval and patient consents were obtained. We recorded baseline demographics, in-hospital characteristics, precipitating/predisposing conditions, angiographic features (assessed by core laboratory), in-hospital major adverse events (MAE), and 30-day major adverse cardiovascular events (MACE). We prospectively enrolled 750 SCAD patients from June 2014 to June 2018. Mean age was 51.8 ± 10.2 years, 88.5% were women (55.0% postmenopausal), 87.7% were Caucasian, and 33.9% had no cardiac risk factors. Emotional stress was reported in 50.3%, and physical stress in 28.9% (9.8% lifting >50 pounds). Predisposing conditions included fibromuscular dysplasia 31.1% (45.2% had no/incomplete screening), systemic inflammatory diseases 4.7%, peripartum 4.5%, and connective tissue disorders 3.6%. Most were treated conservatively (84.3%), but 14.1% underwent percutaneous coronary intervention and 0.7% coronary artery bypass surgery. In-hospital composite MAE was 8.8%; peripartum SCAD patients had higher in-hospital MAE (20.6% vs. 8.2%, P = 0.023). Overall 30-day MACE was 8.8%. Peripartum SCAD and connective tissue disease were independent predictors of 30-day MACE. CONCLUSION: Spontaneous coronary artery dissection predominantly affects women and presents with MI. Despite majority of patients being treated conservatively, survival was good. However, significant cardiovascular complications occurred within 30 days. Long-term follow-up and further investigations on management are warranted.

Late Onset Postcapillary Pulmonary Hypertension in Patients With Transposition of the Great Arteries and Mustard or Senning Baffles.

BACKGROUND: There is a paucity of data regarding late-onset pulmonary hypertension (PH) in patients with transposition of the great arteries and atrial switch surgery. METHODS AND RESULTS: A retrospective cohort study was conducted on 140 adults with transposition of the great arteries and atrial switch surgery, age 37.3±7.8, 37.1% female, in order to assess the prevalence and characteristics of late-onset PH and explore associated factors. Patients were followed for a median of 32.3 years after atrial switch surgery and 10.0 years after their first referral visit. PH was detected in 18 of 33 (54.5%) patients who had invasive hemodynamic studies. Average age at diagnosis of PH was 33.9±8.1 years. PH was postcapillary in all, with a mean pulmonary artery pressure of 36±12 mm Hg and mean pulmonary capillary wedge pressure of 28±8 mm Hg. PH was diagnosed in 13 of 17 (76.5%) patients who had cardiac catheterization for heart failure or decreased exercise tolerance. In multivariable analyses, systemic hypertension (odds ratio 9.4, 95% confidence interval 2.2-39.4, P=0.002) and heart failure or New York Heart Association class III or IV symptoms (odds ratio 49.8, 95% confidence interval 8.6-289.0, P<0.001) were independently associated with PH. Patients with PH were more likely to develop cardiovascular comorbidities including atrial (P=0.001) and ventricular (P=0.008) arrhythmias, require hospitalizations for heart failure (P<0.001), and undergo tricuspid valve surgery (P<0.001). Mortality was significantly higher in patients with PH (hazard ratio 9.4, 95% confidence interval 2.1-43.0], P<0.001). CONCLUSIONS: Late-onset postcapillary PH is highly prevalent in adults with transposition of the great arteries and atrial switch surgery and is associated with an adverse prognosis.

Surgery Versus Transcatheter Interventions for Significant Paravalvular Prosthetic Leaks.

OBJECTIVES: This study sought to assess the relative merit of surgical correction (SC) versus transcatheter reduction on long-term outcomes in patients with significant paravalvular leak (PVL) refractory to medical therapy. BACKGROUND: PVL is the most frequent dysfunction following prosthetic valve replacement. Although repeat surgery is the gold standard, transcatheter reduction (TR) of PVL has been associated with reduced mortality. METHODS: From 1994 to 2014, 231 patients underwent SC (n = 151) or TR (n = 80) PVL correction. Propensity matching and Cox proportional hazards regression models were used to assess the effect of either intervention on long-term rates of all-cause death or hospitalization for heart failure. Survival after TR and SC were further compared with the survival in a matched general population and to matched patients undergoing their first surgical valve replacement. RESULTS: Over a median follow-up of 3.5 years, SC was associated with an important reduction in all-cause death or hospitalization for heart failure compared with TR (hazard ratio: 0.28; 95% confidence interval: 0.18 to 0.44; p < 0.001). There was a trend towards reduced all-cause death following SC versus TR (hazard ratio: 0.61; 95% confidence interval: 0.37 to 1.02; p = 0.06). Neither intervention normalized survival when compared with a general population or patients undergoing their first surgical valve replacement. CONCLUSIONS: In patients with significant prosthetic PVL, surgery is associated with better long-term outcomes compared with transcatheter intervention, but results in important perioperative mortality and morbidity. Future studies are needed in the face of increasing implementation of transcatheter PVL interventions across the world.

Results of a multimodal approach for the management of aortic coarctation and its complications in adults.

OBJECTIVES: We aimed to assess the results of various tailored management strategies for adults with coarctation in our centre. METHODS: We reviewed all adults patients treated for aortic caorctation between January 2000 and December 2015 in our institution. The primary end point was a composite of death, perioperative stroke, paraplegia, need for unplanned reoperation or occurrence of pseudoaneurysm during the follow-up. The mean follow-up was 82 ± 5 months. RESULTS: Sixty-three adults were treated for a native coarctation (n = 34), a recurrent coarctation (n = 14) or aneurysmal complication (n = 15). Mean age of the patients was 42 ± 1.7 years. All but 1 patient with native coarctation (33/34, 97%) and recurrent coarctation (13/14, 93%) underwent endovascular repair and 10 (67%) patients with aneurysmal complications were treated surgically. Freedom from the primary composite end point was 94, 84 and 81% at 1, 5 and 10 years, respectively, without difference between the 3 indication groups (P = 0.96). CONCLUSIONS: A tailored management strategy is necessary to provide good results for the treatment of adults with aortic coarctation. Thus, centres that are involved in the care of this complex pathology should be able to propose a multimodal approach, either endovascular or surgical depending on patient's characteristics and anatomic features.

Incidence and Clinical Impact of Device-Associated Thrombus and Peri-Device Leak Following Left Atrial Appendage Closure With the Amplatzer Cardiac Plug.

OBJECTIVES: Routine device surveillance after successful left atrial appendage closure is recommended to evaluate for intermediate to late complications. The aim of this study was to assess the incidence and clinical impact of these complications on cardiovascular events. METHODS: Centers participating in the Amplatzer Cardiac Plug multicenter study were requested to submit their post-procedural transesophageal echocardiograms for independent adjudication. Thirteen of 22 centers contributed all their post-procedural echocardiograms, which included 344 from 605 consecutive patients. These images were submitted to a core laboratory and reviewed by 2 independent experts for peri-device leak, device-associated thrombus, device embolization, device migration, left atrial appendage thrombus, and left atrial thrombus. Clinical events were prospectively collected by each center. RESULTS: Of the 344 transesophageal echocardiograms, 339 were deemed analyzable. Patients' mean age was 74.4 ± 7.5 years, and 67.3% were men. The mean CHADS2 score was 2.7 ± 1.3, the mean CHA2DS2-VASc score was 4.3 ± 1.5, and the mean HAS-BLED score was 3.0 ± 1.2. Amplatzer Cardiac Plug implantation was successful in all patients. Periprocedural major adverse events occurred in 2.4%. Median clinical follow-up duration was 355 days (range 179 to 622 days). Follow-up transesophageal echocardiography was performed after a median of 134 days (range 88 to 227 days). Device-associated thrombus was observed in 3.2% and peri-device leak in 12.5% (5.5% minimal, 5.8% mild, 0.6% moderate, 0.6% severe). Neither device-associated thrombus nor peri-device leak was associated with an increased risk for cardiovascular events. Independent predictors of device-associated thrombus were smoking (odds ratio: 5.79; p = 0.017) and female sex (odds ratio: 4.22; p = 0.027). CONCLUSIONS: Following successful left atrial appendage closure with the Amplatzer Cardiac Plug, the presence of peri-device leak was relatively low, and device-associated thrombus was infrequent. Neither was associated with increased risk for thromboembolism.

Genotype-Dependent Effects of Dalcetrapib on Cholesterol Efflux and Inflammation: Concordance With Clinical Outcomes.

BACKGROUND: Dalcetrapib effects on cardiovascular outcomes are determined by adenylate cyclase 9 gene polymorphisms. Our aim was to determine whether these clinical end point results are also associated with changes in reverse cholesterol transport and inflammation. METHODS AND RESULTS: Participants of the dal-OUTCOMES and dal-PLAQUE-2 trials were randomly assigned to receive dalcetrapib or placebo in addition to standard care. High-sensitivity C-reactive protein was measured at baseline and at end of study in 5243 patients from dal-OUTCOMES also genotyped for the rs1967309 polymorphism in adenylate cyclase 9. Cholesterol efflux capacity of high-density lipoproteins from J774 macrophages after cAMP stimulation was determined at baseline and 12 months in 171 genotyped patients from dal-PLAQUE-2. Treatment with dalcetrapib resulted in placebo-adjusted geometric mean percent increases in high-sensitivity C-reactive protein from baseline to end of trial of 18.1% (P=0.0009) and 18.7% (P=0.00001) in participants with the GG and AG genotypes, respectively, but the change was -1.0% (P=0.89) in those with the protective AA genotype. There was an interaction between the treatment arm and the genotype groups (P=0.02). Although the mean change in cholesterol efflux was similar among study arms in patients with GG genotype (mean: 7.8% and 7.4%), increases were 22.3% and 3.5% with dalcetrapib and placebo for those with AA genotype (P=0.005). There was a significant genetic effect for change in efflux for dalcetrapib (P=0.02), but not with placebo. CONCLUSIONS: Genotype-dependent effects on C-reactive protein and cholesterol efflux are supportive of dalcetrapib benefits on atherosclerotic cardiovascular outcomes in patients with the AA genotype at polymorphism rs1967309. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov; Unique Identifiers: NCT00658515 and NCT01059682.

Right atrial mass in a patient with breast cancer: percutaneous transcatheter biopsy under intracardiac echocardiography guidance.

Precise diagnosis of intracardiac masses is fundamental to their treatment. However, the findings of non-invasive imaging techniques are frequently inconclusive. In this setting, percutaneous transcatheter biopsy might represent a valid alternative to surgical biopsy. Intracardiac echocardiography (ICE)-guided biopsy offers high-quality imaging, is a relatively quick and easy interventional procedure to perform and does not require patient intubation or the assistance of an echocardiographer. We describe the case of a 47-year-old woman undergoing chemotherapy for breast cancer, who presented with a right atrial mass. Non-invasive imaging was inconclusive. Since no changes in the aspect or size of the mass were noticed after 2-week treatment with heparin, ICE-guided biopsy was performed, which confirmed the thrombotic nature of the mass. The patient underwent surgical resection of the thrombus and curative treatment of her breast cancer was pursued.

Transcatheter reduction of paravalvular leaks: a systematic review and meta-analysis.

BACKGROUND: Significant paravalvular leak (PVL) after surgical valve replacement can result in intractable congestive heart failure and hemolytic anemia. Because repeat surgery is performed in only few patients, transcatheter reduction of PVL is emerging as an alternative option, but its safety and efficacy remain uncertain. In this study we sought to assess whether a successful transcatheter PVL reduction is associated with an improvement in clinical outcomes. METHODS: We identified 12 clinical studies that compared successful and failed transcatheter PVL reductions in a total of 362 patients. A Bayesian hierarchical meta-analysis was performed using cardiac mortality as a primary end point. The combined occurrence of improvement in New York Heart Association functional class or hemolytic anemia and the need for repeat surgery, were used as secondary end points. RESULTS: A successful transcatheter PVL reduction was associated with a lower cardiac mortality rate (odds ratio [OR], 0.08; 95% credible interval [CrI], 0.01-0.90) and with a superior improvement in functional class or hemolytic anemia, compared with a failed intervention (OR, 9.95; 95% CrI, 2.10-66.73). Fewer repeat surgeries were also observed after successful procedures (OR, 0.08; 95% CrI, 0.01-0.40). CONCLUSIONS: A successful transcatheter PVL reduction is associated with reduced all-cause mortality and improved functional class in patients deemed unsuitable for surgical correction.

Intra-procedural imaging of the left atrial appendage: implications for closure with the Amplatzer™ cardiac plug.

OBJECTIVES: To evaluate intra-procedural imaging with transesophageal echocardiography and angiography during left atrial appendage occlusion using the Amplatzer™ Cardiac Plug with regard to sizing and final device shape. METHODS: Left atrial appendage ostium dimensions and diameter at a depth of 10mm from the ostium were measured by transesophageal echocardiography (0-180°) and angiography (RAO 30° - Cranial 20°) in consecutive patients undergoing left atrial appendage occlusion using the ACP with an oversizing strategy of 10-20% relative to the baseline measurements. After delivery, ACP dimensions were measured and device shape was assessed. RESULTS: Twenty-seven consecutive patients underwent successful uncomplicated left atrial appendage closure with Amplatzer™ Cardiac Plug. We found a significant difference between the largest and smallest left atrial appendage diameter measured with transesophageal echocardiography (22.3±4.2 vs. 18.1±4.1mm, p<0.001). By the end of the procedure (by angiography), ACP had an optimal shape in 17 patients (63%), a strawberry-like shape in 7 patients (26%), and a square-like shape in 3 patients (11%). ACP was oversized on average by 1.5±2.7 and 3.3±2.3mm compared to transesophageal echocardiography and angiography, respectively. The final shape of the device was not significantly associated with the degree of oversizing. CONCLUSIONS: We found a considerable variability in the assessment of the left atrial appendage, using transesophageal echocardiography and angiography. The degree of Amplatzer™ Cardiac Plug expansion within the left atrial appendage and the final shape of the device were not associated with the degree of oversizing.

Intra-procedural imaging of the left atrial appendage: Implications for closure with the AmplatzerTM cardiac plug / Evaluación de la orejuela izquierda durante el cierre percutáneo con el dispositivo AmplatzerTM cardiac plug

Objectives: To evaluate intra-procedural imaging with transesophageal echocardiography and angiography during left atrial appendage occlusion using the Amplatzer™ Cardiac Plug with regard to sizing and final device shape. Methods: Left atrial appendage ostium dimensions and diameter at a depth of 10 mm from the ostium were measured by transesophageal echocardiography (0-180°) and angiography (RAO 30° - Cranial 20°) in consecutive patients undergoing left atrial appendage occlusion using the ACP with an oversizing strategy of 10-20% relative to the baseline measurements. After delivery, ACP dimensions were measured and device shape was assessed. Results: Twenty-seven consecutive patients underwent successful uncomplicated left atrial appendage closure with Amplatzer™ Cardiac Plug. We found a significant difference between the largest and smallest left atrial appendage diameter measured with transesophageal echocardiography (22.3 ± 4.2 vs. 18.1 ± 4.1 mm, p <0.001). By the end of the procedure (by angiography), ACP had an optimal shape in 17 patients (63%), a strawberry-like shape in 7 patients (26%), and a square-like shape in 3 patients (11%). ACP was oversized on average by 1.5±2.7 and 3.3±2.3mm compared to transesophageal echocardiography and angiography, respectively. The final shape of the device was not significantly associated with the degree of oversizing. Conclusions: We found a considerable variability in the assessment of the left atrial appendage, using transesophageal echocardiography and angiography. The degree of Amplatzer™ Cardiac Plug expansion within the left atrial appendage and the final shape of the device were not associated with the degree of oversizing.

Objetivos: Evaluar las dimensiones de la orejuela izquierda antes del cierre percutáneo y la correlación de sus dimensiones finales y la forma del dispositivo Amplatzer™ cardiac plug con ecocardiografia transesofágica y angiografia. Métodos: Se midieron las dimensiones de la orejuela izquierda a una distancia de 10 mm a partir del ostium con ecocardiografia transesofágica (0 a 180°) y angiografia (RAO 30° Craneal 20°). Se utilizó una estrategia para sobre dimensionar el tamano del dispositivo del 10 al 20% con respecto a las mediciones iniciales. Se evaluaron las dimensiones y la forma final del dispositivo. Resultados: Se realizó el procedimiento en 27 pacientes. Se encontró una diferencia significativa entre el diámetro mayor y menor de orejuela izquierda medido por ecocardiografia transesofágica (22.3±4.2 vs 18.1 ±4.1 mm, p< 0.001). Una vez liberado el dispositivo, se encontró que en 17 pacientes (63%) adoptó una forma óptima, de "fresa" en 7 (26%) y cuadrada en 3 (11%). El tamaño del dispositivo seleccionado se sobre dimensionó en promedio 1.5 ± 2.7mm con la ecocardiografia transesofágica y 3.3 ± 2.3 mm con la angiografia. La forma final del dispositivo no se asoció de manera significativa con el grado de sobre dimensionamiento del mismo. Conclusiones: Existe variabilidad considerable en la evaluación de la orejuela izquierda entre la ecocardiografia transesofágica y la angiografia. No se encontró asociación entre el grado de expansión del dispositivo dentro de la orejuela izquierda ni de su forma final con el grado de sobre dimensionamiento del mismo.

Transcatheter aortic valve implantation by the left axillary approach: a single-center experience.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an accepted alternative treatment for severe symptomatic aortic stenosis in high-risk and inoperable patients. Femoral or transapical accesses are commonly used. We report our initial clinical experience with TAVI using the left-axillary artery approach. METHODS: A single-center, retrospective study of patients undergoing transaxillary TAVI between January 2010 and December 2012 was performed. Procedural success was defined as successful device implantation with reduction in the mean aortic gradient and without need for conversion to open-heart surgery. Short-term echocardiographic follow-up was obtained in all patients. RESULTS: A total of 18 consecutive patients with severe aortic stenosis who were not candidates for surgical replacement underwent transaxillary TAVI. Mean age was 81.1±7.3 years and 14 patients (78%) were male. Median logistic European System for Cardiac Operative Risk Evaluation was 8.5% (range, 1.5% to 54.1%). Procedural success was obtained in 17 out of 18 patients (94%). There was no in-hospital or 30-day mortality. One major bleeding complication in the form of an upper gastrointestinal bleeding was observed. No stroke or major vascular complication was reported. Postoperative implantation of a permanent pacemaker was performed in 7 patients (39%). At a mean follow-up of 326±213 days, mean aortic gradient was 10.8±4.8 mm Hg. Mean aortic valve area was 1.7±0.4 cm2 and aortic insufficiency grade was mild or less in all but 1 patient, who showed moderate regurgitation. CONCLUSIONS: The transaxillary approach for TAVI is associated with high procedural success and low rates of stroke, vascular, or bleeding complications. This approach is an appealing alternative to the commonly used transfemoral and transapical TAVI.

Percutaneous paravalvular leak reduction: procedural and long-term clinical outcomes.

BACKGROUND: Significant paravalvular leak (PVL) after prosthetic replacement can result in hemolysis and/or congestive heart failure (CHF). Percutaneous PVL reduction (PPVR) represents an alternative to repeat surgery for a selected population. The purpose of this study was to assess the procedural and long-term clinical efficacy of percutaneous PPVR and its effect on survival free of rehospitalization for CHF, surgical reintervention, and death. METHODS: We analyzed a cohort of 56 consecutive patients who underwent 61 PPVRs in our institution between June 2001 and December 2010. Procedural success was defined as a reduction in regurgitation severity free from procedural complications. Patients were followed-up for vital status, clinical events, and symptoms. RESULTS: Patients were aged 65 ± 11 years, with an average logistic EuroSCORE of 19 ± 14%. Indications for PPVR included CHF (61%), hemolysis (9%), or both (30%), caused by mitral (n = 44) or aortic (n = 12) PVL. Procedural success was achieved in 75% of cases. Three major complications, including 2 deaths, occurred during the initial 30-day follow-up in the 42 patients who were treated with a device. After adjusting for the logistic EuroSCORE, prosthesis type (mitral vs aortic), and time interval since the last valve surgery, a successful PPVR was associated with a better survival free of rehospitalisation for CHF, need for surgical reintervention, and death compared with patients with a failed PPVR. (hazard ratio = 0.34; 95% confidence interval, 0.17-0.71). CONCLUSIONS: PPVR is associated with a reasonable rate of procedural success and favourable cardiovascular outcomes, and represents an appropriate option when technically possible.