Impact of mitral intervention on outcomes of patients with mitral valve dysfunction and annulus calcification.

OBJECTIVES: To compare all-cause mortality in patients with mitral annulus calcification (MAC) and severe mitral valve dysfunction (MVD) who received standard mitral intervention versus no intervention. BACKGROUND: Patients with MAC often have high surgical risk due to advanced age, comorbidities, and technical challenges related to calcium. The impact of a mitral intervention on outcomes of patients with MAC and severe MVD is not well known. METHODS: Retrospective review of patients with MAC by transthoracic echocardiography (TTE) in 2015 at a single institution. Patients with severe mitral stenosis (MS) or regurgitation (MR) were analyzed and stratified into two groups: surgical or transcatheter intervention performed <1 year after the index TTE, and no or later intervention. The primary endpoint was all-cause mortality. RESULTS: Of 5502 patients with MAC, 357 had severe MVD (MS = 27%, MR = 73%). Of those, 108 underwent mitral intervention (surgery = 87; transcatheter = 21). They were younger (73 ± 11 vs. 76 ± 11 years, p < 0.01) and less frequently had cardiovascular diseases compared with no-intervention. Frequency in women was similar (45% vs. 50%, p = 0.44). During median follow-up of 3.2 years, the intervention group had higher estimated survival than those without intervention (80% vs. 72% at 1 year and 55% vs. 35% at 4 year, p < 0.01). Adjusted for age, eGFR, LVEF < 50%, and pulmonary hypertension, mitral intervention was an independent predictor of lower mortality (hazard ratio = 0.66, 95% confidence interval 0.43-0.99, p = 0.046). CONCLUSION: Patients with MAC and severe MVD who underwent mitral intervention <1 year from index TTE had lower mortality than those without intervention. Mitral intervention was independently associated with lower mortality.

Efficacy and safety of percutaneous mitral balloon valvotomy in patients with mitral stenosis: A systematic review and meta-analysis.

AIMS: Percutaneous mitral balloon valvotomy PMBV is an acceptable alternative to Mitral valve surgery for patients with mitral stenosis. The purpose of this study was to explore the immediate results of PMBV with respect to echocardiographic changes, outcomes, and complications, using a meta-analysis approach. METHODS: MEDLINE, and EMBASE databases were searched (01/2012 to 10/2018) for original research articles regarding the efficacy and safety of PMBV. Two reviewers independently screened references for inclusion and abstracted data including article details and echocardiographic parameters before and 24-72 h after PMBV, follow-up duration, and acute complications. Disagreements were resolved by third adjudicator. Quality of all included studies was evaluated using the Newcastle-Ottawa Scale NOS. RESULTS: 44/990 references met the inclusion criteria representing 6537 patients. Our findings suggest that PMBV leads to a significant increase in MVA (MD = 0.81 cm2; 0.76-0.87, p < 0.00001), LVEDP (MD = 1.89 mmHg; 0.52-3.26, p = 0.007), LVEDV EDV (MD = 5.81 ml; 2.65-8.97, p = 0.0003) and decrease in MPG (MD = -7.96 mmHg; -8.73 to -7.20, p < 0.00001), LAP (MD = -10.09 mmHg; -11.06 to -9.12, p < 0.00001), and SPAP (MD = -15.55 mmHg; -17.92 to -13.18, p < 0.00001). On short term basis, the pooled overall incidence estimates of repeat PMBV, mitral valve surgery, post-PMBV severe MR, and post-PMBV stroke, and systemic thromboembolism were 0.5%, 2%, 1.4%, 0.4%, and 0.7%% respectively. On long term basis, the pooled overall incidence estimates of repeat PMBV, mitral valve surgery, post-PMBV severe MR, and post-PMBV stroke, systemic thromboembolism were 5%, 11.5%, 5.5%, 2.7%, and 1.7% respectively. CONCLUSION: PMBV represents a successful approach for patients with mitral stenosis as evidenced by improvement in echocardiographic parameters and low rate of complications.

Institutional learning experience for combined edge-to-edge tricuspid and mitral valve repair.

BACKGROUND: Transcatheter edge-to-edge repair with MitraClip is only approved for treatment of mitral regurgitation but is increasingly used to treat concomitant tricuspid regurgitation (TR) due to its common coexistence and association with poor outcomes. This study aimed to describe the learning curve associated with the challenge of off-label treatment of concomitant TR. METHODS: This is a retrospective review of initial and consecutive patients who underwent combined edge-to-edge repair of mitral and tricuspid valves (TVs) at our institution from August 2017 to October 2019. RESULTS: Repair of both valves with MitraClip was performed in 22 patients (median age 81.5 years, 32% female). Mean procedure time was 176 ± 47 min; mean fluoroscopy time was 65 ± 24 min. Procedure duration in the first tertile was significantly longer (223 ± 13 min) than in the third tertile (143 ± 23 min, p = .0003). Median number of total clips placed per case was 3; in 15 patients (68%), the anterior and septal leaflets of the TV were clipped. The average changes in mean right atrial (RA) and left atrial (LA) pressures were -1.7 ± 2.5 mmHg (p = .0080) and -3.2 ± 4.6 mmHg (p = .0045), respectively. The average changes in RA and LA V-wave heights were -3.3 ± 4.0 mmHg (p = .0009) and -8.1 ± 9.9 mmHg (p = .038), respectively. There was a significant trend toward decreasing residual TR over the course of the series (p = .046). At 30 days, survival was 100% and mean NYHA class decreased from 2.8 to 1.8 (p < .0001). CONCLUSIONS: Combined edge-to-edge tricuspid and mitral valve repair is safe and feasible. With experience, procedure duration and residual TR decreased.

Characteristics and outcomes of patients with normal left atrial pressure undergoing transcatheter mitral valve repair.

OBJECTIVE: A subset of patients at the time of transcatheter mitral valve repair (TMVR) will have normal left atrial pressure (LAP) (<13 mm Hg) despite having severe mitral regurgitation (MR). The goal of this study was to determine clinical characteristics and outcomes in patients with normal LAP undergoing TMVR. METHODS: A single-centre retrospective cohort of consecutive patients who underwent transcatheter edge-to-edge mitral valve clip and continuous LAP monitoring between 5/1/2014 and 5/1/2018 was analysed. One-year mortality was compared by Kaplan-Meier survival curves. Multivariable analysis was performed to identify predictors of normal LAP and 1 year mortality. RESULTS: Of the 204 patients undergoing TMVR, 65% were men and the mean age was 81. Of these patients, 31 (15%) had normal LAP (mean LAP 10.5 mm Hg, mean V wave 16.5 mm Hg) and 173 had elevated LAP (mean LAP 19 mm Hg, mean V wave 32.5 mm Hg). The prevalence of severe MR was not different between groups, although the normal LAP group had significantly lower effective regurgitant orifice area and regurgitant volume. Other notable baseline characteristics including prior cardiac surgery, atrial fibrillation, hypertension, diabetes, congestive heart failure, body mass index, mechanism of MR and ejection fraction were similar between groups. However, there was an increased prevalence of chronic lung disease (CLD) (45.2% vs 17.3%, p<0.001) in the normal LAP group. On multivariate analysis, the only significant predictor of normal LAP was the presence of CLD (OR 4.79 (1.83-12.36), p=0.001) and 1-year mortality was significantly higher in the normal LAP group (32.3% vs 12.7%, p=0.006). After adjustment for comorbidities, normal LAP was no longer a predictor of 1-year mortality (RR 1.62 (0.64-4.06), p=0.32); however, CLD (RR 3.44 (1.37-8.67), p=0.01) remained a statistically significant predictor. CONCLUSION: Normal LAP at the time of TMVR is associated with a higher incidence of CLD which independently predicts increased 1-year mortality. In patients with CLD and apparently severe MR, measurement of LAP may help identify those with lower likelihood of benefit from TMVR.

Novel Antegrade Approach to Transcatheter Aortic Valve Paravalvular Leak Closure.

Aortic paravalvular leak (PVL) is a known complication of TAVR. PVL closure using vascular occluder devices can be used, particularly in cases with annular calcification preventing adequate seal; however, delivery of equipment can be challenging in TAVR patients due to interaction with the valve stent. We describe a novel antegrade closure approach to treat transcatheter aortic PVL.

Quantitative Three-Dimensional Echocardiographic Correlates of Optimal Mitral Regurgitation Reduction during Transcatheter Mitral Valve Repair.

BACKGROUND: Patient selection for transcatheter edge-to-edge mitral valve repair (TMVR) remains challenging because of heterogenous mitral valve pathology and highly variable anatomy. The aim of this study was to investigate whether quantitative three-dimensional (3D) transesophageal echocardiographic modeling parameters are associated with optimal mitral regurgitation (MR) reduction in patients undergoing TMVR. METHODS: Fifty-nine patients underwent 3D transesophageal echocardiography during TMVR. Volumetric data sets were retrospectively analyzed using mitral valve quantitative 3D modeling software (Mitral Valve Navigator). Optimal MR reduction was defined as less than moderate residual MR. Logistic regression was used to correlate 3D transesophageal echocardiographic quantitative data to procedural success. RESULTS: Thirty-five patients had primary MR, 24 had mixed or secondary MR, and all patients had grade ≥ 3/4 MR before the procedure. Optimal MR reduction was achieved in 40 of 59 patients (68%). Univariate correlates of optimal MR reduction in patients with primary MR were lower mitral leaflet tenting volume (P = .049) and lower tenting height (P = .025); tenting height < 3 mm and tenting volume < 0.7 mL were associated with increased likelihood of optimal MR reduction (92% vs 48% [P = .01] and 81% vs 47% [P = .03], respectively). In mixed or secondary MR, annular height ≥ 5.5 mm was associated with increased likelihood of optimal MR reduction (94% vs 38%; P = .03). During follow-up, redo TMVR or surgical mitral valve replacement occurred exclusively in patients with suboptimal anatomy defined by 3D transesophageal echocardiography (10% vs 0%, P = .045). CONCLUSIONS: Quantitative 3D echocardiographic data are associated with favorable response to TMVR and could help optimize patient selection.

Effect of saline administration on left atrial pressure during transcatheter mitral valve repair.

OBJECTIVES: To measure the intraprocedural change in left atrial pressure (LAP) with saline administration during transcatheter mitral valve repair (TMVR). BACKGROUND: TMVR with MitraClip offers an alternative to surgery in select patients. During this procedure, large volumes of fluid are routinely administered with anesthesia and to facilitate transcatheter valve repair. LAP, a measure used to guide repair, may thereby change as a result of volume expansion, suggesting a need for continuous intracardiac pressure monitoring. METHODS: Consecutive patients with severe mitral regurgitation underwent TMVR with MitraClip and continuous LAP monitoring through a dedicated sampling catheter. Specific LAP values were acquired immediately after transseptal access; before first clip deployment; and after deployment of the last clip. RESULTS: 151 patients (age 80 ± 8 years, 64% male) underwent TMVR with MitraClip and continuous LAP monitoring. Mean LAP and v-wave pressure increased significantly from baseline to pre-MitraClip deployment (P < 0.0001) and decreased significantly from deployment to procedure end (P < 0.0001). Linear regression of v-wave pressure change (from procedure start to clip deployment) relative to volume administration yielded a significantly nonzero slope (0.28 mmHg/min, P < 0.0001, r = 0.30). CONCLUSION: Fluid administration during TMVR leads to time-dependent increases in LAP. Such intraprocedural change underscores the need for targeted, if not continuous, LAP measurement during TMVR to optimize MitraClip placement and mitral regurgitation reduction.

Feasibility of Performing Radiofrequency Catheter Ablation and Endomyocardial Biopsy in the Same Setting.

In patients with unexplained cardiomyopathy, electroanatomical mapping can identify abnormal tissue to target during electrophysiology-guided endomyocardial biopsy (EP-guided EMB). The objective of this study is to determine whether catheter ablation performed in the same setting as EP-guided EMB increases procedural risk. Sixty-seven patients (mean age 54.4 ± 13.8, 57% male) undergoing EP-guided EMB were included. Radiofrequency catheter ablation was performed in 17 patients (25%) for ventricular arrhythmias and in 2 (3%) for typical atrial flutter. Femoral arterial access was obtained in 90% ablation patients and 40% biopsy-only patients; vascular access complications were more common in the ablation group than in the EMB-only group (p = 0.02). There were no significant differences in rate of tricuspid regurgitation, thromboembolism, or pericardial effusion, whether procedural anticoagulation was used. In conclusion, catheter ablation and procedural anticoagulation can be combined with EP-guided EMB with an increased risk of vascular access complications, but no significant increase in intracardiac complications.

The Use of Intraprocedural Reinfusion During MitraClip Implantation to Reduce Blood Loss and Transfusion Requirements.

BACKGROUND: MitraClip implantation has been shown to reduce mitral regurgitation and is an effective treatment option for patients at high risk for conventional surgery. Blood loss is common during the procedure. We assessed the utility of intraprocedural reinfusion of blood aspirated during MitraClip implantation. METHODS: We compared hemoglobin before and after MitraClip implantation and transfusion requirements in patients who did (n = 83) and did not receive reinfusion (n = 31) during their procedure. For patients who received reinfusion, blood removed during device manipulation was carefully injected back into the patient through the 24 Fr delivery sheath, followed by a saline flush. RESULTS: As expected, patients who received reinfusion had a smaller reduction in hemoglobin post procedure compared to those who did not (0.96 ± 1.0 g/dL vs 1.55 ± 0.94 g/dL; P<.01). There was a trend to lower requirements for blood transfusion in the reinfusion groups (0.39 ± 0.96 units/patient vs 0.15 ± 0.53 units/patient; P<.10). At 30-day follow-up, there was no difference in mortality, stroke, endocarditis, or thromboembolic events between groups. CONCLUSION: Reinfusion of aspirated blood during MitraClip was associated with reduced blood loss and a trend to reduced requirement for blood transfusion post procedure. Reinfusion during the procedure appeared safe, with no complications.

Transcatheter and Surgical Management of Mitral Paravalvular Leak: Long-Term Outcomes.

OBJECTIVES: The aim of this study was to report the use trends and immediate and long-term outcomes of a large cohort of patients who underwent redo surgery or transcatheter repair of paravalvular leaks (PVLs) at a tertiary referral center. BACKGROUND: Percutaneous treatment of mitral PVL has emerged as an alternative to surgical treatment in high-risk surgical candidates. There are limited data on the utilization trends, safety, and efficacy of both procedures in the management of mitral PVL. METHODS: Patients who underwent treatment of mitral PVL at the Mayo Clinic between January 1995 and December 2015 were enrolled. Utilization trends, procedural details, technical success, and in-hospital and long-term outcomes were assessed. RESULTS: Three hundred eighty-one patients underwent percutaneous (n = 195) or surgical (n = 186) treatment of mitral PVLs. The mean age was 66 ± 12 years, and 37% of patients had bioprosthetic valves. Technical success was higher in the surgical group (95.5% vs. 70.1%; p < 0.001). In-hospital major adverse events were more common after surgery (22.5% vs. 7.7%; p < 0.001). In-hospital death occurred in 3.1% and 8.6% of patients undergoing percutaneous and surgical treatment, respectively (p = 0.027). However, in a multivariate logistic regression analysis, only active endocarditis, chronic renal failure, and severe mitral annular calcifications were significant predictors of in-hospital mortality. Reintervention rates were similar (11.3% vs. 17.2% in the percutaneous and surgical groups, respectively; p = 0.10), with the majority of reinterventions in the percutaneous group occurring early because of residual leak or persistent hemolysis. After risk adjustment, there was no significant difference in long-term survival between patients who underwent surgical versus transcatheter treatment of PVLs. CONCLUSIONS: In contemporary practice, patients with symptomatic mitral PVLs are best treated with an integrated team approach incorporating both surgical and percutaneous techniques. Patient selection and timing of intervention are critical to achieve optimal results.

Percutaneous transcatheter biopsy for intracardiac mass diagnosis.

AIMS: The differential diagnosis of intracardiac masses (ICM) is wide. While imaging modalities can suggest a diagnosis, clinical decision making usually requires histopathologic diagnosis. The aim of this study was to describe the procedural technique, safety outcomes, diagnostic accuracy and clinical utility of percutaneous transcatheter biopsy (TCB) for histopathologic diagnosis of ICM. The records of all patients undergoing TCB of ICM at the Mayo Clinic catheterisation laboratories in Rochester, Minnesota, between 2002 and 2017 were retrieved and reviewed. METHODS AND RESULTS: TCB of ICM to establish histopathologic diagnosis was performed in 29 patients. Masses were located in the right-sided chambers in 93% of cases. Echocardiographic guidance was used. Ventricular arrhythmias requiring immediate cardioversion occurred in 7% of patients. No other complications were noted. The average number of samples retrieved per procedure was 7±3.6. A histopathologic diagnosis was made by TCB in 72% and altered clinical decision making in 52% of patients overall. Eleven patients (38%) who would otherwise have required excisional biopsy were able to avoid cardiovascular surgery. Each additional biopsy sample was associated with an increase in the likelihood of making a histopathologic diagnosis (OR 1.74, 95% CI: 1.05-2.87, p=0.032). CONCLUSIONS: Echo-guided percutaneous TCB of ICM provides an accurate diagnosis and alters clinical management in the majority of cases. The procedural complication rate is low. An increase in the number of samples retrieved markedly improves the ability to render a diagnosis. TCB may therefore be considered as a first-line approach for the histopathologic diagnosis of ICM.

Characteristics and outcomes of re-do percutaneous paravalvular leak closure.

BACKGROUND: Percutaneous paravalvular leak (PVL) closure is an alternative treatment option for severely symptomatic, high-surgical risk patients with PVL. Some patients require multiple percutaneous PVL closure procedures. However, the procedural characteristics and success rate of re-do PVL closure have not been well studied. AIMS: The aim of this study is to investigate the indications, procedural characteristics, technical success rate, and 30-day major adverse cardiovascular events (MACE) in patients who underwent re-do PVL closure. METHODS: Consecutive patients who underwent percutaneous paramitral or paraaortic leak closure at Mayo Clinic, Rochester, Minnesota from 2004 through 2015 were studied. Clinical and procedural characteristics of patients who underwent re-do PVL closure were compared to age- and sex-matched patients who underwent their first percutaneous PVL closure. Procedure success and 30-day MACE were compared in both the groups. RESULTS: Among 223 identified percutaneous PVL closures, 16 (7%) were re-do procedures. Patients who underwent re-do PVL closure were predominantly men (87.5%) with a mean age of 68 ± 15 years and an estimated mean Society of Thoracic Surgery (STS) 30-day mortality of 4.6 ± 2.8. Half of the re-do PVL closures were performed on mechanical valves and 62.5% were performed on paramitral defects. Indications for re-do PVL closure were: (1) emergence of new significant paravalvular defects in 50%, (2) incomplete index defect closure in 43.75%, and (3) index procedural complication in 6.25% of the cases. Procedural success was 75% in re-do procedures vs. 85.4% in age- and sex-matched control group (P = 0.45). Thirty-day MACE was 12.5% in the re-do group compared to 4.2% in the age- and-sex matched patients who underwent PVL closure for the first time (P = 0.35). CONCLUSION: Re-do percutaneous PVL closure is feasible with favorable procedural success rate and low 30-day MACE. Development of new paravalvular defects is the most common indication for re-do PVL closure, highlighting the importance of careful longitudinal monitoring and follow-up. © 2017 Wiley Periodicals, Inc.

Techniques and Outcomes of Percutaneous Aortic Paravalvular Leak Closure.

OBJECTIVES: The aim of this study is to provide a summary of the currently applied aortic paravalvular leak (PVL) closure techniques and describe the procedural and long-term outcomes in a large consecutive cohort of patients. BACKGROUND: Percutaneous repair has emerged as an effective therapy for patients with PVL. To date, clinical outcome data on percutaneous closure of aortic PVL are limited. METHODS: All patients who underwent catheter-based treatment of aortic PVL between 2006 and 2015 were identified. Procedural and short-term results were assessed. Patients were contacted for clinical events and symptoms. RESULTS: Eighty-six procedures were performed in 80 patients. The mean age was 68 ± 15 years, and 70% were men. The primary indications for PVL closure were symptoms of heart failure, hemolysis, and both in 83%, 5%, and 12%, respectively. Successful device deployment was accomplished in 94 defects (90%). Reduction in PVL to mild or less was achieved in 62% of patients. In-hospital major adverse events occurred in 8% of procedures. Symptomatic improvement at 30 days was achieved in 64% of patients. Patients who had reduction in the PVL grade to mild or less experienced more improvement in New York Heart Association functional class (from 2.93 ± 0.62 to 1.72 ± 0.73) compared with those with mild or greater residual leak (from 3.03 ± 0.57 to 2.52 ± 0.74) (p < 0.001). In patients with severe hemolysis (n = 8), transfusion requirements were eliminated in 7 (88%) after PVL closure. Kaplan-Meier survival analysis showed that the cumulative probability of freedom from repeat surgery at 2 years was 98 ± 2% in patients who had mild or less residual leak compared with 68 ± 10% in patients with higher grades of residual PVL (log-rank p = 0.004). CONCLUSIONS: Percutaneous reduction of aortic PVL is associated with durable symptom relief and lower rates of repeat cardiac surgery. The magnitude of benefit is greatest with PVL reduction to a grade of mild or less. Therefore, attempts should be made to reduce PVL as much as possible.

The Learning Curve for Transcatheter Mitral Valve Repair With MitraClip.

OBJECTIVES: This study sought to assess the learning curve for TMVR for treatment of primary mitral regurgitation (MR). BACKGROUND: Data are lacking regarding the technical experience required to achieve optimal clinical outcomes with transcatheter mitral valve repair (TMVR) using the edge-to-edge MitraClip technique. METHODS: We examined the sequential experience of the first 75 patients (age 80 ± 9 years; 77% male) who underwent TMVR at our institution. A sequence number of each patient was assigned as a continuous variable and in tertiles for analysis. RESULTS: TMVR with MitraClip was successful in 97% with an average procedural time of 106 ± 39 minutes. The 30-day rate of major adverse cardiovascular events was 7%. With increased case experience, there were decreases in procedural time, fluoroscopy time, length of hospital stay, and major adverse cardiovascular events. Procedural success, residual mitral regurgitation and NYHA functional classification at 30-day follow-up remained unchanged throughout the experience. CONCLUSIONS: The learning curve for TMVR with MitraClip for treatment of primary MR is characterized by a sequential reduction in procedure time, fluoroscopy time, procedural complications, and hospital length of stay at a tertiary academic medical center. Thirty-day procedural results are favorable and similar during the initial learning period.

Clinical Outcomes After Transapical and Transfemoral Transcatheter Aortic Valve Insertion: An Evolving Experience.

BACKGROUND: Prior publications note increased adverse events after transapical compared with transfemoral access transcatheter aortic valve insertion (TAVI). We reviewed our TAVI experience to understand the differences in baseline patient characteristics and outcomes associated with the two access methods. METHODS: The records were reviewed of 567 patients who underwent transfemoral (n = 351, 61.9%) and transapical (n = 216, 38.1%) TAVI from November 2008 through July 2015. RESULTS: Compared with patients who underwent transfemoral access, the patients who underwent transapical access were older (82.0 ± 7.5 versus 79.6 ± 9.7 years; p = 0.006), had more peripheral vascular disease (78.2% versus 54.7%; p < 0.001), more previous coronary artery bypass graft operations (50.9% versus 32.5%; p < 0.001), and higher Society of Thoracic Surgeons predicted risk of mortality (9.4% ± 5.4% versus 8.8% ± 6.5%; p = 0.032). In-hospital and 30-day mortality rates, however, were similar between the two groups (transapical, n = 7, 3.2%; transfemoral, n = 13, 3.7%; p = 0.772). Follow-up echocardiography in 547 (100.0%) surviving patients at a median of 182 days (interquartile range, 35 to 420) demonstrated less paravalvular regurgitation grade of moderate or greater in patients who underwent transapical access (transapical, n = 6, 2.9%; transfemoral, n = 35, 10.4%; p = 0.001) but similar ejection fraction in the two groups (transapical, 55.4% ± 12.2%; transfemoral, 55.9% ± 13.0%; p = 0.419). Mortality rates at 1 year (transapical, 19.2% ± 3.0%; transfemoral,14.7% ± 3.2%) and 4 years (transapical, 47.4% ± 6.4%; transfemoral, 42.7% ± 4.9%) were also similar between the two groups (p = 0.342). CONCLUSIONS: Transapical and transfemoral transcatheter aortic valve insertions result in similar operative and longer term mortality rates, despite differences in baseline patient risk. The findings support the concept that access does not influence treatment-related mortality rates.

The Role of Balloon Aortic Valvuloplasty in Patients With Aortic Valve Stenosis and Society of Thoracic Surgeons Risk of 15% or Higher.

BACKGROUND: Extreme-risk patients (ie, Society of Thoracic Surgeons [STS] risk 15% or higher) with severe aortic valve stenosis may not obtain mortality benefit from aortic valve replacement (AVR). We reviewed our experience with this group of patients to better understand our triage process and outcomes. METHODS: We performed a retrospective review of 97 patients with severe aortic valve stenosis and STS risk of 15% or higher treated from 2008 through 2013. The median patient age was 85 years (minimum, 44; maximum, 97 years), and 47 patients (48.5%) were male. The STS risk of mortality was 19.8% (minimum, 15.1%; maximum, 60.9%). Patients were assigned to treatment groups based on the first aortic valve intervention of balloon aortic valvuloplasty (BAV group, 66 [68%]) or de novo AVR (d-AVR group, 31 [32%]). RESULTS: Patients in the BAV group were sicker, with a reduced ejection fraction (0.35 vs 0.57; p = 0.002) and greater prevalence of urgent/emergency operative status (32% vs 10%; p = 0.004) compared with those in the d-AVR group. After BAV, 33 patients (50%) demonstrated clinical improvement and went on to receive subsequent staged AVR after a median of 64 days (minimum, 3; maximum, 390 days). The mortality rate at 2 years was worse in the BAV group (57.3% ± 6.3%) than in the d-AVR group (29.5% ± 8.3%; p = 0.015), but was similar in patients who received BAV followed by staged AVR and de novo AVR (p = 0.426). CONCLUSIONS: BAV may triage select patients with STS risk 15% or higher who are questionable candidates for AVR. Patients with clinical improvement after BAV experience benefit from staged AVR.

Vanishing V-Wave: Percutaneous Edge-to-Edge Repair for Severe Mitral Regurgitation.

Transcatheter mitral valve repair is an effective treatment option for patients with symptomatic mitral regurgitation and high surgical risk. Typically, transcatheter mitral valve repair is less effective in reducing mitral regurgitation severity compared to surgical mitral valve repair. Herein is presented a case of complete resolution of mitral regurgitation, as assessed by Doppler echocardiography and left atrial V-wave.

Percutaneous ablation and retrieval of a right atrial myxoma.

We report the first case of percutaneous myxoma ablation and retrieval from the right atrium. This novel procedure may reduce the need for repeat surgical excisions in patients with Carney Complex and other recurrent myxoma syndromes.

Electrogram guidance: a method to increase the precision and diagnostic yield of endomyocardial biopsy for suspected cardiac sarcoidosis and myocarditis.

OBJECTIVES: The aim of this study was to describe the method used to perform electrogram-guided EMB and correlate electrogram characteristics with pathological and clinical outcomes. BACKGROUND: Endomyocardial biopsy (EMB) is valuable in determining the underlying etiology of a cardiomyopathy. The sensitivity, however, for focal disorders, such as lymphocytic myocarditis and cardiac sarcoidosis (CS), is low. The sensitivity of routine fluoroscopically guided EMB is low. Abnormal intracardiac electrograms are seen at sites of myocardial disease. However, the exact value of electrogram-guided EMB is unknown. METHODS: We report 11 patients who underwent electrogram-guided EMB for evaluation of myocarditis and CS. RESULTS: Of 40 total biopsy specimens taken from 11 patients, 19 had electrogram voltage <5 mV, all of which resulted in histopathologic abnormality (100% specificity and positive predictive value). A voltage amplitude cutoff value of 5 mV had substantially higher sensitivity (70% vs. 26%) and negative predictive value (62%) than 1.5 mV. Abnormal electrogram appearance at biopsy site had good sensitivity (67%) and specificity (92%) in predicting abnormal myocardium. Normal signals with voltage >5 mV signified normal myocardium with no significant diagnostic yield. Biopsy results guided therapy in all patients, including 5 with active myocarditis or CS, all of whom subsequently received immunosuppressive therapy. There were no procedural complications. CONCLUSIONS: In patients with suspected myocarditis or CS, electrogram-guided EMB targeting sites with abnormal or low-amplitude electrograms may increase the diagnostic yield for detecting abnormal pathological findings.

Radiation reduction in pediatric and adult congenital patients during cardiac catheterization.

OBJECTIVES: Our objective was to determine if technical changes combined with radiation safety initiatives reduced the radiation dose delivered to patients during congenital catheterization. BACKGROUND: Use of ionizing radiation is necessary during cardiac catheterization. Minimizing radiation dose, while maintaining clinically useful image quality, is an important safety issue. In our congenital heart center intentional practice changes, including technical changes and provider awareness initiatives, were implemented to decrease radiation dose. METHODS: Data were retrospectively collected for all procedures involving children and adults with congenital heart disease (CHD) undergoing catheterization over 45 months. Cases were divided into three categories including: noninterventional (NI), simple intervention (SI), and complex intervention (CI). The change in dose was modeled as log of cumulative air kerma (Ka,r ). The change in Ka,r was evaluated for each procedural category as well as changes occurring as a function of age and weight. RESULTS: Considering all procedures (n = 1,082), Ka,r decreased by 61%. In the NI group (n = 481), Ka,r decreased by 71%. In the SI group (n = 424), Ka,r decreased by 74%. The Ka,r for the 10-17 year old group (n = 125) and those ≥18 years (n = 709) decreased 74 and 67%, respectively. The Ka,r decreased 72 and 66% for those 20-60 kg and ≥60 kg, respectively. Groups not showing significant change in Ka,r included CI, age ≤9 years, and weight ≤20 kg. CONCLUSIONS: Through technical changes and provider awareness initiatives, our institution dramatically reduced the radiation dose in the majority of pediatric and adult CHD patients undergoing cardiac catheterization.