Simultaneous transcatheter transfemoral aortic and transeptal mitral valve replacement using Edward SAPIEN S3.

Patients with concomitant severe aortic stenosis (AS) and severe mitral stenosis (MS) with mitral annular calcification (MAC) constitute an elderly high-risk population with multiple baseline comorbidities that coexist even before they develop severe valvular dysfunction. Transcatheter mitral valve replacements (TMVR) offer an alternative option for high-risk patient with severe MS with MAC. A simultaneous transfemoral Transcatheter aortic valve replacement (TAVR) and transseptal TMVR is feasible and offers the least invasive approach of management. We are reporting a case of an 83-year-old man with very symptomatic severe AS and severe native MS with associated severe MAC and moderate mitral regurgitation with high STS score who underwent a simultaneous transfemoral TAVR and transseptal TMVR with good results and great improvement in symptoms that was maintained on 10 months follow-up.

Thoracic endovascular repair versus medical management for acute uncomplicated type B aortic dissection.

BACKGROUND: Current treatment options and outcomes for acute uncomplicated thoracic Type-B aortic dissection (TBAD) remain unclear between medical management (MED) and thoracic endovascular aortic repair (TEVAR). In this study we aim to compare both strategies in terms of all-cause mortality, aortic dilation, and aortic rupture. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1990 through March 2017. Only studies comparing TEVAR to MED for acute uncomplicated TBAD were included. Random-effects meta-analysis was used to pool outcomes across studies. Study outcomes included short (1 month), intermediate (1 year), and mid-term (2-5 year) all-cause mortality. Additional outcomes included aortic dilation and rupture at 1 year. RESULTS: A total of 1,960 patients (64.3 years; 75.8% male) were included from six studies (one prospective and five retrospective). No difference was observed in short-term (odd ratio [OR] 0.73 with 95% confidence interval [CI] 0.47 to 1.12, P = 0.15), intermediate (OR 0.99 with 95% CI 0.56 to 1.73, P = 0.96), or mid-term all-cause mortality (OR 1.12 with 95% CI 0.54 to 2.32, P = 0.75). No difference in aortic dilation with either modality was noted at 1-year (OR 1.11 with 95% CI 0.76 to 1.64, P = 0.59). TEVAR was associated with a significantly lower 1-year risk of aortic rupture (OR 2.49 with 95% CI 1.23 to 5.06, P = 0.01). CONCLUSION: There were no short, intermediate, or mid-term differences in mortality between TEVAR or MED in patients with acute uncomplicated TBAD. Although the dilation rate was similar between both groups, TEVAR was associated with lower likelihood of aortic rupture at 1 year.

Percutaneous thoracic aortic aneurysm repair through transcaval aortic access.

Transcaval aortic access has been used for deployment of transcatheter aortic valves in patients in whom conventional arterial approaches are not feasible. This access can be vital in other situation when large bore access is needed. We described a case of 65-year-old man who had large thoracic descending aortic aneurysm with diffuse bilateral iliac disease precluding the arterial access required for the procedure. The patient underwent successful transcaval access with placement of 22-Fr balloon expandable sheath followed with successful deployments of 32 mm × 32 mm × 150 mm Valiant stent graft (Medtronic, Minneapolis, MN). The aorto-vena cava tract was closed successfully using 12 × 10 PDA occluder device with no residual flow at the end of the case, which was confirmed on repeated CT next day.

Percutaneous exclusion of a rapidly enlarging left main coronary artery aneurysm using coils and an Amplatzer™ septal occluder.

Coronary artery aneurysms (CAAs) are often an incidental finding amongst patients undergoing coronary angiography. Most CAAs are managed conservatively; rarely a larger CAA can lead to intramural thrombus formation and coronary artery embolization/obstruction even without the presence of significant stenosis. Despite these clinical implications, therapeutic options are limited to case reports and no clearly defined guidelines have been established for treatment. In this article, we present a unique case of a rapidly enlarging left main CAA, with no identifiable etiology that was treated with percutaneous exclusion via coil embolization and an Amplatzer™ septal occluder device. We also discuss existing literature, pathophysiology, and management options for CAAs. © 2016 Wiley Periodicals, Inc.

Comparison of the boomerang wire vascular access management system versus manual compression alone during percutaneous diagnostic and interventional cardiovascular procedures: The boomerang™ wire vascular access management trial II.

OBJECTIVES: To evaluate the use of the Boomerang™ Wire as an adjunct to manual compression (MC) in patients requiring diagnostic (Dx) or interventional (Ix) percutaneous procedures. BACKGROUND: MC remains the standard of care for closure of femoral artery access sites. Adjunctive use of a device to facilitate closure, reduce time to hemostasis (TTH) and ambulation (TTA) without increasing complication rates could reduce costs and hospital resource demands. METHODS: The Boomerang™ Trial was a prospective, multicenter, randomized, controlled trial comparing use of the Boomerang™ wire, (Cardiva Medical, Sunnyvale, CA) in conjunction with MC versus MC alone to achieve hemostasis in Dx and Ix patients undergoing percutaneous procedures requiring femoral artery access. Endpoints included TTH, TTA, major, and minor access-site related complications. Subjects were randomized 3:1, Boomerang versus MC. RESULTS: No minor or major device-related adverse events were reported. Nondevice related complication rates were 3 (0.9%) in the Boomerang arm (n = 327) and 1 (0.8%) in MC arm (n = 123). Mean TTH for Boomerang vs. MC was 11.2 ± 4.3 vs. 23.2 ± 11 min for Dx (P < 0.0001) and 13.9 ± 5.4 vs. 38.4 ± 57.3 min for Ix patients (P < 0.0001). Mean TTA for Boomerang vs. MC was 3.3 ± 3.0 vs. 4.5 ± 2.0 hr (P < 0.0001)for Dx and 5.4 ± 3.3 vs. 6.8 ± 3.2 hr (P < 0.0001) for Ix patients. CONCLUSIONS: Boomerang™ use, in conjunction with MC, was associated with low rates of complications and demonstrated that Boomerang™ as an adjunct to MC can significantly decrease TTH and TTA after both Dx and Ix procedures. © 2015 Wiley Periodicals, Inc.

Endovascular management of splenic artery aneurysms: case series using telescoping guide and cage/coil technique.

Splenic artery aneurysms are rare, but still the third most common abdominal aneurysm. Rupture is associated with significant morbidity and mortality. Traditionally, cardiologists have rarely been involved in the management of this entity. We present a series of four patients managed percutaneously by interventional cardiology using a combined telescoping guide and cage/coil technique.

Case Report: the transcatheter extraction of an atrial mass (TEXAS) technique.

Background: Intracardiac masses are historically treated with surgery. As percutaneous technologies continue to evolve, non-surgical techniques for mass removal may become options. We present a case of a woman with a large right atrial mass that was percutaneously removed en bloc without surgery. Case summary: A 77-year-old woman presents with a 40 mm right atrial mass. The mass was increasing in size, and she preferred to avoid surgical removal. The tumour was removed percutaneously from the femoral vein using a large suction cannula in combination with transection of the stalk using an electrified snare. The case was complicated by a haemopericardium that was treated successfully by injecting a haemostatic matrix into the pericardial space. The pathology returned papillary fibroelastoma. Discussion: The TEXAS technique used to remove the right atrial mass in this case is a modification of a previously described technique (SEATTLE procedure). Using this method, we were able to remove a 40 mm tumour from the right atrium without surgery. This is the largest reported intracardiac tumour that has been removed en bloc percutaneously. Percutaneous removal of right atrial tumours appears feasible, although this may be limited to smaller tumours based on the results of our case.

Cardiovascular risk factors of airport visitors in India: results from a nation-wide campaign.

Cardiovascular diseases have become the major cause of death in India, but overall awareness is still low. Therefore, the initiative was undertaken to set up health care screening booths at eight airports and one hospital throughout India to increase awareness and to determine cardiovascular risk factors. Participants were screened for hypertension (systolic blood pressure (BP) ≥140 mmHg or diastolic BP≥90 mmHg), diabetes [fasting blood glucose (FBG) level ≥126  or ≥200 mg/dL for random blood glucose (RBG)], and body mass index (BMI). Among 100 107 participants screened (46 ± 13 years; 17% women), prevalence of diabetes was 12 571 (15%), hypertension: 30 345 (33%) and overweight: 61 219 (65%). Diabetes was treated more often than hypertension (44% vs 11%). Hypertension and diabetes prevalence values were relatively high in young obese adults; BMI correlated significantly (p < .001) stronger to both systolic BP and RBG for subjects younger than 40 years than for those who were older (r = 0.27 vs r = 0.06 and r = 0.15 vs r = 0.03, respectively). Among obese women aged 60 years and older the hypertension prevalence was higher than 40%, in obese men this prevalence value was already seen from the group of 30 to 40 years old. For participants older than 50 years with hypertension, diabetes prevalence was 20%. These results show that screening initiatives like these are highly needed to increase the overall awareness of diabetes and particularly of hypertension. Systematic screening programs also help to identify specific patient populations and cope with undertreatment of those at the highest cardiovascular risk. The fact that women were underrepresented in the present screening campaign suggests actions are needed to encourage them to participate in health care programs.

Clinical relevance of double-arm blood pressure measurement and prevalence of clinically important inter-arm blood pressure differences in Indian primary care.

Hypertension guidelines recommend measuring blood pressure (BP) in both arms at least once. However, this is seldom done due to uncertainties regarding measurement procedure and the implications of finding a clinically important inter-arm BP difference (IAD). This study aimed to provide insight into the prevalence of clinically important IADs in a large Indian primary care cohort. A number of 134 678 (37% female) unselected Indian primary care participants, mean age 45.2 (SD 11.9) years, had BP measured in both arms using a standardized, triplicate, automated simultaneous measurement method (Microlife WatchBP Office Afib). On average, there were clinically minor differences in right and left arm BP values: systolic BP 134.4 vs 134.2 mmHg (p < .01) and diastolic BP 82.7 vs 82.6 mmHg (p < .01), respectively. Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7,813 (5.8%). Systolic IAD ≥ 15 mmHg 2,980 (2.2%) and diastolic IAD ≥ 10 mmHg 7,151 (5.3%). In total, there were 7,595 (5.6%) and 8,548 (6.3%) participants with BP above the 140/90 mmHg threshold in only the left or right arm, respectively. Prevalence of participants with elevated BP on one arm only was highest in patients with a systolic IAD ≥ 15 mmHg; 19.1% and 13.7%, for left and right arm, respectively. This study shows that a substantial prevalence of IAD exists in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasize the importance of undertaking bilateral BP measurement in routine clinical practice.

Long-term outcomes of drug-eluting stents versus bare-metal stents in saphenous vein graft disease: results from the Prairie "Real World" Stent Registry.

OBJECTIVES: This study was designed to compare long-term clinical outcomes of drug-eluting stents (DES) versus bare metal stents (BMS) in patients with saphenous vein graft (SVG) disease in the "real world." BACKGROUND: The safety and efficacy of DES versus BMS in SVG remains uncertain due to contradictory reports of either lower revascularization rates with DES; or clinical equivalence to BMS; or even an excess of clinical events associated with DES use. METHODS: We identified consecutive patients who underwent stent placement within a de novo SVG lesion between May 1, 2003 and July 31, 2007. Follow-up was obtained at regular intervals. The Kaplan-Meier method was used to produce actuarial survival estimates. Cox regression analysis was used to predict the risk associated with stent type, and propensity scores were generated to risk-adjust the results. RESULTS: The study group included 379 stent recipients (284 DES; 95 BMS) with 410 stented lesions. BMS were placed more frequently in current smokers, acute myocardial infarctions, larger vessels, and longer lesions. In-hospital mortality was higher in BMS recipients than in their DES counterparts (3.2% vs. 0, respectively; P = 0.015). At 3 years, there was no significant difference in clinical adverse event rates between DES and BMS recipients, even after risk adjustment. CONCLUSIONS: Three-year adverse event rates are similar among patients treated with DES or BMS in SVG lesions. Therefore, while DES are safe, they do not appear to offer an advantage in terms of long-term graft patency.

Renal nerves in the maintenance of hypertension: a potential therapeutic target.

Renal sympathetic efferent and afferent nerves, which lie within and immediately adjacent to the wall of the renal arteries, contribute to the maintenance of hypertension. Because the causative factors of hypertension change over time, denervation of both efferent and afferent renal nerves should result in long-term attenuation of hypertension. The importance of the renal nerves in hypertensive patients can now be defined with the novel development of percutaneous, minimally invasive renal denervation from within the renal artery using radiofrequency energy as a therapeutic strategy. Studies thus far show that catheter-based renal denervation in patients with resistant essential hypertension lowers systolic blood pressure 27 mm Hg by 12 months, with the estimated glomerular filtration rate remaining stable. The decrease in arterial pressure after renal denervation is associated with decreased peripheral sympathetic nervous system activity, suggesting that the kidney is a source of significant central sympathetic outflow via afferent renal nerve activity.

Redo MitraClip for Late Recurrent Severe Mitral Regurgitation: Case Report and Literature Review.

Transcatheter mitral valve repair using the MitraClip (Abbott Vascular, Santa Clara, CA) is a reasonable option for the treatment of patients with severe symptomatic degenerative mitral regurgitation (MR) who are at prohibitive surgical risk. The occurrence of recurrent severe MR after initial successful MitraClip repair is uncommon. Data are sparse on the management of recurrent severe MR after initial successful repair using the MitraClip. We describe a successful case of redo MitraClip repair for late recurrent severe MR secondary to progressive degenerative mitral valve disease after a successful initial MitraClip procedure and review the literature.

La réparation transcathéter de la valve mitrale au moyen d'un dispositif MitraClip (Abbott Vascular, Santa Clara, CA) constitue une bonne option pour le traitement de l'insuffisance mitrale (IM) dégénérative symptomatique grave lorsque la chirurgie représente un risque prohibitif pour le patient. Il est rare qu'une IM grave récurrente survienne après l'implantation réussie d'un dispositif MitraClip. On dispose de très peu de données sur la prise en charge de l'IM grave récurrente après une première réparation au moyen d'un dispositif MitraClip. Nous présentons le cas d'une seconde réparation au moyen d'un dispositif MitraClip pour remédier à une IM grave récurrente tardive secondaire à une atteinte dégénérative évolutive de la valve mitrale survenue après une première intervention efficace au moyen d'un dispositif MitraClip, et nous passons en revue les publications portant sur cette question.

Echocardiographic Derived Parameters Association With Long-Term Outcomes After Transcatheter Valve Replacement.

BACKGROUND: Transaortic flow, maximum velocity (V max), mean gradient (MG), left ventricular ejection fraction (LVEF), Aortic valve area (AVA) and dimensional index (DI) are important determinants of prognosis in patients with severe aortic stenosis. The specific role of these echocardiography-derived values in predicting prognosis of severe aortic stenosis patients undergoing Transcatheter aortic valve replacement (TAVR) is less defined. METHODS: We identified all severe AS patients who underwent TAVR between 01/2012 and 6/2016. Baseline characteristics, clinical, procedural and one year follow-up data were obtained. Hierarchical logistic regression was used to assess predictors of 1-year mortality after TAVR. Normal flow (NF) was defined as having stroke volume index (SVI) of ≥35 ml/m2; while low Flow (LF) was defined as SVI < 35 ml/m2. High gradient (HG) was defined as mean gradient of ≥40 mmHg; while low gradient (LG) was defined as <40 mmHg. RESULTS: A total of 399 patients were analyzed. There were no significant differences in baseline characteristics. LVEF less than 35% was associated with higher rate of 1-year mortality (17.6% LVEF <35% vs. 8.9% LVEF≥35%; RR = 2.19; CI 1.05 to 4.54; P = 0.03). There was no difference in 1-year mortality outcomes after TAVR in relation to: Mean Gradient MG, transaortic flow/Stroke Volume Index SVI, DI, V max or AVA. CONCLUSION: Low LVEF <35% remains the strongest parameter associated with 1 year mortality after TAVR.

Transcatheter Mitral Valve Therapy With Novel Supra-Annular AltaValve: First Experience in the United States.

This case demonstrates the feasibility and procedural success of a novel supra-annular transcatheter mitral valve, the AltaValve via transapical approach in a patient with severe symptomatic mitral regurgitation who was a prohibitive surgical risk candidate. (Level of Difficulty: Advanced.).

Endovascular repair of complex Juxtarenal aortic aneurysm using a combined fenestrated endograft and chimney technique.

Chimney EVAR (CHEVAR) and Fenestrated EVAR (FEVAR) are two options for management of very complex abdominal aortic aneurysm (AAA). While some anatomical factors may favor one strategy over the other, there are some cases where the anatomical challenges may require using a hybrid approach. We are reporting the case of an 84-year-old male with a 6.8×5.7cm infrarenal abdominal aortic aneurysm that arises immediately below the level of the renal arteries and extends down to just above the iliac bifurcation with occluded celiac and inferior mesenteric arteries and severe bilateral renal artery stenosis with caudally oriented right renal and cranially oriented left renal artery. This case shows that a combined strategy with fenestrated graft and Chimney stenting is feasible for aortic aneurysm repair and may offer a reasonable option for patients with very complex aortic anatomy.

Transcatheter aortic valve replacement through transcaval aortic access in a patient with duplicated inferior vena cava and poor iliofemoral anatomy.

Transthoracic (transapical and transaortic) access is inferior compared with femoral artery access. Percutaneous transcaval aortic access is a reasonable alternative approach that is being used in transcatheter aortic valve replacement (TAVR) in patients with poor iliofemoral anatomy. Duplicated Inferior vena cava (DIVC) is an uncommon abnormality. We report the case of 76-year-old lady with history of severe peripheral vascular disease, morbid obesity, diabetes, hypertension, hyperlipidemia and duplicated IVC that had severe symptomatic aortic stenosis. The patient had diffuse bilateral iliac disease precluding the arterial access required for TAVR. Other comorbidities made transthoracic access less desirable. We report the first successful Transcaval TAVR in a patient with DIVC.

A prospective, randomized, pivotal trial of a novel extravascular collagen-based closure device compared to manual compression in diagnostic and interventional patients.

OBJECTIVES: The RESPECT trial was aimed at evaluating safety/efficacy of a new extravascular closure system in diagnostic (Dx) and interventional (Ix) procedures performed through 6 or 7 Fr introducer sheaths. BACKGROUND: Although vascular closure devices (VCDs) have been available for two decades, manual compression (MC) remains the standard of care in many institutions. VCDs have not been shown to have greater safety than MC. METHODS: The RESPECT trial was a multicenter, randomized comparison of the Vascade VCD (Cardiva Medical, Inc) versus MC in Dx and Ix patients undergoing femoral access. Endpoints included time to hemostasis (TTH), time to ambulation (TTA), time to discharge eligibility (TTDe), device and procedure success, major and minor complications. Subjects were randomized 2:1 (Vascade vs MC). RESULTS: A total of 420 patients were enrolled (211 Dx, 209 Ix). Mean age was 62 ± 11 years and 29% were female. For Ix Vascade/MC patients, 77%/69% received bivalirudin, 27%/26% received heparin, and 8%/3% received glycoprotein IIb/IIIa inhibitors, respectively. Patients were followed for 30 ± 7 days. A total of 415 subjects (98.8%) completed follow-up. TTH was 3.0 minutes (range, 0.6-31.6 minutes) for Vascade vs 20.0 minutes (range, 0.0-97.0 minutes) for MC; TTA was 3.2 hours (range, 1.0-78.0 hours) for Vascade vs. 5.2 hours (range, 1.7-22.8 hours) for MC; and TTDe was 3.6 hours (range, 1.4-78.4 hours) for Vascade vs. 5.7 hours (range, 2.2-23.2 hours) for MC. Device and procedure success rates were 98% for Vascade and 100% for MC. Minor events were 1.1% for Vascade and 7% for MC. No major access-site related complications were reported in either arm. CONCLUSION: Despite high percentage of bivalirudin use, there were no major access-site related complications in either arm. Vascade use reduced rates of minor access-site related complications, and significantly shortened TTH, TTA, and TTDe compared to MC.

A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study.

OBJECTIVES: This study conducted a prospective, single-arm, multicenter trial to evaluate the safety and efficacy of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis, using the EkoSonic Endovascular System (EKOS, Bothell, Washington). BACKGROUND: Systemic fibrinolysis for acute pulmonary embolism (PE) reduces cardiovascular collapse but causes hemorrhagic stroke at a rate exceeding 2%. METHODS: Eligible patients had a proximal PE and a right ventricular (RV)-to-left ventricular (LV) diameter ratio ≥0.9 on chest computed tomography (CT). We included 150 patients with acute massive (n = 31) or submassive (n = 119) PE. We used 24 mg of tissue-plasminogen activator (t-PA) administered either as 1 mg/h for 24 h with a unilateral catheter or 1 mg/h/catheter for 12 h with bilateral catheters. The primary safety outcome was major bleeding within 72 h of procedure initiation. The primary efficacy outcome was the change in the chest CT-measured RV/LV diameter ratio within 48 h of procedure initiation. RESULTS: Mean RV/LV diameter ratio decreased from baseline to 48 h post-procedure (1.55 vs. 1.13; mean difference, -0.42; p < 0.0001). Mean pulmonary artery systolic pressure (51.4 mm Hg vs. 36.9 mm Hg; p < 0.0001) and modified Miller Index score (22.5 vs. 15.8; p < 0.0001) also decreased post-procedure. One GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries)-defined severe bleed (groin hematoma with transient hypotension) and 16 GUSTO-defined moderate bleeding events occurred in 15 patients (10%). No patient experienced intracranial hemorrhage. CONCLUSIONS: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis decreased RV dilation, reduced pulmonary hypertension, decreased anatomic thrombus burden, and minimized intracranial hemorrhage in patients with acute massive and submassive PE. (A Prospective, Single-arm, Multi-center Trial of EkoSonic® Endovascular System and Activase for Treatment of Acute Pulmonary Embolism (PE) [SEATTLE II]; NCT01513759).

Localization of a coronary artery fistula using contrast transesophageal echocardiography.

With the increasing use of transesophageal and other cardiac imaging, coronary fistulas are being discovered more often. The clinical significance of these communications is unclear. Microbubble echo-contrast has been used to enhance endocardial definition, myocardial perfusion, and augment Doppler signals. This case describes the use of microbubbles to enhance the color Doppler signals to better define location and extent of a coronary artery fistula communicating with the left ventricle.

An unusual presentation of congenital heart disease.

We describe an unusual presentation of congenital heart disease mimicking preeclampsia in a young, gravid girl. The diagnosis of Shone's complex was confirmed by echocardiography. This complex is manifested by multiple levels of obstruction involving the left side of the heart and the systemic circulation. It is extremely rare, especially in pregnant adolescents. We briefly describe the patient's clinical history, physical examination, and treatment, as well as our clinical decisions regarding her case. The discussion focuses on the spectrum of findings in Shone's complex and the physiologic impact of therapy on this patient.