Fast-slow atrioventricular nodal re-entrant tachycardia incorporating superior and inferolateral left atrial slow pathways.

BACKGROUND: A 70-year-old man revealed a rare type of atrioventricular nodal re-entrant tachycardia (AVNRT) involving distinct retrograde pathways, superior slow pathway, and inferolateral left atrial slow pathway. RESULT: Radiofrequency ablation was successfully performed on the noncoronary cusp and in the left atrium, respectively, to eliminate the tachycardias. DISCUSSION AND CONCLUSION: Due to the anomalous electrical conduction patterns, careful diagnosis and ablation strategies were necessary to avoid the risk of atrioventricular block. These findings underscore the diversity and complexity of AVNRT and highlight the importance of tailored therapeutic approaches.

Effect of Celiac Plexus Neurolysis for Pain Relief in Patients with Upper Abdominal Malignancy: A Retrospective Observational Study and Review of Literature.

BACKGROUND: Abdominal pain from primary cancer or metastatic disease is a significant cause of pain for patients undergoing treatment for the disease. Patient's pain may be resistant or non-responsive to the pharmacological management, hence minimal invasive pain intervention like celiac plexus neurolysis or splanchnic nerve rhizolysis may be required to relieve pain of such patients. OBJECTIVE: The aim of this retrospective study is to assess the effect of celiac plexus neurolysis for pain relief in patients with upper gastro-intestinal malignancies. STUDY DESIGN: This is a retrospective, observational study with short review. METHODS: This retrospective observational study was done in the Pain Medicine unit from 2016 and November 2018. Ninety-four patients with upper abdominal malignancy and unrelenting pain, non-responsive or poorly responsive to pharmacological treatment as per WHO ladder of analgesics, received fluoroscopy-guided celiac plexus neurolysis (CPN). All the patients underwent celiac plexus neurolysis through Trans-Aortic approach and the primary outcome measure was pain as assessed with Visual Analogue Scale (VAS) ranging from 0 to 10; the secondary outcome measures were morphine consumption per day (M), quality of life (QOL) as assessed by comparing the percent of positive responses and complications, if any. These were noted and analyzed prior to intervention and then on day 1, and months 1, 2, 3, 4, 5, 6 following CPN. RESULTS: Follow up was completed 6 months after the procedure. VAS score, daily morphine consumption, and the quality of life showed improvement for the duration of the study. There was some relapse in pain and deterioration in QOL during the fourth to sixth month of pain intervention due to disease progression. Some transient known side effects also occurred. CONCLUSION: Trans-Aortic celiac plexus neurolysis with low volume of alcohol is a safe procedure providing up to 6 months of pain relief and is an effective, well established, minimally invasive procedure for abdominal pain due to primary malignancy or metastatic spread.

Transcranial measurement of cerebral microembolic signals during left-sided catheter ablation with the use of different approaches- the potential microembolic risk of a transseptal approach.

Aims: Subclinical brain damage due to microembolization could occur during catheter ablation procedures. We evaluated the microembolic signals (MESs) detected by transcranial Doppler during ablation of supraventricular tachycardias (SVTs) or idiopathic ventricular arrhythmias (VAs) with the use of different approaches. Methods and results: This study included 36 patients (23 men, 49 ± 21 years) who underwent catheter ablation of SVTs (n = 27) or idiopathic VAs (n = 9). Left-sided ablation was performed by either a transaortic (Group 1, n = 11) or transseptal approach (Group 2, n = 9). A sole right-sided ablation was performed in the remaining 16 patients (Group 3). The MESs were counted throughout the procedure, and then analysed offline with a frequency analysis. The mean number of radiofrequency applications, total energy delivery time, total application energy, and total procedure time were 5.8 ± 5.0, 4.3 ± 3.3 min, 6625 ± 4633 J, and 81 ± 40 min, respectively, and there was no significant difference in the parameters between the three groups. The mean total number of MESs was 3.8 ± 3.1 in Group 1, 75 ± 58 in Group 2, and 0.3 ± 0.6 in Group 3 (P = 0.001). Few MESs were detectable during the radiofrequency energy deliveries in all groups. In Group 2, 19 ± 18 MESs were detected during the transseptal puncture period, and subsequently a relatively even distribution of emboli formation was observed. A frequency analysis suggested that 99, 91, and 100% of MESs were gaseous, in Group 1, Group 2, and Group 3, respectively. No neurological impairment was observed in any patients after the procedure. Conclusion: The retrograde aortic approach might potentially have a lower risk of subclinical brain damage than the transseptal approach during left-sided catheter ablation.

Repair of an aorto-right ventricular tunnel in a newborn.

A newborn presented with an aorto-right ventricular tunnel, a defect connecting the left aortic sinus to the right ventricle. The patient underwent repair on 4th day of life.

[Transaortic Implantation of Aortic Valve Bioprosthesis in High-Risk Patient With Simultaneous Off-Pump Coronary Artery Bypass Grafting].

Transaortic approach represents an alternative variant of transcatheter aortic valve implantation (TAVI) which combines benefits of antegrade transapical approach and high safety profile characteristic of transfemoral approach. This method has substantial advantages over subclavian and transapical approaches in cases of pronounced myocardial hypertrophy, left ventricular dysfunction, thinning of left ventricular wall. We describe here a hybrid intervention with simultaneous coronary artery bypass grafting and TAVI in a patient from high surgical risk group with multivessel coronary artery involvement and critical aortic stenosis. The intervention was a successful alternative to open heart surgery with cardiopulmonary bypass.

Emergent use of Impella CP™ during transcatheter aortic valve replacement: Transaortic access.

Sudden onset of hypotension is a rare but emergent event in patients undergoing transcatheter aortic valve replacement (TAVR). This primarily occurs due to coronary artery obstruction, valve misplacement/migration, ventricular perforation, cardiac tamponade, severe paravalvular regurgitation, stunned myocardium, ventricular arrhythmia, and annulus rupture. While the operator makes an attempt to identify and correct the underlying problem, an emergent placement of mechanical hemodynamic assist device may be necessary and crucial for a successful outcome. We describe a unique and challenging case of complete circulatory collapse in a patient undergoing transaortic TAVR with Edwards SAPIEN prosthesis (Edwards Lifesciences, CA) who required rescue Impella CP™ (Abiomed, Danvers, MA) placement directly through the ascending aorta due to unfavorable femoral access.

Dual ruptured sinus of Valsalva aneurysms.

Ruptured sinus of Valsalva (RSOV) aneurysm is a rare anomaly accounting for around 0.14-3.5% in patients undergoing open cardiac surgeries. We report a rare case of an 18-year-old male with dual RSOV aneurysms who was managed successfully by patch closure via the transaortic approach and which to our knowledge has never been reported ("PubMed" and "Google Scholar" as the search engine with dual, ruptured, sinus of Valsalva aneurysm as the MeSH words). Dual RSOV aneurysm in a single patient is an extremely rare condition which can lead to early cardiogenic shock and should be managed surgically at the earliest.

Transaortic approach for the repair of the basal ventricular septal rupture.

A 53-year-old man who suffered acute inferior myocardial infarction was recently transferred to our hospital due to occlusion of the right coronary artery. The results of the echocardiogram revealed a basal ventricular septal rupture (VSR). Since hemodynamic instability had been observed, we performed emergency surgery 5 days after the myocardial infarction began. We used a recently developed novel technique to treat this case: a patent ductus arteriosus occluder placed on the left ventricular side of the septum to close the VSR site, placed directly via the transaortic approach. Simple intermittent mattress sutures with gaskets were used for further fixation. The mild residual shunt was detected postoperatively. The patient was discharged 3 weeks after surgery.

Complete Atrioventricular Block Caused by Retrograde Transaortic Approach.

A 61-year-old female was referred for catheter ablation of symptomatic and frequent premature ventricular complexes presented with right bundle branch block and a prominent inferior frontal plane QRS axis. A retrograde transaortic approach was routinely performed. A sustained complete atrioventricular block was repeatedly encountered while the ablation catheter was attempting to cross the aortic valve with different curves and manipulations. The procedure was abandoned. The mechanical atrioventricular block could only have been caused by the retrograde transaortic approach. We should be cautious when performing a retrograde transaortic catheter manipulation in some patients.

Case report: Total thoracoscopic repair of sinus of Valsalva aneurysm combined with ventricular septal defect.

The sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly. It can develop into the heart failure if it ruptures, which requires early intervention. However, such congenital anomalies are usually treated using a median sternotomy approach. Here, we report a rare case of SVA combined with a ventricular septal defect in which the patient underwent patch repair of the defects under a total thoracoscopy approach. She was discharged uneventfully and showed no residual shunt or aortic regurgitation postoperatively or at the 12-month follow-up. The total thoracoscopic approach for SVA repair is technically feasible.

Usefulness of transaortic approach for a complex double-outlet right ventricle.

Surgical procedures for double-outlet right ventricle with ventricular septal defect are based on rerouting the blood flow of the left ventricle to the aorta through the ventricular septal defect (VSD) with an intraventricular baffle. The right atriotomy is the most common approach combined with a right ventriculotomy in some cases, particularly in pulmonary stenosis association. However, in complex cases, this standard operative strategy may not provide an adequate exposure. We describe the transaortic approach as an alternative procedure to repair a complex case of double-outlet right ventricle (DORV) with subaortic stenosis. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-021-01261-7.

Total Debranching Plus Antegrade Thoracic Endovascular Aortic Repair without Side Clamping in a Patient with Arch Aneurysm and Ascending Aorta Calcification.

A high-risk patient with aortic arch aneurysm, associated with severe calcification of the ascending aorta and iliac arteries, was treated with total debranching and antegrade thoracic endovascular aortic repair (TEVAR) via the ascending aorta. Proximal anastomosis for a triple-branched graft to the ascending aorta was performed without side clamping using the "real chimney technique." After bypassing the supra-aortic branches, a TEVAR was performed in an antegrade fashion through the ascending aorta. This case suggests that the approaches mentioned above should be considered in patients with arch aneurysms and severe calcified degeneration.

Safety and effectiveness of a transaortic approach for TAVI: procedural and midterm outcomes of 265 consecutive patients in a single centre.

OBJECTIVES: Transcatheter aortic valve implantation with a transaortic approach (TAo-TAVI) is an alternative to transapical or femoral access. We studied the procedural and midterm efficacy and safety of TAo-TAVI with Edwards Sapien XT and Medtronic CoreValve devices. METHODS: Among 901 patients receiving TAVI since 2006, 265 consecutive patients underwent TAo-TAVI between January 2011 and September 2014. Procedural and midterm results were evaluated according to Valve Academic Research Consortium-2 criteria. RESULTS: The mean age was 83 ± 5 years. Sapien XT and CoreValve were used in 191 (72.1%) and 74 (27.9%) patients, respectively. Full sternotomy made elective concomitant off-pump coronary artery bypass grafting possible in 38 patients (14.3%) with severe coronary artery disease unsuitable for percutaneous coronary intervention. The device success rate was 95.5%. Postprocedural paravalvular leak ≥2/4 was observed in 16 patients (6.4%). Emergency open chest surgery was required in 10 patients (3.8%) (3 aortic dissections, 3 valve embolizations, 2 LMCA occlusions, 1 aortic annulus rupture and 1 aortic rupture). Cerebrovascular accidents occurred in 3 patients (1.1%). Transfusions ≥4 units were required in 36 patients (13.6%). New pacemakers were implanted in 26 patients (9.8%). Thirty-day and 1-year mortality were 8.7% and 16.2%, respectively. Mean follow-up duration was 24 ± 6 months. At 3 years, freedom from all-cause death was 80% ± 4%. New York Heart Association class

Impact of procedural volume on outcome optimization in transaortic transcatheter aortic valve implantation.

BACKGROUND: An adequate procedural volume seems to be required to minimize the complication rate in TAVI. However, very few studies have investigated the relationship between procedural volume and outcomes in TAVI especially via the transaortic approach. The aim of this study was to evaluate the effect of procedural volume on the outcomes of transaortic TAVI (TAo-TAVI). METHODS: 257 consecutive TAo-TAVI cases performed by 2 cardiac surgeons between January 2011 and June 2014 were included in the current analysis. Cumulative sum (CUSUM) failure analysis of combined 30-day safety endpoints was used in order to evaluate the learning curves. We divided the cases into two groups: early experience and late experience, respectively. Procedure and outcome variables were compared. RESULTS: The CUSUM analysis revealed a learning curve regarding the occurrence of adverse events at 30days with an improvement after the initial 128 cases. We divided the cases into two groups (early group: cases 1 to 128; late group: cases 129 to 257). Although the rate of 30-day mortality was not significantly different between the 2 groups (11% and 7%, p=0.268), the incidence of adverse events such as life-threatening bleeding, stroke and AKI was significantly decreased in the late phase group (9% and 1%, p=0.002; 5% and 0%, p=0.014; 16% and 6%, p=0.002, respectively). CONCLUSIONS: The incidence of adverse events was significantly decreased in the late phase group. An appropriate number of procedures seems to be required to reduce the TAo-TAVI complication rate.

Transaortic transcatheter aortic valve implantation: Results of the Polish arm of the ROUTE registry.

BACKGROUND: Transaortic (TAo) transcatheter aortic valve implantation (TAVI) is an alter-native approach in patients considered to be at high risk for classical open surgery with poor peripheral vessel access. The purpose of this study was to determine the feasibility of using TAo access for TAVI procedures employing the Edwards SAPIEN transcatheter heart valve. The primary objective was to determine overall 30-day mortality. METHODS: A total of 32 patients with severe aortic valve stenosis underwent TAo-TAVI using Edwards SAPIEN bioprostheses. Postoperative results were collected according to the Registry of the Utilization Of the TAo-TAVI approach using the Edwards SAPIEN Valve (ROUTE) study protocol. Complications were assessed using Valve Academic Research Consortium- 2 (VARC-2) criteria. RESULTS: The mean age of the population was 80.9 ± 5.2 years, with 53.1% being female. All patients received either the SAPIEN XT or the SAPIEN 3 bioprosthesis (Edwards Lifesciences). Device success was achieved in 100% of cases. One (3.25%) patient subsequently suffered an aortic dissection and required ascending aorta replacement. Paravalvular leakage was absent or mild in 26 (81%) patients, and moderate in 6 (19%) patients. Other complications included permanent pacemaker implantation in 2 (6.5%), and transient post operative delirium in 2 (6.5%) patients. The total hospital stay was 6.7 ± 2.4 days. New York Heart Association class decreased significantly on follow-up. Thirty-day mortality rate was 2 (6.5%) patients. CONCLUSIONS: Use of TAo access for TAVI procedures has a reasonable clinical outcome and is a safe alternative to the transfemoral and transapical approaches, especially for patients with high-risk peripheral vessel access.

The transaortic approach for transcatheter aortic valve implantation: a valid alternative to the transapical access in patients with no peripheral vascular option. A single center experience.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) in patients with poor peripheral vessels still remains problematic, as the transapical approach is not always feasible and is sometimes associated with myocardial damage, bleeding, post-procedural chest pain and pleural effusion. In order to address these issues, we adopted the recently introduced transaortic (TAo) approach. The purpose of this study was to evaluate the efficacy and safety of the TAo-TAVI approach using both the Sapien XT and the CoreValve according to VARC criteria. METHODS: Of 492 patients (October 2006 to February 2012), TAo-TAVI was performed in 94 consecutive patients with unfavourable peripheral access between January 2011 and February 2012. Aortic root condition, valve anatomy and annulus size were carefully assessed by multidetector computed tomography (MDCT) for possible TAo-TAVI. The aorta was exposed through an inverted 'T' manubriotomy. After retrograde guidewire crossing of the aortic valve, sheath insertion allowed device positioning and deployment subsequent to balloon valvuloplasty. RESULTS: Mean age was 84.1 ± 5.4 years (67-96) and logistic EuroSCORE 17.6 ± 10.2%. The Sapien XT was used in 88.3% and the CoreValve in 11.7% of patients. Full sternotomy allowed concomitant complete off-pump revascularization (2-4 grafts) in 11 patients. Device success rate was 92.6%. Paravalvular leak ≥2/4 was observed in 7.4%. Conversion to open chest surgery was required in 5.3% (3 aortic dissections, 1 valve migration and 1 left main occlusion). Three cerebrovascular accidents (2 transient ischaemia and 1 delayed stroke) were noted. Transfusion ≥4 units was performed in 12 patients (12.8%). Intensive care unit (ICU) and total hospital stay were 4.9 ± 5.0 and 12.2 ± 6.2 days, respectively. Thirty-day mortality and combined safety endpoint were reported in 7.4 and 16.0%, respectively. CONCLUSIONS: The TAo approach for both Sapien XT and CoreValve implantation can be used with satisfactory clinical outcome and an acceptable risk. This access route could prove a valid alternative to the transapical approach.