Transcatheter tricuspid valve intervention in the presence of a cardiac implantable electronic device; state of the art review.

A large proportion of patients referred for transcatheter tricuspid valve intervention (TTVI) will have the presence of a cardiac implantable electronic device (CIED). In such patients, surgical correction of tricuspid regurgitation (TR) is associated with high rates of morbidity and mortality. Transvenous lead extraction (TLE) could potentially ameliorate CIED-induced TR; however, it carries inherent risks and frequently does not result in TR improvement. As multiple TTVI devices are in trial to gain regulatory approval, understanding which therapy is most appropriate among patients with a CIED is essential. This review centers on the nonsurgical treatment, including TLE and transcatheter tricuspid valve repair and replacement options, aimed at enhancing outcomes in patients with TR who also have concurrent CIEDs.

Balloon rupture during transcatheter aortic valve replacement.

A distinctive complication with balloon-expandable (BE) THV platforms such as the Edwards Sapien (Edwards Lifescience) is the possibility of balloon rupture during THV deployment. Balloon rupture is a rare occurrence that can result in stroke due to fragment embolism, incomplete THV expansion, and/or vascular injury upon retrieval of the balloon. Careful evaluation of preoperative computed tomography is essential to identify high-risk cases. While annular and left ventricular outflow tract (LVOT) calcification are widely acknowledged as common risks for balloon injury, it's essential to note that balloon injury can manifest at various anatomical sites. In this review, we discuss the mechanism behind balloon rupture, methods to identify cases at a heightened risk of balloon injury, approaches to mitigate the risk of rupture, and percutaneous retrieval strategies.

Contemporary experience of mitral transcatheter edge-to-edge repair technology in patients with mitral annular calcification.

BACKGROUND: Mitral annular calcification (MAC) has been an exclusion for many of the earlier pivotal trials that were instrumental in gaining device approval and indications for mitral transcatheter edge-to-edge repair (M-TEER). AIMS: To evaluate the impact of MAC on the procedural durability and success of newer generation MitraClip® systems (G3 and G4 systems). METHODS: Data were collected from Northwell TEER registry. Patients that underwent M-TEER with third or fourth generation MitraClip device were included. Patients were divided into -MAC (none-mild) and +MAC (moderate-severe) groups. Procedural success was defined as ≤ grade 2 + mitral regurgitation (MR) postprocedure, and durability was defined as ≤ grade 2 + MR retention at 1 month and 1 year. Univariate analysis compared outcomes between groups. RESULTS: Of 260 M-TEER patients, 160 were -MAC and 100 were +MAC. Procedural success was comparable; however, there were three patients who required conversion to cardiac surgery during the index hospitalization in the +MAC group versus none in the -MAC group (though this was not statistically significant). At 1-month follow-up, there were no significant differences in MR severity. At 1-year follow-up, +MAC had higher moderate-severe MR (22.1% vs. 7.5%; p = 0.002) and higher mean transmitral gradients (5.3 vs. 4.0 mmHg; p = 0.001) with no differences in mortality, New York Heart Association functional class or ejection fraction. CONCLUSION: In selective patients with high burden of MAC, contemporary M-TEER is safe, and procedural success is similar to patients with none-mild MAC. However, a loss of procedural durability was seen in +MAC group at 1-year follow-up. Further studies with longer follow-ups are required to assess newer mTEER devices and their potential clinical implications in patients with a high burden of MAC.

Chargemaster Pricing Variation for Commonly Billed Procedures in Interventional Cardiology.

OBJECTIVES: A chargemaster is a database of all of the billable items offered by a hospital with their base price listings. A 2018 executive order required all American hospitals to publish their chargemasters to increase price transparency and reduce healthcare expenditures. Chargemaster listings, however, demonstrate marked variability and inconsistency and have not been associated with consumer benefit. The objective of this study was to analyze chargemasters for commonly billed interventional cardiology procedures across five diverse states to explore relationships between price listings and hospital characteristics, ownership, location, and hospital quality. METHODS: Chargemasters were downloaded from hospitals in five states selected to represent the nation's healthcare diversity. Price listings for five interventional cardiology procedures (percutaneous coronary angiography, coronary angiography, single-vessel angioplasty, single-vessel stent, and percutaneous coronary intervention of acute myocardial infarction) were extracted. Statistical analyses such as the Kruskal-Wallis test were performed to explore relationships between mean chargemaster price listings for each procedure and hospital characteristics, ownership, location, and quality ratings. RESULTS: The median mean chargemaster price of four of the five interventional cardiology procedures significantly differed across all states. Price listings were significantly higher in urban versus rural areas and in general acute care hospitals and state government-owned facilities. The highest prices were found with the highest hospital quality rating. CONCLUSIONS: Chargemaster price listings for common interventional cardiology procedures varied significantly across these five states. Urban and metropolitan hospital location, hospital type, and hospital ownership could be factors driving increased chargemaster procedure prices. Prices were highest at hospitals with the highest quality rating.

Comparison of clinical outcomes between use of overexpanding an undersized versus nominal-sized SAPIEN 3 ultra transcatheter heart valve in patients with borderline annulus area.

BACKGROUND: For patients with borderline annulus areas that fall between two valve sizes, overinflating a smaller balloon-expandable transcatheter heart valve (THV) may be preferable to nominal sizing of a larger THV. OBJECTIVES: To evaluate the outcomes of nominal preparation versus over-expanding an under-sized SAPIEN 3 Ultra (S3U) transcatheter heart valve (OE-THV) in cases with borderline annuli. METHODS: 958 patients that underwent TAVR with the S3U at four high-volume TAVR centers between January 2017 and December 2020 were retrospectively reviewed. 336 patients were identified as borderline annuli size, of which 146 (44%) received OE-THVs and 190 (56%) received nominal-sized THVs. The primary composite endpoint included: in-hospital mortality, aortic injury, moderate/severe paravalvular leak (PVL), permanent pacemaker implant (PPM), stroke, or conversion to surgery. RESULTS: Baseline characteristics were similar except for a larger percentage of females in the OE-THV (53.42% vs. 42.11%, p = 0.04). TAVR with OE-THV resulted a reduction in the primary composite endpoint (13.69% vs. 22.63%, p = 0.04). On subgroup analysis, there was no difference between 20 mm OE-THV versus 23 mm nominal or 23 mm OE-THV versus 26 mm nominal, but there was a reduction in the primary composite endpoint in patients with larger annuli that received a 26 mm OE-THV compared to the 29 mm nominally sized THV (9.7% vs. 27.4%, p = 0.02). At 1 month and 1 year follow-up, there was no significant difference in mortality, PVL rates, NYHA class, and/or KCCQ score. CONCLUSION: Overinflating a smaller-sized S3U THV may be a safer option in comparison to nominal sizing in patients with borderline annular area.

Transcatheter heart valve selection in patients with low ejection fraction and aortic stenosis.

OBJECTIVE: The aim of this study was to compare outcomes of transcatheter heart valve (THV) choice in patients with left ventricular (LV) systolic dysfunction. BACKGROUND: The management congestive heart failure with combined LV systolic dysfunction and severe aortic stenosis (AS) is challenging, yet transcatheter aortic valve replacement (TAVR) has emerged as a suitable treatment option in such patients. Head-to-head comparisons among the balloon-expandable (BEV) and self-expandable (SEV) THV remain limited in this subgroup of patients. METHODS: In this retrospective study, we included patients with severe AS with LV systolic dysfunction (LVEF ≤40%) who underwent TAVR at four high volume centers. Two thousand and twenty-eight consecutive patients were analyzed, of which 335 patients met inclusion criteria. One hundred fourty-six patients (43%) received a SEV, and 189 patients (57%) received a BEV. RESULTS: Baseline characteristics were similar except for a higher proportion of females in the SEV group. The primary composite endpoint of in-hospital mortality, moderate or greater paravalvular (PVL), stroke, conversion to open surgery, aortic valve reintervention, and/or need for permanent pacemaker (PPM) was no different among THV choice. There was more PVL in the SEV group, but higher transaortic gradients in the BEV group. Clinical outcomes and quality of life measures were similar up to 1 year follow-up. CONCLUSION: The choice of THV in patients with severe AS and systolic dysfunction must be weighed on a case-by-case basis.

Problems with interpreting troponins in chronic kidney disease patients for ruling out acute coronary syndrome.

Chest pain is one of the most common reasons for emergency department visits worldwide, and troponins play a central role in diagnosing acute coronary syndrome (ACS) in these patients. Hence, the tests for these molecules are imperative in triage for ACS. Presently, multiple high-sensitivity troponin tests are available, including those for troponin T and I. However, in the presence of physiological and pathological alterations such as chronic kidney disease (CKD) and muscle dysfunction, these tests lose their sensitivity and specificity, especially if not interpreted in the right clinical background. Further, no guidelines exist for interpreting the results in patients with CKD. We identified studies that compared the relative efficacy, sensitivity, and specificity of tests for troponin T and I in patients with CKD to understand the practical problems in the clinical interpretation of these results in the specific setting of CKD and highlight the measures to be taken into consideration.

Transcatheter aortic valve-in-valve-in-valve implantation with three-dimensional printing guidance: A case report.

BACKGROUND: Valve-in-valve implantation (ViV) has become a valid option for the treatment of bioprosthetic valve failure. We describe the first in-man transfemoral transcatheter aortic valve replacement (TAVR) or "turducken" in a patient with previous TAVR within surgical aortic valve replacement with preprocedural guidance utilizing three-dimensional (3D) printing and intraprocedural guidance with fusion imaging. CASE SUMMARY: A 65-year-old male with a previous valve-in-valve with a transcatheter Melody valve presented with symptomatic severe valvular and paravalvular aortic incompetence. Using 3D printing for preprocedural guidance and computed tomography angiography-fluoroscopy fusion imaging for intraprocedural guidance we successfully placed a 29 mm self-expanding valve with minimal residual gradients. The patient continued to be asymptomatic at 1- and 5-year follow-up. DISCUSSION: We describe the first in man aortic valve-in-valve-in-valve using preprocedural guidance with 3D printing and intraprocedural guidance with fusion imaging. The valve has continued to demonstrate good function up to 5 years postprocedure suggesting that transcatheter aortic valve-in-valve-in-valve may be feasible with the proper pre- and intraprocedural guidance.

Long-term survival in triple-vessel disease: Hybrid coronary revascularization compared to contemporary revascularization methods.

BACKGROUND: Hybrid coronary revascularization (HCR) constitutes a left internal mammary artery graft to the left anterior descending (LAD) coronary artery, coupled with percutaneous coronary intervention (PCI) for non-LAD lesions. This management strategy is not commonly offered to patients with complex multivessel disease. Our objective was to evaluate 8-year survival in patients with triple-vessel disease (TVD) treated by HCR, compared with that of concurrent matched patients managed by traditional coronary artery bypass grafting (CABG) or multivessel PCI. METHODS: A retrospective review was undertaken of 4805 patients with TVD who presented between January 2009 and December 2016. A cohort of 100 patients who underwent HCR were propensity-matched with patients treated by CABG or multivessel PCI. The primary endpoint was all-cause mortality at 8 years. RESULTS: Patients with TVD who underwent HCR had similar 8-year mortality (5.0%) as did those with CABG (4.0%) or multivessel PCI (9.0%). A composite endpoint of death, repeat revascularization, and new myocardial infarction, was not significantly different between patient groups (HCR 21.0% vs CABG 15.0%, P = .36; HCR 21.0% vs PCI 25.0%, P = .60). Despite a higher baseline synergy between percutaneous coronary intervention with taxus and cardiac surgery(SYNTAX) score, HCR was able to achieve a lower residual SYNTAX score than multivessel PCI (P = .001). CONCLUSIONS: In select patients with TVD, long-term survival and FREEDOM from major adverse cardiovascular events after HCR are similar to that seen after traditional CABG or multivessel PCI. HCR should be considered for patients with multivessel disease, presuming a low residual SYNTAX score can be achieved.

Preoperative multidetector computed tomography for isolated surgical aortic valve replacement: Planning for future transcatheter options.

BACKGROUND: Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has become a valuable option in patients with bioprosthetic failure. However, potential issues with ViV TAVR may occur in patients with high-risk anatomy for coronary obstruction and patients with baseline smaller bioprosthetic valves at risk for patient prosthesis mismatch. The purpose of this study was, therefore, to use preoperative electrocardiography-gated, multidetector computed tomography (MDCT) in patients undergoing isolated surgical aortic valve replacement (SAVR) to (1) identify which would be high risk for coronary occlusion with ViV TAVR, and (2) predict intraoperative SAVR sizing. METHODS: Among 223 patients from our institutions' database that underwent SAVR for aortic insufficiency (AI) or aortic stenosis (AS) between January 2012 and January 2020, 48 patients had MDCT imaging before surgery (AI; n = 31, AS; n = 17). Of all patients, 67% (n = 32) were bicuspid morphology. RESULTS: With the use of virtual valve implantation, all patients with AI and bicuspid AS had feasible anatomy for ViV TAVR, while 38% of patients with tricuspid AS were high risk for coronary obstruction. There was a strong correlation between actual valve size implanted and preoperative MDCT measurements using annulus average diameter, area, and/or perimeter. CONCLUSION: Preoperative MDCT in patients undergoing SAVR is a useful tool for lifetime management, particularly in patients with tricuspid AS. Decisions for surgical management may change based on MDCT's ability to predict intraoperative SAVR size and determine which patients may be high-risk candidates for future ViV TAVR due to coronary artery obstruction.

The role of advanced glycation end-products in the development of coronary artery disease in patients with and without diabetes mellitus: a review.

BACKGROUND: Traditional risk factors are insufficient to explain all cases of coronary artery disease (CAD) in patients with diabetes mellitus (DM). Advanced glycation end-products (AGEs) and their receptors may play important roles in the development and progression of CAD. BODY: Hyperglycemia is the hallmark feature of DM. An increase in the incidence of both micro-and macrovascular complications of diabetes has been observed with increased duration of hyperglycemia. This association persists even after glycemic control has been achieved, suggesting an innate mechanism of "metabolic memory." AGEs are glycated proteins that may serve as mediators of metabolic memory due to their increased production in the setting of hyperglycemia and generally slow turnover. Elevated AGE levels can lead to abnormal cross linking of extracellular and intracellular proteins disrupting their normal structure and function. Furthermore, activation of AGE receptors can induce complex signaling pathways leading to increased inflammation, oxidative stress, enhanced calcium deposition, and increased vascular smooth muscle apoptosis, contributing to the development of atherosclerosis. Through these mechanisms, AGEs may be important mediators of the development of CAD. However, clinical studies regarding the role of AGEs and their receptors in advancing CAD are limited, with contradictory results. CONCLUSION: AGEs and their receptors may be useful biomarkers for the presence and severity of CAD. Further studies are needed to evaluate the utility of circulating and tissue AGE levels in identifying asymptomatic patients at risk for CAD or to identify patients who may benefit from invasive intervention.

Antiplatelet and anticoagulation therapy during percutaneous coronary interventions: A review for the interventionalist.

Pharmacotherapy for percutaneous coronary interventions is essential to optimize the balance between thrombosis and bleeding. Currently, choices abound for the selection of antiplatelet and anticoagulation therapies during percutaneous intervention (PCI). This review article discusses the mechanisms, pharmacokinetics/dynamics, and clinical data behind the various pharmacotherapies including; aspirin, thienopyridines, glycoprotein IIb/IIIa inhibitors, vorapaxar, heparin, direct thrombin inhibitors, and factor Xa inhibitors.

A standardized protocol to reliably visualize the left atrial appendage with intracardiac echocardiography: Importance of multiple imaging sites.

BACKGROUND: Currently, there is no accepted protocol for left atrial appendage (LAA) imaging with intracardiac echocardiography (ICE). OBJECTIVE: This study aimed to assess the utility of ICE to reliably visualize the entire cavity of the LAA and propose a specific procedural protocol to achieve the above objective. METHODS: We created a three-dimensional reconstruction of the LAA, using two-dimensional ICE sections obtained from three different location (the right atrium [RA], right ventricle inflow [RVI], and right ventricular outflow [RVOT]). We then compared the three-dimensional LAA reconstruction by ICE with one obtained by cardiac computed tomography angiography (CCTA) for morphological and volume differences. RESULTS: Three-dimensional reconstruction with ICE could reliably reproduce the LAA as visualized with CCTA but only when ICE sampling was performed from at least two catheter positions. There was no statistically significant difference between LAA volumes obtained with ICE and CCTA (P = 0.33). The contribution of each anatomical location to the total volume was 17% ± 16.6%, 74% ± 13.3%, and 33% ± 26% for RA, RVI, and RVOT, respectively. CONCLUSION: In comparison with CCTA, the LAA can be reliably visualized in its entity by ICE, but only if multiple imaging positions (RA, RV inflow, and RVOT) are used.

The role of percutaneous vacuum-assisted thrombectomy for intracardiac and intravascular pathology.

Vacuum-assisted thrombectomy (VAT) is a mechanical suction device that can be deployed to aspirate thrombi in the heart and vascular system. Successful percutaneous aspiration of iliocaval, right heart, and pulmonary arterial thrombi have been reported, in addition to the debulking of intravascular and intracardiac masses and vegetations. VAT is indicated for patients who are poor surgical candidates and/or have a contraindication to thrombolysis. This review discusses the mechanism, current results, potential clinical indications, and limitations of VAT for iliocaval and intracardiac mass removal.

Timing of Percutaneous Coronary Intervention and Therapeutic Hypothermia in Patients With ST-Elevation Myocardial Infarction and Out-of-hospital Cardiac Arrest.

The American College of Cardiology/American Heart Association guidelines include a Class 1 recommendation to initiate therapeutic hypothermia (TH) in comatose patients with out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm who have achieved return of spontaneous circulation. There is also a Class 1 recommendation for immediate angiography in these patients whose initial electrocardiography shows ST-elevation myocardial infarction (STEMI). However, due to a lack of clinical trials evaluating these patients who have received both percutaneous coronary intervention (PCI) and TH, controversy remains regarding whether the two can be safely combined. Furthermore, in patients who receive TH and PCI, another question to address is which therapy to initiate first. This article focuses on how best to manage comatose OHCA survivors who have an initial shockable rhythm and STEMI.

Intracardiac Echocardiography for Structural Heart and Electrophysiological Interventions.

PURPOSE OF REVIEW: With an increasing number of interventional procedures performed for structural heart disease and cardiac arrhythmias each year, echocardiographic guidance is necessary for safe and efficient results. The purpose of this review article is to overview the principles of intracardiac echocardiography (ICE) and describes the peri-interventional role of ICE in a variety of structural heart disease and electrophysiological interventions. RECENT FINDINGS: Both transthoracic (TTE) and transesophageal echocardiography have limitations. ICE provides the advantage of imaging from within the heart, providing shorter image distances and higher resolution. ICE may be performed without sedation and avoids esophageal intubation as with transesophageal echocardiography (TEE). Limitations of ICE include the need for additional venous access with possibility of vascular complications, potentially higher costs, and a learning curve for new operators. Data supports the use of ICE in guiding device closure of interatrial shunts, transseptal puncture, and electrophysiologic procedures. This paper reviews the more recent reports that ICE may be used for primary guidance or as a supplement to TEE in patients undergoing left atrial appendage (LAA) closure, interatrial shunt closure, transaortic valve implantation (TAVI), percutaneous mitral valve repair (PMVR), paravalvular leak (PVL) closure, aortic interventions, transcatheter pulmonary valve replacement (tPVR), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) closure. ICE imaging technology will continue to expand and help improve structural heart and electrophysiology interventions.

Snare technique to facilitate 'tall-in-short' redo-TAVR.

An 82-year-old man with a prior history of transcatheter aortic valve replacement (TAVR) with a 23-mm balloon-expandable transcatheter heart valve (THV) presented with bioprosthetic stenosis.

Fusion Imaging Guidance for Coronary Reaccess After Valve-in-Valve Transcatheter Aortic Valve Replacement.

Coronary reaccess can be difficult after valve-in-valve transcatheter aortic valve replacement. We present a case whereby prior valve-in-valve transcatheter aortic valve replacement created difficulty with coronary reaccess. Computed tomography-fluoroscopy fusion imaging was used for guidance to successfully engage the coronary arteries and perform percutaneous coronary intervention.

Multiple Valvular Heart Disease in the Transcatheter Era: A State-of-the-Art Review.

Although existing guidelines offer strong recommendations for single valvular dysfunction, the growing prevalence of multiple valvular heart disease (MVHD) in our aging population is challenging the clarity of clinical guidance. Traditional diagnostic modalities, such as echocardiography, face inherent constraints in precisely quantifying valvular dysfunction due to the hemodynamic interactions that occur with multiple valve involvement. Therefore, many patients with MVHD present at a later stage in their disease course and with an elevated surgical risk. The expansion of transcatheter therapy for the treatment of valvular heart disease has added new opportunities for higher-risk patients. However, the impact of isolated valve therapies on patients with MVHD is still not well understood. This review focuses on the etiology, diagnostic challenges, and therapeutic considerations for some of the most common concomitant valvular abnormalities that occur in our daily clinic population.

Using novel machine learning tools to predict optimal discharge following transcatheter aortic valve replacement.

BACKGROUND: Although transcatheter aortic valve replacement has emerged as an alternative to surgical aortic valve replacement, it requires extensive healthcare resources, and optimal length of hospital stay has become increasingly important. This study was conducted to assess the potential of novel machine learning models (artificial neural network and eXtreme Gradient Boost) in predicting optimal hospital discharge following transcatheter aortic valve replacement. AIM: To determine whether artificial neural network and eXtreme Gradient Boost models can be used to accurately predict optimal discharge following transcatheter aortic valve replacement. METHODS: Data were collected from the 2016-2018 National Inpatient Sample database using International Classification of Diseases, Tenth Revision codes. Patients were divided into two cohorts based on length of hospital stay: optimal discharge (length of hospital stay 0-3 days); and late discharge (length of hospital stay 4-9 days). χ2 and t tests were performed to compare patient characteristics with optimal discharge and prolonged discharge. Logistic regression, artificial neural network and eXtreme Gradient Boost models were used to predict optimal discharge. Model performance was determined using area under the curve and F1 score. An area under the curve≥0.80 and an F1 score≥0.70 were considered strong predictive accuracy. RESULTS: Twenty-five thousand and eight hundred and seventy-four patients who underwent transcatheter aortic valve replacement were analysed. Predictability of optimal discharge was similar amongst the models (area under the curve 0.80 in all models). In all models, patient disposition and elective procedure were the most important predictive factors. Coagulation disorder was the strongest co-morbidity predictor of whether a patient had an optimal discharge. CONCLUSIONS: Artificial neural network and eXtreme Gradient Boost models had satisfactory performances, demonstrating similar accuracy to binary logistic regression in predicting optimal discharge following transcatheter aortic valve replacement. Further validation and refinement of these models may lead to broader clinical adoption.