Transcatheter aortic valve implantation using coplanar and cuspal overlap techniques in Indian patients.

INTRODUCTION: Transcatheter Aortic Valve Implantation (TAVI) techniques gradually evolved since 2002 and have undergone various refinements. Achieving optimal implantation depth has become crucial for good long term outcome. High implantation decreases the likelihood of conduction disturbances. Conventionally TAVI valve is positioned in a tricusp coplanar (CON) fluoroscopic projection however it does not ensure a optimal implantation. In an attempt to attain higher implantation(3 mm) and decrease rate of permanent pacemaker, cuspal overlap technique (COT) view has been developed. There is scarcity of Indian literature comparing TAVI deployment using coplanar and cuspal overlap techniques. METHODS: We included 111 patients who underwent TAVR with a self-expanding Core Valve Evolut R (Medtronic, Minneapolis, Minnesota), between January 2017 to September 2022 at our centre.Transcatheter Heart Valves (THV) were implanted using the traditional coplanar in 55 patients, while in 56 patients valves were implanted using the COT. RESULTS: Baseline characteristics including electrocardiographic findings were comparable in both groups. In all patients Evolut R or Evolut PRO valves were used. Procedure was done in conscious sedation in 90.9 % of patients in CON and 96.4 % in COT group. Predilatation and postdilatation was used in 38.8 % vs 33.9 % and 27 % vs 32 % in CON and COT groups respectively. 90 day PPI rate was less in COT group (7.3 % CON vs 3.5 % COP). Majority of patients who received permanent pacemaker implantation (PPI) had baseline ECG abnormality (RBBB in 50 %, LBBB in 16 %, Grade 1 AV block 16 %). Mean time of post procedure PPI was 5.6 days in COT group and 7.3 days in CON group. New onset LBBB was also less in COT group (21 % CON vs 12.5 % COT).There were 3.6 % intraprocedural deaths in CON group and 1.8 % in COT group. Depth of deployed valve was 4.8 ± 2.34 mm in COT and 6.6 ± 2.11 mm in CON group. Valve deployment time was more in COT group(10.40 CON vs 14.34 min COT). Average valve recapture rate was 2.58 in COP and 2.11 in CON. Stroke rate was more in COT group(3.6 % CON vs 7.14 % COT). Pericardial effusions were also more in COT group. All cause mortality at 3 months was 10.9 % in CON group and 5.3 % in COT. CONCLUSION: In this study we achieved lower rates of PPI and new onset LBBB using COT technique in Indian patients using self-expandable prostheses. However valve deployment time, stroke rate and pericardial effusion were seen more in COT group. All cause mortality was low in cuspal overlap technique.

Anesthesia challenges and role of transesophageal echocardiography during MitraClip implantation in a patient with end stage heart failure.

Patients with dilated cardiomyopathy who have developed mitral valve regurgitation (MR) with reduced left ventricular ejection fraction and are too sick to undergo any surgical repair or replacement are being treated worldwide through catheter-based percutaneous intervention techniques to treat MR like MitraClip system®. There are very few case reports especially from India on anesthetic management during MitraClip device implantation and its specific considerations. We present a case of a 48-year-old male patient, diagnosed as post-myocarditis dilated cardiomyopathy with poor left ventricular ejection fraction (30-35%) and severe MR who underwent mitral clip implantation with fluoroscopy and transesophageal echocardiography guidance under general anesthesia. We hope that our experience will help and guide future such undertakings in our country.

Transcatheter aortic valve replacement in the developing world: Lessons learnt and its implications for practice.

Backrground: Transcatheter aortic valve replacement (TAVR) has become an accepted modality of treatment in intermediate and high surgical risk patients of symptomatic severe calcific aortic stenosis (AS). We herein report Indian data of 84 intermediate and high-risk patients who underwent TAVR at two Armed Forces cardiac centres. Methods: Most of the patients underwent TAVR in cardiac catheterization lab by percutaneous transfemoral approach, under conscious sedation. Patients were followed up and echocardiographic parameters were assessed after six months of procedure. Results: Total of 84 intermediate and high-risk patients underwent TAVR between Jan 2017 and June 2021. Mean age of population was 71.5 ± 8.4 years; 28.5% of patients had bicuspid aortic valve and Mean STS score was 6.34 ± 2.08. Majority (92.8%) patients underwent the procedure under conscious sedation. Self-expanding valves were used in 72.6% and balloon expandable in 27.4% of patients. Predilatation was done in 64% patients while 13% cases underwent post dilatation. Procedural mortality was 2.3%. Rate of permanent pacemaker implantation was 4.9%. Ischemic stroke occurred in 1.1% of patents. There was no case of severe paravalvular leak. Emergency surgical aortic valve replacement was done in 2.4% patients. Procedural success in this study was 97.6%. All-cause mortality was 9.5% at 6 months. Conclusions: TAVR is an effective treatment modality in intermediate and high-risk Indian patients with severe aortic stenosis. Patients with bicuspid or previous bio prosthetic aortic valves also have a good outcome post TAVR.

Drug-eluting balloon: Initial experience in patients with in-stent restenosis (ISR).

BACKGROUND: In-stent restenosis is the most important limitation of modern coronary angioplasty. Drug-eluting stents solve this problem but at the cost of late stent thrombosis and longer duration of dual-antiplatelet therapy. Drug-eluting balloon (DEB) technology is now available and offers an attractive option for treatment of restenosis. METHODS: A cohort of 20 patients with in-stent restenosis after stenting were treated with a drug-eluting balloon and were followed up clinically and angiographically for 6 months. RESULTS AND CONCLUSION: Procedural success was achieved in all patients. 6 month clinical follow-up was available for all and 6 month angiographic follow up for 17 patients. On 6 month follow-up, 5 of the 20 patients had recurrence of angina and 4 patients had angiographic restenosis (2 focal, 2 diffuse). The mean Canadian Cardiovascular Society angina score improved significantly from 3.1 to 1.1. DEB offers a novel method of treatment for patients with in-stent restenosis with a good safety and efficacy profile.

Percutaneous Closure of Perimembranous Ventricular Septal Defect with Amplatzer Device.

BACKGROUND: The Amplatzer perimembranous ventricular septal occluder is an innovative device for percutaneous closure of perimembranous ventricular septal defects (PMVSD). In appropriately selected cases this procedure is safe and effective. METHODS: Fourteen patients with the mean age 10.53 years (range 18 months to 55 years) and mean body weight 20.64 kg (range 6 to 52 kg) underwent PMVSD closure. RESULT: The PMVSD mean diameter was 5.28 mm (range from 4 to 9 mm). Implantation was successful in 92% of the cases and all patients had complete occlusion of the shunt within three months. CONCLUSION: Device orientation was excellent in all cases. Device-related aortic insufficiency, tricuspid insufficiency or left ventricular dysfunction was not observed. One patient had embolisation of the device and another had complete heart block which required a permanent pacemaker implantation. The excellent short term results need to be confirmed over long-term follow-up.