Using Coronary Guide Catheters with the Sheath-in-sheath Technique to Retrieve a Micra™ Leadless Pacemaker.

As the prevalence of leadless pacemaker systems increases, identifying various methodologies for retrieval of these devices in certain instances becomes even more paramount. We describe a case demonstrating the utility of a coronary guide catheter as part of an improvised sheath-in-sheath technique for the challenging retrieval of a Micra™ leadless pacing system (Medtronic, Minneapolis, MN, USA).

Single-Operator Left atrial appendage Occlusion utilizing Conscious sedation TEE, Lack of Outpatient pre-imaging, and Same-day Expedited discharge (SOLO-CLOSE): A comparison with conventional approach.

BACKGROUND: Left atrial appendage occlusion (LAAO) with WATCHMAN currently requires preprocedural imaging, general anesthesia, and inpatient overnight admission. We sought to facilitate simplification of LAAO. AIMS: We describe and compare SOLO-CLOSE (single-operator LAA occlusion utilizing conscious sedation TEE, lack of outpatient pre-imaging, and same-day expedited discharge) with the conventional approach (CA). METHODS: A single-center retrospective analysis of 163 patients undergoing LAAO between January 2017 and April 2022 was conducted. The SOLO-CLOSE protocol was enacted on December 1, 2020. Before this date, we utilized the CA. The primary efficacy endpoint was defined as successful LAAO with ≤5 mm peri-device leak at time of closure. The primary safety endpoint was the composite incidence of all-cause deaths, any cerebrovascular accident (CVA), device embolization, pericardial effusion, or major postprocedure bleeding within 7 days of the index procedure. Procedure times, 7-day readmission rates, and cost analytics were collected as well. RESULTS: Baseline characteristics were similar in both cohorts. Congestive heart failure (37.5% vs. 11.1%) and malignancy (28.8% vs. 12.5%) were higher in SOLO-CLOSE. Median CHA2D2SVASc score was 5 in both cohorts. The primary efficacy endpoint was met 100% in both cohorts. Primary safety endpoint was similar between cohorts (p = 0.078). Mean procedure time was 30 min shorter in SOLO-CLOSE (p < 0.01). Seven-day readmissions for SOLO-CLOSE was zero. After SOLO-CLOSE implementation, there was a 188% increase in positive contribution margin per case. CONCLUSIONS: The SOLO-CLOSE methodology offers similar efficacy and safety when compared to the CA, while improving clinical efficiency, reducing procedural times, and increasing economic benefit.

Complications in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy: distribution and relevance. Results from an international, multicentre cohort study.

AIMS: Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) restores circulation and tissue oxygenation in cardiogenic shock (CS) patients, but can also lead to complications. This study aimed to quantify VA-ECMO complications and analyse their association with overall survival as well as favourable neurological outcome (cerebral performance categories 1 + 2). METHODS AND RESULTS: All-comer patients with CS treated with VA-ECMO were retrospectively enrolled from 16 centres in four countries (2005-2019). Neurological, bleeding, and ischaemic adverse events (AEs) were considered. From these, typical VA-ECMO complications were identified and analysed separately as device-related complications. n = 501. Overall, 118 were women (24%), median age was 56.0 years, median lactate was 8.1 mmol/L. Acute myocardial infarction caused CS in 289 patients (58%). Thirty-days mortality was 40% (198/501 patients). At least one device-related complication occurred in 252/486 (52%) patients, neurological AEs in 108/469 (23%), bleeding in 192/480 (40%), ischaemic AEs in 123/478 (26%). The 22% of patients with the most AEs accounted for 50% of all AEs. All types of AEs were associated with a worse prognosis. Aside from neurological ones, all AEs and device-related complications were more likely to occur in women; although prediction of AEs outside of neurological AEs was generally poor. CONCLUSION: Therapy and device-related complications occur in half of all patients treated with VA-ECMO and are associated with a worse prognosis. They accumulate in some patients, especially in women. Aside from neurological events, identification of patients at risk is difficult, highlighting the need to establish additional quantitative markers of complication risk to guide VA-ECMO treatment in CS.

A Novel Percutaneous Snare-Assisted Manipulation and Repositioning of a ProtekDuo Cannula in a COVID-19 Acute Respiratory Distress Syndrome.

Venovenous extracorporeal membrane oxygenation [VV-ECMO] has gained increasing notoriety during the COVID-19 pandemic as a salvation therapy for fulminant respiratory failure. Various configurations can present unique challenges in management. For instance, the ProtekDuo cannula is a 29Fr to 31Fr dual-lumen cannula inserted by way of the right internal jugular vein that allows for right atrium to pulmonary artery bypass with an attached oxygenator, essentially resulting in VV-ECMO. Understanding that these different configurations inevitably dictate the types of complications that can arise during the circuit implantation and management is imperative. However, in a hemodynamically unstable patient, time or resources may not permit standard maneuvers for management. In conclusion, we present an innovative, percutaneous approach which allowed the restoration of flow and oxygenation in a decompensating ProtekDuo patient without having to explant/disconnect the circuit or implant a new VV-ECMO circuit.

Case Report: It's not always about the veins; intervention of bilateral May-Thurner Syndrome secondary to iliac aneurysm.

May-Thurner Syndrome (MTS) remains evasive because of the insidiousness and variable etiologies by which it can manifest. In this study, we examine a unique presentation of MTS resulting from compression of both common iliac veins by a right common iliac artery aneurysm that required complex endovascular venous and arterial intervention.

Severe aortic insufficiency-induced cardiogenic shock treated with left atrial VA-ECMO and emergent valve-in-valve TAVR.

Conventional venoarterial extracorporeal membrane oxygenation (VA-ECMO) places a functional afterload burden on the left ventricle. In the setting of acute severe aortic insufficiency-induced cardiogenic shock, the utility of VA-ECMO in combination with a failing valve may result in catastrophic haemodynamic consequences. This challenge is compounded when the culprit is a failing surgical bioprosthetic valve. We present a case of severe rapid-onset bioprosthetic aortic insufficiency-induced cardiogenic shock successfully resuscitated with left atrial VA-ECMO promptly followed by emergent percutaneous valve-in-valve transaortic valve replacement. We discuss the logistics, implications, and associated haemodynamic manifestations in utilizing this strategy for such disease processes.

Percutaneous endovascular vacuum assisted removal of intracardiac lesions using the AngioVac system: A real-world experience.

The AngioVac© system (AngioDynamics, Latham, NY, USA) is a percutaneous catheter-based approach indicated for the removal of unwanted intravascular material from venous circulation and offers a safe alternative to conventional surgical extraction. This series describes various pathologies that were high risk for surgical management in which AngioVac© proved to be a suitable alternative. Learning objectives: Demonstrate the utility of minimally invasive techniques for removal of unwanted venous material using percutaneous endovascular vacuum assisted aspiration. Formulate a new treatment algorithm in the management of unwanted right-sided material.

Single-operator left atrial appendage occlusion utilizing conscious sedation, transoesophageal echocardiography, lack of outpatient pre-imaging, and same-day expedited discharge: a feasibility case series.

Background: Contemporary procedural guidelines for percutaneous left atrial appendage occlusions (LAAO) with the WATCHMAN device often require the utilization of pre-screening imaging, general anaesthesia, intubation, a dedicated intra-procedural echocardiographer, and overnight observation. For these reasons, LAAO with the WATCHMAN is not economically feasible for many hospital systems. Thus, we sought to evaluate a newstrategy for implantation that may provide a more minimalistic and less cumbersome approach to LAAO. Case summary: We describe five cases utilizing single-operator left atrial appendage occlusion utilizing conscious sedation, transoesophageal echocardiography, lack of outpatient pre-imaging, and same-day expedited discharge (SOLO-CLOSE)-a novel single-operator procedural strategy for LAAO that safely foregoes the aforementioned procedural requirements and allows for same-day early discharge. All five patients were observed according to our newly devised SOLO-CLOSE protocol and were safely discharged home the same day. Follow-up transoesophageal echocardiography (TEE) at 45 days and 1 year revealed well-seated and well-anchored devices with no leaks (<5 mm) or device-related thrombi. Discussion: The SOLO-CLOSE series is the first ever documented WATCHMAN strategy that utilizes a single-operator, TEE-guided, nurse-driven conscious sedation protocol that defers pre-screening imaging and allows for same-day discharge. The versatility of this technique allows proceduralists to comfortably achieve successful LAAO despite a wide range of risk profiles. This single-operator technique has potential to become a widely accepted universal approach for non-pharmacological cardioembolic stroke prophylaxis due to its efficacy, safety, simplicity, and presumable cost-effectiveness.

Acquired Cardiac Dextroposition: A Step in the Right Direction?

Despite tremendous advancements in electrocardiography machine algorithms, accurately diagnosing dextrocardia, pseudodextrocardia, and limb lead reversal remains a serious challenge. We present the case of a patient with acquired cardiac dextroposition, or "pseudodextrocardia," in which the electrocardiography machine algorithm incorrectly interpreted the finding as "dextrocardia vs limb lead reversal." (Level of Difficulty: Advanced.).

Endocarditis of the forgotten valve: vacuum-assisted aspiration (AngioVac) of the eustachian valve: a case report.

Background: Eustachian valve endocarditis (EVE) is a rare entity that traditionally has been treated with antibiotics or surgery, if refractory to antibiotic treatment. Case summary: A 64-year-old man presented with right shoulder pain and new-onset hypoxia. His blood cultures were positive for methicillin-sensitive staphylococcal aureus (MSSA) 1 month ago and he was treated with antibiotics at that time. Blood cultures during this admission were again positive for MSSA. Trans-oesophageal echocardiogram showed a large independently mobile echogenic density consistent with vegetation (3.0 × 1.6 cm) on the eustachian valve (EV). The patient was a poor surgical candidate due to his multiple co-morbidities, and therefore, a non-invasive procedure called AngioVac® was selected. Discussion: In the setting of infective endocarditis refractory to antibiotics, the large-bore percutaneous mechanical aspiration (AngioVac®, AngioDynamics, Latham, NY, USA) system is gaining increasing momentum as the treatment of choice over standard surgical intervention for debulking large vegetations. AngioVac® has provided a minimally invasive and effective measure especially in those unable to tolerate surgery. The novel percutaneous technique is linked to great success in right-sided endocarditis, with the tricuspid valve accounting for a majority of the cases. However, in rare instances, the EV may be involved. To our knowledge, we report the first case of EVE treated with AngioVac®.

Utilization of WATCHMAN FLX for surgically incomplete left atrial appendage occlusion: a multicentre case series.

Background: In patients with non-valvular atrial fibrillation, the vast majority of thrombi originate in the left atrial appendage (LAA). Thus, occluding the LAA significantly reduces one's risk for developing an ischaemic stroke. To date, many different surgical methodologies in LAA occlusion (LAAO)/exclusion have been studied and utilized. Unfortunately, patients are often left with incomplete closure of their LAA, leaving behind residual lobes that continue to allow thrombus formations. With the recent rise in percutaneous approaches and devices such as the WATCHMAN FLX, there have been proven success rates in achieving total closure of the LAA. Reports and investigations regarding the utilization of WATCHMAN FLX devices in patients with surgically incomplete LAAO remain limited. Case summary: We present three cases of patients who had previously undergone surgical exclusion of the LAA yet unfortunately were left with residual LAA that continued to place them at high risk for an ischaemic stroke. Percutaneous LAAO with the WATCHMAN FLX was utilized to successfully achieve complete sealing of the residual lobes in failed LAA surgical closures. Discussion: Our multicentre case series elucidates that an increased risk of stroke due to surgical LAAO failure is a real-world possibility that is likely to be encountered in clinical practice. We demonstrate in this series how the WATCHMAN FLX may provide a feasible and safe method to supplement a surgically incomplete LAAO to allow for improved ischaemic stroke and systemic embolization risk reduction.

Catheter-directed thrombolysis as an emergent intervention for failed vacuum thrombectomy of pulmonary embolism.

Acute pulmonary embolism [PE] in the setting of hemodynamic instability and right ventricular strain is a complex presentation and typically is associated with high mortality rates. Prompt recognition and early intervention are critical to the survival of these patient. In such cases, current guidelines recommend use of systemic thrombolytics, along with as needed cardiopulmonary support. If contraindications are present, mechanical thrombectomy is advised. However, guidelines poorly define the next steps in intervention if mechanical thrombectomy were to fail. We present such a scenario and the methods implored to successful remove clot burden. We add to the literature, use of catheter directed thrombolysis at a designated 2 mg/h rate as a form of emergent intervention in failed mechanical thrombectomy.

To intervene or not to intervene: A case of symptomatic neurocysticercosis complicated by ventriculitis.

Although well described in the current literature, Neurocysticercosis [NCC] remains an enigma when confronted by practitioners. This is in part due to the haphazard nature of the parasitic infection on the central nervous system [CNS]. These include single or multiple anatomic sites of infection, stage of parasitosis, and the resultant inflammatory response. As a result, NCC can present with a complex constellation of symptomatic presentations, making therapeutic regiments highly individualized. Despite intervention, other impediments may arise post-therapy due to the nature of the infection. We present a case of rapidly progressive symptomatic NCC that initially was successfully treated, however would eventually succumb to complications of ventriculitis.

Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy.

BACKGROUND: It is currently unclear if active left ventricular (LV) unloading should be used as a primary treatment strategy or as a bailout in patients with cardiogenic shock (CS) treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). OBJECTIVES: This study sought to evaluate the association between timing of active LV unloading and implantation of VA-ECMO with outcomes of patients with CS. METHODS: Data from 421 patients with CS treated with VA-ECMO and active LV unloading at 18 tertiary care centers in 4 countries were analyzed. Patients were stratified by timing of device implantation in early vs delayed active LV unloading (defined by implantation before up to 2 hours after VA-ECMO). Adjusted Cox and logistic regression models were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as successful weaning from ventilation. RESULTS: Overall, 310 (73.6%) patients with CS were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (HR: 0.64; 95% CI: 0.46-0.88) and a higher likelihood of successful weaning from ventilation (OR: 2.17; 95% CI: 1.19-3.93) but not with more complications. Importantly, the relative mortality risk increased and the likelihood of successful weaning from ventilation decreased almost proportionally with the time interval between VA-ECMO implantation and (delayed) initiation of active LV unloading. CONCLUSIONS: This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO, although the findings need to be validated in a randomized controlled trial.

Amniotic fluid embolism-induced cardiopulmonary collapse successfully treated with combination VA-ECMO and Impella CP.

Amniotic fluid embolism (AFE) is a rare but potentially fatal complication of pregnancy. Prompt and aggressive resuscitative strategies are crucial in promoting survivability. We present a case of AFE resulting in cardiopulmonary collapse and subsequent cardiac arrest where we were able to safely deliver the baby and resuscitate the mother with veno-arterial extracorporeal membrane oxygenation and Impella CP-a novel combination known as ECPELLA. We discuss the implications of this approach as a more efficacious strategy in resuscitating AFE-induced cardiogenic shock and arrest.

Utilizing Provocative Maneuvers Intraoperatively in Conjunction With IVUS to Diagnose vTOS: The New Gold Standard.

Current methodologies of diagnosing and managing venous thoracic outlet syndrome (vTOS) remain controversial, as pertinent studies using modern advancements in medicine are limited. We present a case in which we innovatively used a modified Wright's test during venography coupled with intravascular ultrasound, which allowed us to definitively determine the etiology of a vTOS. (Level of Difficulty: Intermediate.).

Percutaneous repositioning of Impella RP: the Snare-Manoeuvre-Prolapse technique-a case report.

Background: Impella RP (Abiomed, Danvers, MA, USA) is indicated for right ventricular failure after left ventricular assist device insertion or biventricular shock. Once the peel-away sheath is removed, Impella RP repositioning can only be achieved with manual manipulation of the catheter itself. This method does not always accomplish appropriate positioning of the catheter and can result in continued haemodynamic instability. Case summary: A young male presented to our institution with recurrent ventricular fibrillation and ST-elevation myocardial infarction that underwent emergent coronary intervention but was in progressive cardiogenic shock requiring implantation of Impella 5.0 and Impella RP. After insertion of the right ventricular support, the patient stabilized transiently then became unstable once more, and repeat fluoroscopy demonstrated that the Impella RP had 'fallen back' into the right ventricle. Due to continued instability, we improvised a previously undescribed method of repositioning of the Impella RP catheter with the use of a goose-neck snare. Discussion: The snare-manoeuvre-prolapse method of Impella RP repositioning is a relatively novel approach at the management of Impella RP retrograde migration into the right ventricle and prevents the need for large-bore venous closure and re-access and the use of a new Impella RP catheter while providing rapid improvement of haemodynamics.