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.

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.

Clinical Trial Principles and Endpoint Definitions for Paravalvular Leaks in Surgical Prosthesis.

The VARC (Valve Academic Research Consortium) for transcatheter aortic valve replacement set the standard for selecting appropriate clinical endpoints reflecting safety and effectiveness of transcatheter devices, and defining single and composite clinical endpoints for clinical trials. No such standardization exists for circumferentially sutured surgical valve paravalvular leak (PVL) closure. This document seeks to provide core principles, appropriate clinical endpoints, and endpoint definitions to be used in clinical trials of PVL closure devices. The PVL Academic Research Consortium met to review evidence and make recommendations for assessment of disease severity, data collection, and updated endpoint definitions. A 5-class grading scheme to evaluate PVL was developed in concordance with VARC recommendations. Unresolved issues in the field are outlined. The current PVL Academic Research Consortium provides recommendations for assessment of disease severity, data collection, and endpoint definitions. Future research in the field is warranted.

Congenital Abnormalities of the Pericardium.

Congenital abnormalities of the pericardium are a rare group of disorders that include congenital absence of the pericardium, pericardial cysts, and diverticula. These congenital defects result from alterations in the embryologic formation and structure of the pericardium. Although many cases are incidentally found, they can present as symptomatic, life-threatening disease. Owing to their rarity, many cases are inappropriately diagnosed. Alterations in the embryologic formation and structure may result in the formation of these congenital abnormalities. We review the presentation, diagnosis, and management of congenital absence of the pericardium, pericardial cysts, and diverticula. A summary of multimodality imaging features is provided.

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.

Clinical Trial Principles and Endpoint Definitions for Paravalvular Leaks in Surgical Prosthesis: An Expert Statement.

The VARC (Valve Academic Research Consortium) for transcatheter aortic valve replacement set the standard for selecting appropriate clinical endpoints reflecting safety and effectiveness of transcatheter devices, and defining single and composite clinical endpoints for clinical trials. No such standardization exists for circumferentially sutured surgical valve paravalvular leak (PVL) closure. This document seeks to provide core principles, appropriate clinical endpoints, and endpoint definitions to be used in clinical trials of PVL closure devices. The PVL Academic Research Consortium met to review evidence and make recommendations for assessment of disease severity, data collection, and updated endpoint definitions. A 5-class grading scheme to evaluate PVL was developed in concordance with VARC recommendations. Unresolved issues in the field are outlined. The current PVL Academic Research Consortium provides recommendations for assessment of disease severity, data collection, and endpoint definitions. Future research in the field is warranted.

Acute Pericarditis.

Acute pericarditis is an acute inflammatory disease of the pericardium, which may occur in many different disease states (both infectious and non-infectious). Usually the diagnosis is based on symptoms (chest pain, shortness of breath), electrocardiographic changes (ST elevation), physical examination (pericardial friction rub) and elevation of cardiac biomarkers. It may occur in isolation or be associated with an underlying inflammatory disorder. In routine clinical practice, acute pericarditis can be associated with myocarditis due to their overlapping etiologies.

Right Atrial Vacuum-Assisted Thrombectomy: Single-Center Experience.

BACKGROUND: Right heart thrombus in the absence of structural heart disease, atrial fibrillation, or intracardiac catheter is rare. It typically represents a thrombus migrating from the venous system to the lung, known as thrombi-in-transit, and can lead to a life-threatening pulmonary embolism. The optimal therapy for thrombi-in-transit remains controversial. We report our experience using percutaneous removal of right heart thrombus using vacuum aspiration. METHODS: Patients with right atrial mass who were hemodynamically stable and underwent vacuum thombectomy using the AngioVac system (AngioDynamics) at our institution were included in this analysis. Between December 2012 and August 2014, a total of 7 patients (2 men, 5 women) with a mean age of 51.5 years (range, 20-83 years) underwent right atrial thrombectomy. Data during the procedure and follow-up period were collected and analyzed. RESULTS: All patients were hemodynamically stable before the procedure. The procedure was considered successful in 6 patients. All patients survived through hospitalization. No periprocedural bleeding, stroke, or myocardial infarction occurred. One patient developed cardiogenic shock after the procedure that required extracorporeal membrane oxygenation support for <24 hours. There was no recurrent venous thromboembolism at a mean follow-up of 9 months. CONCLUSION: Vacuum-assisted thrombectomy can be a potential treatment option for hemodynamically stable patients with large right-sided intracardiac thrombus who are not surgical candidates.

Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism.

Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.

Transcatheter Therapies for the Treatment of Valvular and Paravalvular Regurgitation in Acquired and Congenital Valvular Heart Disease.

Transcatheter therapies in structural heart disease have evolved tremendously over the past 15 years. Since the introduction of the first balloon-expandable valves for stenotic lesions with implantation in the pulmonic position in 2000, treatment for valvular heart disease in the outflow position has become more refined, with newer-generation devices, alternative techniques, and novel access approaches. Recent efforts into the inflow position and regurgitant lesions, with transcatheter repair and replacement technologies, have expanded our potential to treat a broader, more heterogeneous patient population. The evolution of multimodality imaging has paralleled these developments. Three- and 4-dimensional visualization and concomitant use of novel technologies, such as fusion imaging, have supported technical growth, from pre-procedural planning and intraprocedural guidance, to assessment of acute results and follow-up. A multimodality approach has allowed operators to overcome many limitations of each modality and facilitated integration of a multidisciplinary team for treatment of this complex patient population.

Congenital defects of the pericardium: a review.

Pericardial defects are a rare disorder that can be characterized as acquired or congenital. Congenital defects can be further characterized by location and size of the defect, e.g. left- or right-sided and partial or complete absence of the pericardium. While physical examination and electrocardiogram are not diagnostic, chest radiographs and echocardiography have findings that should alert the clinician to the absence of the pericardium as a possible diagnosis. Despite its limitations with visualizing the normal pericardium in areas of minimal adipose, cardiac magnetic resonance is currently the gold standard for diagnosing the congenital absence of the pericardium. Patients have a similar life expectancy to those without pericardial defects; however in certain cases, herniation and strangulation of cardiac chambers can be life threatening and lead to sudden cardiac death. Treatment is tailored to the patient's symptoms, presentation, and the size and location of the defect.

Footprints of cardiac mechanical activity as expressed in lung Doppler signals.

AIMS: To determine the diagnostic information contained in cardiac pulsatile pressure waves as expressed in the Doppler signals recorded over the right lung. METHODS AND RESULTS: The pulsatile characteristics of the pulmonary vascular system were studied by means of the novel pulse Doppler technology in 38 control volunteers, 31 patients with atrial fibrillation (AF) and 7 patients with atrial flutter. The Doppler velocity waveforms recorded were interpreted in relation to the cardiac cycle mechanical events that generate them: Ventricular systole (S), diastole (D) and presystolic left atrial contraction (A). It was demonstrated that in all cases of AF, wave-A was absent. With longer diastole a high frequency velocity waves were visible. It is assumed that they represent the atrial mechanical fibrillation. In the patients with atrial flutter, the single A-wave was replaced by a waveform termed F, the frequency of which exactly matched that of the flutter wave on the ECG. The F-wave had both a positive and negative component. CONCLUSION: The lung Doppler signals contain distinct signatures typical of arrhythmias such as AF and atrial flutter that can be used for both diagnosis and to gain insight into the nature of the phenomena.