Ruptured chordae during percutaneous mitral commissurotomy: immediate recognition by intracardiac echocardiography.

Traditionally, percutaneous mitral commissurotomy (PMC) is performed under fluoroscopy only. In difficult cases, general anesthesia with transesophageal echocardiography (TEE) guidance is needed. Intracardiac echocardiography (ICE) enables operators to perform PMC under local anesthesia while providing intra-procedural imaging guidance, as in TEE. Hereby, we describe a case of PMC guided by ICE to allow early detection of complications.

VA-ECMO With Pericardiocentesis and Autologous Blood Transfusion - Stabilisation Strategy in Acute Cardiac Free Wall Rupture.

A 68-year old lady present with left ventricular free wall rupture and cardiac arrest post-myocardial infarction. This article illustrates a strategy combining pericardiocentesis with autologous transfusion together with VA-ECMO as a bridge to definitive surgical repair.

Comparing the outcomes of bedside percutaneous VA-ECMO decannulation by ProGlide and Manta in a high-ECMO-volume center in Hong Kong.

BACKGROUND: The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation with different percutaneous closure devices has been increasing. At our center, ProGlide devices have been used since November 2018, and Manta devices became an alternative since March 2020. This study aimed to compare the success and complication rates and the clinical outcomes of ProGlide and Manta devices for VA-ECMO decannulation after arteriotomy wound closure. METHODS: We retrospectively reviewed the results of bedside VA-ECMO decannulation between November 2018 and June 2021. Patients with VA-ECMO who could be bridged to recovery were recruited and divided into the ProGlide or Manta group based on the closure device used. Procedure time, amount of blood loss, amount of blood products transfused, and use of vasoactive medications during the procedure were documented. Clinical examination and Doppler ultrasound were performed to detect any complications. RESULTS: After the closure technique, ProGlide was used in 44 patients and Manta was used in 13. There was no significant difference in the success rate between the ProGlide and Manta groups (86.4% vs. 100%). Amount of blood loss was greater in the ProGlide group than in the Manta group (290 [100-400] ml vs. 50 [50-100] ml), and more patients in the ProGlide group required an increased dose of inotropes during the procedure (59.1% vs. 15.4%), but the transfusion requirement was similar between the two groups. CONCLUSIONS: The success rate of hemostasis using arteriotomy wound closure during VA-ECMO decannulation was similar between the two devices.

Orbital-Tripsy: Novel Combination of Orbital-Atherectomy and Intravascular-Lithotripsy, in Calcified Coronaries After Failed Intravascular-Lithotripsy.

Calcified coronary lesions are notorious for posing technical difficulty during angioplasty. Fortunately, more devices are available to tackle coronary calcifications. However, there remain difficult cases whereby a single modality is insufficient. Here we report the feasibility and success of a case, using Novo combination of Shockwave Lithotripsy after Orbital Atherectomy. (Level of Difficulty: Intermediate.).

De-escalation from ticagrelor to clopidogrel in acute coronary syndrome patients: a systematic review and meta-analysis.

De-escalation from ticagrelor to clopidogrel in acute coronary syndrome (ACS) may occur for a variety of reasons, including side effects (bleeding and non-bleeding) and costs. This study sought to assess the prevalence of de-escalation from ticagrelor to clopidogrel and the occurrence of adverse clinical outcomes following de-escalation. We conducted a systematic review of clinical trials and real-world studies in ACS patients treated with ticagrelor. Real-world data on the prevalence of de-escalation during hospitalization or at discharge, after hospital discharge, and during the whole study period were included for meta-analysis. Major adverse cardiovascular events (MACE) and bleeding events occurring after de-escalation were also assessed. A total of 12 studies were eligible for meta-analysis of the prevalence of de-escalation. De-escalation from ticagrelor to clopidogrel therapy occurred with a mean prevalence of 19.8% [95% confidence interval (CI) 11.2-28.4%]. De-escalation occurred more frequently in-hospital or at discharge than after hospital discharge (23.7% vs. 15.8%). For assessment of clinical outcomes, a total of six studies were eligible for meta-analysis. Mean rate of MACE for patients with de-escalation was 2.1% (95% CI 1.1-4.1%) and the rate of major bleeding events was 1.3% (95% CI 0.4-4.5%). In conclusion, de-escalation commonly occurs in real-world practice. Although rates of major cardiovascular and bleeding events in this analysis were generally low, the profile of patients suitable for de-escalation, the impact of de-escalation on adverse clinical outcomes and how this is affected by the timing after index ACS warrants further large-scale investigation.

A Case of Rota-Shock-Pella.

Severe calcified coronary lesions are frequently encountered in today's percutaneous coronary intervention practice and remain a challenging entity in complex and high-risk patients. The present case illustrates the contemporary approach to management of this coronary problem from hemodynamic support, optical coherence tomography assessment, and plaque modification technique. (Level of Difficulty: Advanced.).

Concurrent transcatheter transfemoral tricuspid valve-in-valve and aortic valve implantation using a 3D printed model for pre-OT planning.

Re-operation of a tricuspid bioprosthesis carries high morbidity and mortality, especially when carried out with other concomitant valvular heart surgery. Concurrent transcatheter valve implantation has evolved as an alternative option. Here we report on a 77-year-old lady who suffered from symptomatic severe recurrent stenosis of a tricuspid bioprosthesis (Sorin Pericarbon More, 27) and moderate to severe aortic stenosis (AS) who was declined for redo open heart surgery as it was deemed very high risk. We used a 3D customised printed right heart model for pre-OT rehearsal. Percutaneous V-in-V TVR using a 26 mm Edwards SAPIEN 3 was performed under general anaesthesia via the right femoral vein and showed a satisfactory result in one single attempt. We also evaluated the necessity of aortic valve intervention in detail before and after V-in-V TVR. After confirmation of severe AS, a 26 mm Medtronic CoreValve Evolut R was deployed in the non-calcified rheumatic aortic valve without any predilatation or post-dilatation via the right femoral artery. No significant gradient or leakage was seen. This case shows the feasibility and safety of concurrent transfemoral V-in-V TVR and TAVI. Rehearsal using a 3D printed model helped to increase the accuracy and success rate of the procedure. The transcatheter approach allows detailed haemodynamic assessment after each valvular intervention in the case of multiple valve interventions.

Retrieval of an embolized amplatzer septal occluder.

Percutaneous closure of secundum atrial septal defect (ASD) by various devices has been proven to be an effective and safe treatment modality for patients with congenital heart diseases. However, we have to be aware of the potential early and late complications like device embolization and formulate plan for rescue procedures. We have reported a case of successful closure of a large secundum ASD in a 23-year-old woman by a 40 mm Amplatzer septal occluder (ASO), which embolized into the right ventricle 4 hr after the procedure. This had caused palpitation and nonsustained ventricular tachycardia. Patient safety was our most important concern and after discussion with the cardiac surgeons and the patient, we would like to make a percutaneous stepwise attempt for retrieval. We first applied an endocardial biopsy forcep to grap the disk of the ASO to fix and stabilize the dislodged device. This would prevent the device from obstructing the inflow and outflow tract and causing catastrophic consequences. Then, a 15-mm Amplatz gooseneck snare was used to catch exactly at the connecting hub of the ASO disk, and the whole apparatus could then be cautiously and safely retrieved out from her body without complications. This had saved her from an unplanned emergency open heart operation that carried significant bleeding complication.

Cutaneous and pulmonary sarcoidosis in a Hong Kong Chinese woman with silicone breast prostheses.

Sarcoidosis is rarely reported in Hong Kong. We report cutaneous and pulmonary sarcoidosis in a 54-year-old Chinese woman, who presented with papular lesions over the face and neck. She had silicone breast augmentation surgery 4 years earlier. Skin biopsy revealed granulomatous inflammation and anti-tuberculosis treatment was started empirically but stopped 2 months later owing to a poor response. A right supraclavicular lymph node was aspirated and revealed granulomatous inflammation. The CXR was normal initially but subsequently showed diffuse reticulonodular opacities and a small right-sided pleural effusion. High-resolution CT of the thorax showed mediastinal lymphadenopathy and diffuse perilymphatic nodular opacities consistent with sarcoidosis. Sputum mycobacterial culture was negative. Fibreoptic bronchoscopy showed no endobronchial lesion but the transbronchial biopsy showed granulomatous inflammation with no evidence of infection, malignancy or foreign body. Pulmonary function tests were normal except for impairment of transfer factor. One year later, most of the cutaneous lesions had healed spontaneously. The CXR showed partial improvement of the right pleural opacification but little change in the lung field. The features of sarcoidosis and its association with silicone are reviewed.