Preemptive alcohol septal ablation prior to transcatheter mitral valve replacement.

BACKGROUND: Alcohol septal ablation (ASA) has been shown to increase the neo-left ventricular outflow tract (LVOT) area before transcatheter mitral valve replacement (TMVR) but there is little literature on its success and use with dedicated devices. AIMS: To describe our experience with preemptive ASA to increase the predicted neo-LVOT area and its utility with both dedicated TMVR devices and balloon-expandable valves. METHODS: All patients who underwent ASA for TMVR candidacy in our center between May 2018 and October 2022 and had computed tomography (CT) scans done before and after ASA were included. Each CT was assessed for the minimum predicted neo-LVOT area at end-systole, using a virtual valve of the desired TMVR device for each patient. The primary outcome was an increase in the predicted neo-LVOT area after ASA that was deemed sufficient for safe implantation of the desired TMVR device. The secondary outcome was the absence of acute LVOT obstruction after TMVR. RESULTS: A total of 12 patients underwent ASA and all but 1 (n = 11, 91.6%) achieved the primary outcome of having sufficient predicted neo-LVOT area to proceed with TMVR. The mean increase in neo-LVOT area after ASA was 126 ± 64 mm2 (median 119.5, interquartile range: 65.0-163.5 mm2 ). Two patients (16.7%) required a permanent pacemaker after ASA. Nine patients went on and underwent TMVR with their respective devices and none had LVOT obstruction after the procedure. Among the remaining three patients, one had insufficient neo-LVOT clearance after ASA, one had unrelated mortality before TMVR, and one had advanced heart failure before TMVR. CONCLUSION: In appropriately selected patients and at centers experienced with ASA, preemptive ASA can achieve sufficient neo-LVOT clearance for TMVR with a variety of devices in approximately 90% of patients.

Utilization of TandemHeart in cardiogenic shock: Insights from the THEME registry.

BACKGROUND: TandemHeart has been demonstrated to improve hemodynamic and metabolic complications in cardiogenic shock (CS). Contemporary outcomes have not been reported. OBJECTIVES: To evaluate the outcomes of the TandemHeart (LivaNova) in contemporary real-world use. METHODS: We analyzed baseline characteristics, hemodynamic changes, and outcomes of all patients treated with TandemHeart who were enrolled in the THEME registry, a multicenter, prospective, observational study. RESULTS: Between May 2015 and June 2019, 50 patients underwent implantation of the TandemHeart device. 22% of patients had TandemHeart implanted within 12 h, 32% within 24 h, and 52% within 48 h of CS diagnosis. Cardiac index (CI) was significantly improved 24 h after implantation (median change 1.0, interquartile range (IQR) (0.5-1.4 L/min/m2 ). In survivors, there was a significant improvement in CI (1.0, IQR (0.5-2.25 L/min/m2 ) and lactate clearance -2.3 (-5.0 to -0.7 mmol/L). The 30-day and 180-day survival were 74% (95% confidence interval: 60%-85%) and 66% (95% confidence interval: 51%-79%), respectively. Survival was similarly high in those in whom TandemHeart has been used as a bridge to surgery (85% 180-day survival). CONCLUSION: In a contemporary cohort of patients presenting in CS, the use of TandemHeart is associated with a 74% 30-day survival and a 66% 180-day survival.

Intentional removal of erroneously deployed coronary stents: A case series and review of the literature.

Most reports of stent retrieval involve undeployed, embolized stents. While the retrieval of fully deployed stents has been sporadically reported, most of these were not intentional. The feasibility and safety of intentional retrieval of fully deployed, but erroneously placed stents have not been well described. We report four cases of successful, intentional stent retrieval for stents placed erroneously in an aorto-ostial position. The stents were retrieved at varying times after deployment, ranging from immediately to up to 5 years. In all cases, stents were retrieved successfully with no complication. We conclude that the intentional retrieval of fully deployed, but erroneously placed stents is feasible and safe when stenting involved an aorto-ostial location.

Characteristics and outcomes of surgically ineligible patients with multivessel disease treated with percutaneous coronary intervention.

OBJECTIVES: In this study we evaluated the clinical characteristics and outcomes of surgically ineligible patients with coronary artery disease (CAD) who underwent multivessel percutaneous coronary intervention (PCI). BACKGROUND: Patients with multivessel CAD who are surgically ineligible and undergo PCI are not well represented in large trials. METHODS: Out of 1,061 consecutive patients who underwent a non-emergent PCI for unprotected left main or multivessel CAD at the University of Virginia Medical Center, 137 patients were determined to be surgically ineligible for coronary artery bypass graft (CABG) surgery by a heart team. The clinical characteristics and reasons for surgical ineligibility were collected. The coronary angiograms were reviewed and the SYNTAX score calculated. The Society of Thoracic Surgeons (STS) score was calculated. Outcomes were determined at 30 days and 1-year. RESULTS: The mean age of the cohort was 71 and 59% were women. Hypertension, hyperlipidemia, tobacco abuse, and diabetes were common comorbidities. The average SYNTAX score was 22. The most commonly cited reasons for surgical ineligibility were advanced age, frailty, severe lung disease, ejection fraction ≤ 30% and STS score ≥ 8%. Outcomes at 30 days were excellent and better than those predicted by STS for surgery. Frailty and STS score predicted one-year outcomes. CONCLUSIONS: Patients undergoing PCI for multivessel disease who are surgically ineligible have multiple risk factors and comorbidities. Frailty, lung disease, poor left ventricular function, and high STS score represent common reasons for surgical ineligibility. Frailty and the STS score better predict one-year outcomes after PCI compared to the SYNTAX score.

Coronary Computed Tomography Angiography Demonstrates a High Burden of Coronary Artery Disease Despite Low-Risk Nuclear Studies in Pre-Liver Transplant Evaluation.

We investigated the presence and severity of coronary artery disease (CAD) in orthotopic liver transplantation (OLT) candidates using coronary artery calcium score (CACS) and coronary computed tomography angiography (CCTA) as compared with the prevalence of normal and abnormal single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). A total of 140 prospective OLT candidates without known CAD underwent coronary artery calcium (CAC) scans with (n = 77) or without CCTA and coronary computed tomography angiography-derived fractional flow reserve (FFRCT ; n = 57) using a dual-source computed tomography (CT) and were followed for 2.6 ± 1.4 years. Coronary plaque was quantified using the segment-involvement score (SIS) and segment stenosis score (SSS). The mean age was 59 ± 6 years, and 65.0% of patients were male. Mean Agatston CACS was 367 ± 653, and 15.0% of patients had CACSs of 0; 83.6% received a SPECT MPI, of which 95.7% were interpreted as normal/probably normal. By CCTA, 9.1% had obstructive CAD (≥70% stenosis), 67.5% had nonobstructive CAD, and 23.4% had no CAD. Nonobstructive CAD was diffuse with mean SIS 3.0 ± 2.9 and SSS 4.5 ± 5.4. Only 14 patients had high risk-findings (severe 3v CAD, n = 4, CACS >1000 n = 10) that prompted X-ray angiography in 3 patients who had undergone CCTA, resulting in revascularization of a high-risk obstruction in 1 patient who had a normal SPECT study. Patients with end-stage liver disease have a high prevalence of nonobstructive CAD by CCTA, which is undiagnosed by SPECT MPI, potentially underestimating cardiovascular risk. Deferring X-ray angiography unless high-risk CCTA findings are present is a potential strategy for avoiding unnecessary X-ray angiography.

Typical angina in a patient with Takayasu arteritis.

Takayasu arteritis (TA) is a well-reported form of large-vessel vasculitis that primarily affects the aorta and its major branches. Cardiac manifestations of TA have been reported and can include typical angina secondary to coronary artery involvement; however, typical angina in the setting normal coronary arteries is uncommon. We describe a case of typical angina in a patient with TA with normal coronary arteries secondary to diastolic hypotension, in the absence of significant aortic regurgitation, likely from poor aortic distensibility and elevated left ventricular end-diastolic pressure.

Outcomes of left main revascularization in patients with acute coronary syndromes and stable ischemic heart disease: Analysis from the EXCEL trial.

BACKGROUND: Prompt revascularization is often required in acute coronary syndromes (ACS), whereas stable ischemic heart disease (SIHD) may allow for more measured procedural planning. Whether the acuity of presentation preferentially affects outcomes after coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with left main coronary artery disease (LMCAD) is unknown. We investigated whether the acuity of presentation discriminated patients who derived a differential benefit from PCI versus CABG in the randomized Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial. METHODS: We used multivariable Cox models to assess the interaction between the acuity of presentation, type of revascularization and outcomes in patients with low or intermediate SYNTAX scores enrolled in EXCEL. RESULTS: At baseline, 1151 patients (60.7%) presented with SIHD and 746 patients (39.3%) presented with an ACS. The acuity of presentation was not associated with the primary endpoint of all-cause death, MI, or stroke at 3 years (multivariable adjusted hazard ratio [HR] 0.94; 95% CI 0.70-1.26, P = .64). The primary endpoint rate was similar in patients assigned to PCI versus CABG whether they presented with SIHD (adjusted HR 1.04; 95% CI 0.73-1.48]) or with ACS (HR 0.82; 95% CI 0.54-1.26) (Pinteraction = .34). CONCLUSIONS: The acuity of presentation did not predict outcomes in patients with LMCAD undergoing revascularization, nor did it discriminate patients who derive greater event-free survival from PCI versus CABG.

Tyrosine kinase inhibitor toxicity manifesting as comorbid Moyamoya syndrome and obstructive coronary artery disease: A case report and review of the literature.

Tyrosine kinase inhibitors (TKIs) have assumed an increasingly vital role in treating various hematologic and oncologic malignancies. However, adverse effects with respect to vascular disease have been reported following administration of this class of medications. Here, we present a case report of TKI toxicity, manifesting as comorbid Moyamoya syndrome and obstructive coronary artery disease leading to a type 1 non-ST-elevation myocardial infarction. This patient eventually required percutaneous coronary intervention with drug-eluting stent placement in the right coronary artery. Given the expanding indications of TKI therapy, this case highlights a growing population subset which may require coronary and/or peripheral interventions to treat sequela from otherwise life-prolonging treatment.

Outcomes of patients with cardiogenic shock treated with TandemHeart® percutaneous ventricular assist device: Importance of support indication and definitive therapies as determinants of prognosis.

OBJECTIVES: The objective of this study was to review the characteristics of patients in cardiogenic shock treated with TandemHeart® percutaneous ventricular assist device (pVAD) to determine influential predictors of survival. BACKGROUND: The TandemHeart® pVAD is used in the management of patients with cardiogenic shock resulting from a variety of conditions. Several studies have documented the efficacy of this therapy and outlined its complications. Still, there is little data to guide the effective and appropriate use of this resource. METHODS: Patients referred for TandemHeart® pVAD implant for refractory cardiogenic shock at the University of Virginia between September 2007 and October 2015 were retrospectively analyzed. Univariate analysis was used to identify predictors of mortality. RESULTS: Fifty-five patients underwent successful TandemHeart® implant. Hemodynamics significantly improved following TandemHeart® implant. Cardiac index increased from 1.8 ± 0.6 to 3.1 ± 1.0 L/min/m2 (P = 0.007) and pulmonary capillary wedge pressure decreased from 30. 5 ± 9.9 to 19.6 ± 7.4 mmHg (P =0.0007). Survival was significantly influenced by implant indication with 23.8% surviving in bridge to recovery vs. 51% in bridge to LVAD or surgery (P = 0.04). In patients who did not receive definitive therapy, only 4 (13.8%) were weaned from TandemHeart® support and survived to hospital discharge. Only younger age, 51.8 vs. 62.7 years, predicted survival to hospital discharge (P = 0.004). CONCLUSION: Mortality from refractory cardiogenic shock is high even with TandemHeart® support. Our study found that patients with an exit strategy with either cardiac surgery or durable LVAD implant significantly influenced survival to hospital discharge.

6-Minute walk test predicts prolonged hospitalization in patients undergoing transcatheter mitral valve repair by MitraClip.

BACKGROUND: The 6-minute walk test (6MWT) is a simple functional test that can predict exercise capacity and is widely employed to assess treatment outcomes. Although mortality with transcatheter mitral valve repair (TMVr) using the MitraClip (Abbott Vascular, Menlo Park, CA) is significantly less than for open mitral valve surgery in high-risk patients, identifying which patient will benefit the most from TMVr remains a concern. There are limited prognostic metrics guiding patient selection and, no studies have reported relationship between prolonged hospitalization and 6MWT. This study aimed to determine if the 6MWT can predict prolonged hospitalization in patients undergoing TMVr by MitraClip. METHODS: We retrospectively reviewed 162 patients undergoing 6MWT before TMVr. Patients were divided into three groups according to the 6MWT distance (6MWTD) using the median (6MWTD ≥219 m, 6MWTD <219 m, and Unable to Walk). Multivariate logistic regression model was applied to select the demographic characteristics that were associated with the prolonged hospitalization defined as total length of stay ≥4 days in the study. RESULTS: We found that 6MWT (odds ratio 3.64, 95% confidence interval 2.03-6.52, P < 0.001) was independently associated with prolonged hospitalization after adjustment in multivariate analysis. Area under the curve of 6MWT for predicting prolonged hospitalization was 0.79 (95% confidence interval 0.72-0.85). CONCLUSIONS: Our study demonstrates that 6MWT was independently associated with prolonged hospitalization in patients with TMVr, and has a good discriminatory performance for predicting prolonged hospitalization.

Use of intracardiac echocardiography to guide percutaneous transluminal mitral commissurotomy: A 20-patient case series.

OBJECTIVES: To report the efficacy and safety of the use adjunctive intracardiac echocardiography (ICE) during percutaneous transluminal mitral commissurotomy (PTMC) in patients without transesophageal echocardiography (TEE). BACKGROUND: Patients with mitral stenosis are at a high risk of developing a left atrial (LA) thrombus. Traditionally, TEE has been used prior to PTMC to identify the presence of LA thrombi. There have been no reports of the use of ICE to assess the LA for thrombi prior to PTMC. METHODS: We retrospectively reviewed 20 patients who underwent ICE prior to PTMC. All PTMC procedures were performed via the antegrade transvenous approach using an Inoue balloon. Initially, ICE was used from the right atrium to confirm the absence of a thrombus on the left side of the septum and was subsequently used to guide the transseptal puncture. Following these procedures, the ICE was advanced into the LA through a transseptal sheath to visualize the LAA. RESULTS: Visualization of the thrombus/spontaneous echo contrast was considered to be diagnostic in all cases. Seventy percent of the patients were discharged on day after the procedure. No patients required intubation during the procedure, and there were no complications that could be attributed to the use of ICE. At six months after the PTMC, the incidence of stroke was zero. CONCLUSIONS: ICE-guided PTMC offers excellent visualization of the LA and the LAA with satisfactory clinical outcomes and low risk. As a part of the PTMC procedure, ICE safely provides a valid alternative to a separate TEE procedure.

Adjunctive intracardiac echocardiography imaging from the left ventricle to guide percutaneous mitral valve repair with the MitraClip in patients with failed prior surgical rings.

OBJECTIVES: We evaluated intracardiac echocardiography (ICE) for adjunctively guiding the MitraClip procedure in patients with prior surgical rings. BACKGROUND: Transesophageal echocardiography (TEE) is the standard imaging modality used to guide the MitraClip procedure (Abbott Vascular, CA). However, in patients with post-surgical anatomy, clear imaging of the mitral valve leaflets may be complex because of shadowing from the surgical ring. In these patients, TEE may be suboptimal for guiding the procedure, even using three-dimensional imaging. METHODS: This retrospective analysis included data from 121 consecutive patients with mitral regurgitation who underwent MitraClip procedures at the University of Virginia. ICE was used adjunctively when there was difficulty with TEE, particularly for assessing the insertion of the posterior leaflet into the MitraClip's arms. The ICE catheter was introduced transarterially into the left ventricle and flexed to obtain the short-axis view. RESULTS: Six patients had prior surgical rings, and in five, we used adjunctive ICE. The etiology of the mitral regurgitation was prolapse of the posterior leaflet in one patient and restriction of the posterior leaflet due to ischemic tethering in the remainder. All images were obtained from the left ventricle, and were adequate for assessing posterior leaflet insertion and the perpendicularity of the MitraClip arms. The procedural success rate was 80%. There was no adverse event related to the ICE procedure. CONCLUSIONS: Mitral valve repair with the MitraClip system assisted by ICE is feasible in patients with prior surgical rings, achieving an excellent risk profile and satisfactory procedural success.

Retrieval of Embolized Transcatheter Aortic Valves in Left Ventricle Through Apical Ventriculotomy.

Transcatheter valve placement complicated by left ventricular embolization is often treated with sternotomy, valve removal through the aorta, and conventional aortic valve replacement. We report three cases of ventricular embolization of aortic valves during deployment. We successfully placed a second transcatheter aortic valve in the correct position and retrieved the embolized valve through an apical ventriculotomy. All patients recovered well and survived for more than one year. doi: 10.1111/jocs.12701 (J Card Surg 2016;31:203-205).

Transcaval Aortic Access for Percutaneous Thoracic Aortic Aneurysm Repair: Initial Human Experience.

Transcaval aortic access has been used for deployment of transcatheter aortic valves in patients in whom conventional arterial approaches are not feasible. The present report describes its use for thoracic endovascular aortic repair (TEVAR) in a 61-year-old man with a descending thoracic aneurysm. Transcaval access was performed in lieu of a surgical iliac conduit in view of small atherosclerotic pelvic arteries. TEVAR was successfully performed, followed by intervascular tract occlusion with the use of a ventricular septal occluder. Computed tomography 2 d later demonstrated no extravasation. At 1 mo, the aneurysm was free of endoleaks, the aortocaval tract had healed, and the patient had returned to baseline functional status.

Percutaneous transjugular implantation of MELODY® valve into tricuspid bioprosthesis.

We present the technique of transcatheter balloon expandable (MELODY®) valve-in-valve deployment in a frail octogenarian with a failed previous tricuspid bioprosthesis. In patients who are not candidates for conventional surgery, transcatheter approach provides an alternative that warrants careful consideration.

Bedside Clinician's Guide to Pulmonary Artery Catheters.

BACKGROUND: Pulmonary artery catheters provide important information about cardiac function, mixed venous oxygenation, and right-sided pressures and potentially provide temporary pacing ability. OBJECTIVE: To provide bedside clinicians with guidance for techniques to insert right heart monitors and devices, describe risk factors for difficult insertion and contraindications to placement, and provide updates on new technologies that may be encountered in the intensive care unit. METHODS: An extensive literature review was performed. Experienced clinicians were asked to identify topics not addressed in the literature. RESULTS: Advanced imaging techniques such as transesophageal echocardiography or fluoroscopy can supplement traditional pressure waveform-guided insertion when needed, and several other techniques can be used to facilitate passage into the pulmonary artery. Caution is warranted when attempting insertion in patients with right-sided masses or preexisting conduction abnormalities. New technologies include a pacing catheter that anchors to the right ventricle and a remote monitoring device that is implanted in the pulmonary artery. DISCUSSION: Bedside clinicians should be aware of risk factors such as atrial fibrillation with dilated atria, decreased ventricular function, pulmonary hypertension, and right-sided structural abnormalities that can make pulmonary artery catheter insertion challenging. Clinicians should be familiar with advanced techniques and imaging options to facilitate placement. CONCLUSION: The overall risk of serious complications with right heart catheter placement and manipulation is low and often outweighed by its benefits, specifically pressure monitoring and pacing.

Socioeconomic Distress Associated With Increased Use of Percutaneous Coronary Intervention Over Coronary Artery Bypass Grafting.

BACKGROUND: The influence of socioeconomic determinants of health on choice of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) for coronary artery disease is unknown. We hypothesized that higher Distressed Communities Index (DCI) scores, a comprehensive socioeconomic ranking by zip code, would be associated with more frequent PCI. METHODS: All patients undergoing isolated CABG or PCI in a regional American College of Cardiology CathPCI registry and The Society of Thoracic Surgeons database (2018-2021) were assigned DCI scores (0 = no distress, 100 = severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. Patients who presented with ST-segment elevation myocardial infarction or emergent procedures were excluded. The most distressed quintile (DCI ≥80) was compared with all other patients. Multivariable logistic regression analyzed the association between DCI and procedure type. RESULTS: A total of 23 223 patients underwent either PCI (n = 16 079) or CABG (n = 7144) for coronary artery disease across 28 centers during the study period. Before adjustment, high socioeconomic distress occurred more frequently among CABG patients (DCI ≥80, 12.4% vs 8.42%; P < .001). After multivariable adjustment, high socioeconomic distress was associated with greater odds of receiving PCI, relative to CABG (odds ratio 1.26; 95% CI, 1.07-1.49; P = .007). High socioeconomic distress was significantly associated with postprocedural mortality (odds ratio 1.52; 95% CI, 1.02-2.26; P = .039). CONCLUSIONS: High socioeconomic distress is associated with greater risk-adjusted odds of receiving PCI, relative to CABG, as well as higher postprocedural mortality. Targeted resource allocation in high DCI areas may help eliminate barriers to CABG.

Efficacy and safety of ventricular tachycardia ablation with mechanical circulatory support compared with substrate-based ablation techniques.

AIMS: Catheter ablation of ventricular tachycardia (VT) can be limited by haemodynamic instability. In these cases, substrate-based ablation is typically performed. An alternative is to perform activation and entrainment mapping during VT supported by a percutaneous left ventricular assist device (pVAD). We sought to compare the complication and success rates of pVAD-assisted VT ablation with scar-based techniques. METHODS AND RESULTS: Thirteen consecutive patients with haemodynamically unstable VT underwent pVAD-assisted ablation (pVAD group) and were retrospectively compared with 18-matched patients undergoing a substrate-based VT ablation (non-pVAD group). There was no significant difference in age or ejection fraction between the groups although pVAD patients tended to have more shocks in the preceding months. Procedure times were longer for the pVAD group. The number of monomorphic VTs induced was greater in the pVAD group (3.2 vs. 1.6, P= 0.04); however, after ablation, there was no difference in inducibility between the pVAD and non-pVAD group (10 of 13 vs. 12 of 18; 77 vs. 67%, P = 0.69). There was no difference in acute complications including stroke or death. At 9 ± 3 months, 1-year freedom from implantable cardioverter-defibrillator (ICD) shocks/therapies for sustained VT were similar (P= 0.96). In multivariable analysis, the absence of atrial fibrillation (hazard ratio=0.15, P= 0.04) was associated with a lower incidence of ICD shocks. CONCLUSIONS: In high-risk patients, pVAD-assisted VT ablation guided by activation and entrainment mapping is a feasible alternative to substrate mapping and allows outcomes comparable to substrate mapping.

The "July Effect" in the Cardiac Catheterization Laboratory.

In Interventional Cardiology, the academic year and a new training cycle begin in July. It is unclear if patient outcomes are impacted by the time of year in the training cycle. The National Cardiovascular Data Registry collects outcomes related to percutaneous coronary interventions (PCIs). We used the database for our institution to review the relation between the time of year and patient outcomes. We performed a retrospective review of National Cardiovascular Data Registry data from 2011 to 2017. Outcomes were compared between the end (quarter 2 [Q2]) and the start of the academic year (quarter 3 [Q3]). Chi-square and Fisher's exact test was used: 1,041 (Q2) and 980 (Q3) patients underwent PCI. Patient characteristics were similar between the 2 quarters except for a higher rate of heart failure for patients in Q3 (250 [24%] vs 275 [29%], p = 0.03). There was no difference in overall nonfatal adverse events between Q2 and Q3 (53 [5.1%] vs 58 [5.9%], p = 0.41). Patients in Q3 experienced a higher incidence of stroke (1 [0.1%] vs 7 [0.7%], p = 0.03) and PCI risk-adjusted mortality (8.29 [0.8%] vs 18.13 [1.9%], p = 0.03). In conclusion, there does not appear to be a significant "July Effect" in an academic cardiac catheterization laboratory in terms of most complications with an observed higher incidence of stroke and PCI risk-adjusted mortality early in the year that may be related to a difference in the characteristics of the patient population.