Transcatheter mitral valve implantation in rigid mitral annuloplasty rings: Potential differences between complete and incomplete rings.

Hachinohe D, Latib A, Montorfano M, Colombo A
Transcatheter mitral valve implantation (TMVI) has been performed in high-risk and inoperable patients for degenerated mitral bioprostheses (TMVIinV) and failed annuloplasty rings (TMVIinR). TMVIinR is more challenging compared to TMVIinV because of the differences in dimensions, shapes, and contours between rings and valves. In this report, we present two clinical cases of TMVIinR that were treated by trans-septal implantation of a balloon-expandable prosthesis. In TMVI cases with an incomplete ring, the ring will be stretched out toward its anterior and commissural side, and the open side of the ring will increase in width. The ring may not transform in line with the shape of the transcatheter heart valve (THV) and an interspace can develop between the THV and the ring at the commissural side, resulting in significant paravalvular regurgitation. Our experience suggests that the circumferential completeness of the rings may be an important factor to consider when planning a TMVIinR.

Catheter Cardiovasc Interv: 17 May 2018; epub ahead of print

Bioprosthetic aortic valve leaflet disruption with high energy electrocautery to prevent coronary artery obstruction during valve-in-valve transcatheter aortic valve replacement.

Nelson BC, Chadderdon S, Song H, Zahr FE
Transcatheter aortic valve replacement (TAVR) is well-established for the treatment of bioprosthetic aortic valve stenosis (AS) in high surgical risk patients. Coronary artery obstruction from displacement of the bioprosthetic valve leaflets during valve-in-valve (VIV) TAVR is a rare, but potentially fatal, complication. Recently, the bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure was developed as a method for disrupting bioprosthetic leaflets in patients undergoing VIV TAVR at high risk for coronary obstruction. This case describes a successful VIV TAVR utilizing a simplified concept of the BASILICA technique in a patient where the full procedure could not be completed.

Catheter Cardiovasc Interv: 07 Oct 2018; epub ahead of print

Broken arrow: Successful retrieval of a dislodged coronary orbital atherectomy microtip.

Hirai T, Rosenberg J, Nathan S, Blair JEA
A 68-year-old female with a history of coronary artery disease and prior bypass surgery presented for staged percutaneous coronary intervention (PCI) to a calcified and angulated ostial left circumflex (LCX) artery lesion after PCI of the anastomosis of the left internal mammary artery - to left anterior descending artery. Orbital atherectomy of the LCX was performed at a speed of 80,000 RPM with multiple passes, and was complicated by device microtip dislodgement and entrapment within the vessel. After advancing a \"buddy\" wire beyond the microtip, a tapered microcatheter was advanced over the ViperWire and into the edge of the broken microtip and torqued into the microtip with forward pressure using the 0.014 in ViperWire tip as a \"backstop.\" The guidewire, microcatheter, and microtip were then successfully removed as a unit and the intervention with stent placement was completed over the \"buddy\" wire. Scanning electron microscopy of the shaft revealed evidence of cyclic fatigue, indicating that the fracture occurred while spinning. The fracture when performing atherectomy in a model coronary artery with a radius of approximately 6 mm. This represents a first case of microtip dislodgement and entrapment during the use of a coronary orbital atherctomy device.short.

Catheter Cardiovasc Interv: 17 Jul 2018; epub ahead of print

An unusual case of coronary artery compression that did not preclude successful transcatheter pulmonary valve placement.

Schwartz MC, Felix D, Iacono K, Nykanen D
During transcatheter pulmonary valve placement, coronary compression observed during simultaneous right ventricular outflow tract angioplasty and coronary angiography typically contraindicates valve implantation. We present a unique patient with tetralogy of Fallot who underwent successful transcatheter Melody valve placement despite coronary compression observed during right ventricular outflow tract balloon angioplasty.

Catheter Cardiovasc Interv: 15 Apr 2018; epub ahead of print

Robotic-assisted transradial diagnostic coronary angiography.

Swaminathan RV, Rao SV
Robotic percutaneous coronary interventions have recently been introduced in the cardiac catheterization laboratory. Robotics offers benefits of greater precision for stent placement and occupational hazard protection for operators and staff. First generation systems were able to advance and retract coronary wires, balloons, and stents, but did not have guide control functions. The second-generation robotic system (CorPath GRX) has an active guide management function offering the ability to move guide catheters. Expanding utilization of robotics to perform diagnostic coronary angiography would further reduce radiation scatter exposure and other occupational hazards to operators. This approach is particularly appealing in the setting of radial access, as universal radial diagnostic catheters can engage both the right and left coronary arteries without exchange. We describe here, the first two cases of such a procedure with the CorPath GRX robotic system.

Catheter Cardiovasc Interv: 03 Jan 2018; epub ahead of print

Lost and found: Coronary stent retrieval and review of literature.

Malik SA, Brilakis ES, Pompili V, Chatzizisis YS
A 61-year-old man with a history of percutaneous coronary intervention (PCI) of the mid right coronary artery (RCA) with a drug eluting stent (DES), presented with non-ST segment elevation myocardial infarction. Coronary angiography demonstrated complex disease of the distal RCA as well as in-stent stenosis of the previously placed mid RCA stent. The patient underwent bifurcation PCI of the distal RCA followed by attempted intervention with a DES on the mid RCA lesion. The stent could not cross the lesion and eventually became dissociated from its delivery system. The lost stent was successfully retrieved using two different snaring systems. The procedure was terminated without further attempts for stent delivery. The patient had an uneventful recovery and underwent successful PCI of the mid RCA lesion one month later.

Catheter Cardiovasc Interv: 03 Jan 2018; epub ahead of print

Role of invasive imaging in acute and long-term assessment of bioresorbable scaffold technology.

Chamié D, Garcia-Garcia H, Costa RA, Onuma Y, Abizaid A, Serruys PW
Fully bioresorbable scaffolds (BRS) represent a novel approach for the percutaneous treatment of coronary artery stenosis, providing temporary vessel scaffolding with drug-eluting capability during the restenosis-prone phase of the vascular healing. Beyond this initial critical period, when mechanical scaffolding support is no longer necessary, the device is bioresorbed, restoring the normal vascular physiology with the aim to eliminate the long-term safety concerns related to permanent metallic implants. Nonetheless, current BRS technology suffers from limited mechanical properties as compared to available metallic platforms, requiring careful attention to lesion preparation, accurate vessel sizing, and implantation technique. Intravascular imaging has played an important role in providing knowledge on the acute effects after BRS deployment, and it helped refine the current technique of BRS implantation. In addition, extensive work with multiple intravascular imaging modalities have also contributed to the understanding of the unique dynamic vascular changes that are experienced in the treated segment from post-implantation up to complete device bioresorption. In this manuscript, we review the role of invasive imaging modalities-from angiography to sound- and light-based techniques-to guide BRS implantation procedures, to assess its acute results postimplantation, and the changes experienced in the long-term until complete bioresorption has ensued. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 30 Oct 2016; 88:38-53

Bioresorbable vascular scaffolds for the treatment of coronary artery disease: Clinical outcomes from randomized controlled trials.

Rizik DG, Hermiller JB, Kereiakes DJ
The permanent metal prosthesis common to bare metal stents (BMS) as well as both first- and second-generation drug-eluting stents (DES) following treatment of coronary artery disease represents a long-lasting substrate for late adverse coronary events including restenosis, thrombosis, and neoatherosclerosis. Following resorbtion, bioresorbable scaffolds (BRS) may eliminate this nidus and improve late outcomes through restoration of the vessel to more normal vascular structure and function. BRS represents a single platform which incorporates the mechanical features of metallic stents to provide safe and effective revascularization, suppression of restenosis and prevention of constrictive remodeling with long-term restoration of the treated vessel to a more natural state. The landscape of BRS is rapidly evolving with new materials which target various performance goals for the duration of vascular support and polymer resorption time. The Absorb bioresorbable vascular scaffold (Absorb BVS), recently approved by United States Food and Drug Administration, has extensive clinical evidence to date in support of its clinical efficacy and safety. Recently published data from well-executed randomized clinical trials (RCTs) as part of the ABSORB Clinical development program along with other investigator-initiated trials provide insights into the safety and performance of this device in patients with de novo coronary lesions as well in the setting of ST-segment elevation myocardial infarction (STEMI). This review provides a comprehensive, outcomes based understanding of the available evidence from RCTs that offer head-to-head comparisons of Absorb BVS with metallic everolimus-eluting stents (EES). © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 30 Oct 2016; 88:21-30

Paving the way to a bioresorbable technology: Development of the absorb BRS program.

Perkins LE, Kossuth MB, Fox JC, Rapoza RJ
Bioresorbable scaffolds (BRS) combine attributes of the preceding generations of percutaneous coronary intervention (PCI) devices with new technologies to result in a novel therapy promoted as being the fourth generation of PCI. By providing mechanical support and drug elution to suppress restenosis, BRS initially function similarly to drug eluting stents. Thereafter, through their degradation, BRS undergo a decline in radial strength, allowing a gradual transition of mechanical function from the scaffold back to the artery in order to provide long term effectiveness similar to balloon angioplasty. The principles of operation of BRS, whether of polymeric or metallic composition, follow three phases of functionality reflective of differing physiological requirements over time: revascularization, restoration, and resorption. In this review, these three fundamental performance phases and the metrics for the nonclinical evaluation of BRS, including both bench and preclinical testing, are discussed. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 30 Oct 2016; 88:1-9

Buddy-wire technique during rotational Atherectomy: Simple and effective solution to achieve strong back-up support.

Mitomo S, Demir OM, Latib A, Colombo A
A 52-year-old male underwent percutaneous coronary intervention (PCI) using rotational atherectomy (RA: 1.5-mm burr) for a severely calcified lesion in the proximal to mid obtuse marginal (OM) branch. Even with 7 Fr extra back-up guiding catheter via femoral access, the burr could not cross the lesion due to insufficient back-up support. In order to achieve stronger back-up support, we kept the burr at the position in the OM branch and placed a supportive wire in left anterior descending artery through the side of drive-shaft sheath of the Rotablator, which sufficiently stabilized the guiding catheter during the ablation and the burr crossed the lesion. This case demonstrates that a simple technique of placing additional supportive wire in the other vessel during RA could be an effective and safe solution to facilitate improved back-up support without necessity to change the PCI system used already.

Catheter Cardiovasc Interv: 22 Sep 2018; epub ahead of print

Open sesame technique in percutaneous coronary intervention for ST-elevation myocardial infarction.

Kimura T, Nishibori Y, Miki K, Maruyama T
In patients with ST-elevation myocardial infarction (STEMI), delays in reperfusion attenuate the benefit of primary percutaneous coronary intervention (PCI) and associate with higher mortality rates. Although PCI operators are making their best effort in time saving for reperfusion, it is sometimes challenging and takes time to pass the guide wire across the target lesions. A totally occluded lesion in which a side branch was bifurcating at the proximal end of the occluded segment is one of the most technically challenging anatomies of the target lesion because it is difficult to identify the entry point of the occluded segment. A side branch technique, termed \"Open Sesame Technique\" (OST), has been previously introduced for chronic total occlusion (CTO) lesion in which a side branch was bifurcating at the proximal end of the occluded segment. We herein present two cases applying this technique in STEMI with totally occluded lesions at bifurcation as a culprit lesion, in which the entry point was not identified on the initial angiography. PCI were performed successfully using the OST in both cases, which resulted in saving procedural time and contrast volume without any complications. This technique can be effective not only in PCI for CTO lesions but also in primary PCI for STEMI cases with occluded bifurcation lesions.

Catheter Cardiovasc Interv: 22 Sep 2018; epub ahead of print

Alcohol septal ablation for outflow tract obstruction after transcatheter aortic and mitral valve replacement.

Edris A, Bartel T, Tuzcu EM, Suri RM
Left ventricular outflow obstruction after transcatheter mitral valve replacement is a life-threatening complication. We report a case of a 68-year old female with early degeneration of a transcatheter aortic valve and severely calcified mitral valve stenosis who was considered inoperable by a multidisciplinary heart team and referred for transcatheter aortic and mitral valve replacement. Our aim is to report the planning, procedural aspects, and management of device-related left-ventricular outflow tract obstruction after transcatheter double valve replacement.

Catheter Cardiovasc Interv: 29 Sep 2018; epub ahead of print

Bioresorbable vascular scaffold implantation for severely calcified lesions after excimer laser lesion preparation.

Mitomo S, Jabbour RJ, Latib A, Colombo A
Bioresorbable vascular scaffolds (Absorb BVS, Abbott Vascular, Santa Clara, CA) temporarily elute antiproliferative drugs and provide vessel support, which then subsequently resorb to allow restoration of normal vessel function and architecture. To attain the best possible results with BVS, a dedicated implantation technique (PSP: adequate lesion preparation, proper sizing, postdilatation) is considered mandatory, and calcified lesions are one of the most challenging lesion subsets for BVS implantation. In five cases with severe calcifications refractory to balloon predilatation, we performed excimer laser catheter ablation (ELCA: Turbo Elite catheter; Spectranetics Corporation, Colorado Springs, CO, USA), which facilitated adequate lesion expansion with high-pressure noncompliant balloon inflation and BVS implantation. During the follow-up period (481 days [interquartile range: 445-579]), all patients continued dual antiplatelet therapy (DAPT) and there were no cases of cardiac death, myocardial infarction, or scaffold thrombosis. For treatment of severely calcified lesions with bioresorbable scaffolds, ELCA could be considered an effective potential strategy. After the procedure, prolonged DAPT was prescribed.

Catheter Cardiovasc Interv: 29 Sep 2018; epub ahead of print

Intracardiac echocardiography with ultrasound probe placed in the upper left pulmonary vein to guide left atrial appendage closure: First description.

Patti G, Mantione L, Goffredo C, Ussia GP
Intracardiac echocardiography (ICE) has become an effective alternative to trans-esophageal echocardiography (TEE) as a guidance during interventional procedures for structural heart diseases, allowing to proceed under conscious sedation. To guide percutaneous left atrial appendage (LAA) closure, the ICE probe is usually placed in the right atrium, in the pulmonary artery or in the left atrium (LA); however, the views from the right atrium or the pulmonary artery are often suboptimal, debarring a complete visualization of the LAA and the surrounding structures, whereas the LA location requires trans-septal puncture, may provoke LA wall mechanical stimulation and is often associated with unstable position of the ICE probe. In our case, after a second trans-septal puncture, the ICE probe was placed in the upper left pulmonary vein; this was safely performed and provided an optimal imaging of the LAA, comparable to that obtained by TEE, thus warranting an adequate guide during all procedural steps.

Catheter Cardiovasc Interv: 26 Sep 2018; epub ahead of print

Retrograde recanalization of a nonchronic total occlusion lesion.

Siraj A, Pattanshetty DJ, Agarwal SK, Uretsky BF
The use of the retrograde approach to treat chronic total occlusion (CTO) has improved overall success rate in this lesion subgroup. Its use to treat complex non-CTO lesions unable to be revascularized by an antegrade approach has not been described. We report a case of the use of the retrograde approach to recanalize a non-CTO lesion under Impella support in a patient with critical stenosis and poor left ventricular function. The retrograde approach may be an alternate pathway in selected non-CTO lesions where the antegrade has been unsuccessful.

Catheter Cardiovasc Interv: 27 Sep 2018; epub ahead of print

Bicaval Medtronic Melody valve implantation for treatment of severe mitral regurgitation following the Mustard repair: A case report.

Steinberg ZL, Morray BH, Jones TK
We present a case of successful bicaval Melody valve implantation to treat severe mitral regurgitation in a 44-year-old man with d-transposition of the great arteries, repaired via a Mustard operation. The patient sustained injury to the anterior mitral valve leaflet during laser extraction of a ventricular pacing lead resulting in acute, severe, symptomatic mitral regurgitation. The presence of systemic venous baffles of similar caliber to right ventricular outflow tract conduits allowed for implantation of Melody valves within each baffle. The patient remains asymptomatic with excellent Melody valve function 14 months post procedure.

Catheter Cardiovasc Interv: 31 Dec 2017; 91:86-89

The trap and occlude technique for retrograde wire externalization during chronic total occlusion revascularization.

Gasparini GL, Oreglia JA, Garbo R
Different strategies of retrograde approach were introduced in recent years to improve the success rate of percutaneous coronary intervention for coronary chronic total occlusions. The aim of this report is to describe a new technique, called \"Trap and Occlude Technique,\" for retrograde wire externalization during CTO percutaneous revascularization. This technique may save time and reduce radiation exposure and procedure-related bleeding.

Catheter Cardiovasc Interv: 31 Dec 2017; 91:57-63

Novel use of cutting balloon to treat subintimal hematomas during chronic total occlusion interventions.

Vo MN, Brilakis ES, Grantham JA
Contemporary chronic total occlusion (CTO) percutaneous coronary interventional (PCI) techniques are increasingly dependent upon dissection and reentry techniques (DARTs) especially for long occluded lesions. DARTs can result in compressive hematomas during CTO interventions and traditional treatment with balloon angioplasty and/or coronary stenting are often suboptimal and may extend the hematoma distally. We describe the novel use of a cutting balloon to \"express\" these compressive hematomas and restore antegrade coronary blood flow.

Catheter Cardiovasc Interv: 31 Dec 2017; 91:53-56

Rotational atherectomy in the subadventitial space to allow safe and successful chronic total occlusion recanalization: Pushing the limit further.

Capretti G, Carlino M, Colombo A, Azzalini L
Dissection and re-entry (DR) techniques have played a key role in the increase of success rates of chronic total occlusion (CTO) recanalization. DR usually allows wiring complex occlusions, even in case of important calcification. In extreme cases, such as in balloon failure-to-cross, rotational atherectomy (RA) might be decisive. However, according to experts\' recommendations, RA should not be performed in dissection planes because of the high risk of perforation and further extending the dissection, so that its use after DR might be limited. Here, we describe a case of successful right coronary artery CTO recanalization in which, after failure of several antegrade and retrograde techniques, RA was safely performed antegradely in the subadventitial space, thus eventually enabling reverse controlled antegrade and retrograde subintimal tracking (CART). Although the feasibility of RA in CTO percutaneous coronary intervention had already been suggested, this case reports on the novel use of RA to allow further manipulation of the subadventitial space (reverse CART) prior to successful recanalization. © 2017 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 31 Dec 2017; 91:47-52

Use of chronic total occlusion percutaneous coronary intervention techniques for treating acute vessel closure.

Shaukat A, Mooney M, Burke MN, Brilakis ES
Acute vessel closure due to dissection is a known complication of percutaneous coronary intervention and can be challenging to treat, especially if guidewire position is lost. Re-entering into the distal true lumen is commonly done during chronic total occlusion interventions, as part of antegrade dissection strategies. We report two cases of acute vessel closure and guidewire position loss in which the Stingray LP system was successfully used to advance a guidewire into the distal true lumen and recanalize the occluded vessel.

Catheter Cardiovasc Interv: 13 Sep 2018; epub ahead of print

Retrograde percutaneous coronary intervention for acute myocardial infarction following blunt chest trauma.

Okumura H, Hayashi H, Harada M, Mikuri M
A 78-year-old man was admitted to the emergency department because of chest pain following blunt chest trauma. Chest X-ray revealed multiple rib fractures. However, electrocardiogram showed ST elevation in inferior leads suggesting acute myocardial infarction (AMI). Emergency coronary angiography revealed normal left coronary artery and occluded proximal right coronary artery. Thus, percutaneous coronary intervention (PCI) was performed immediately. Antegrade PCI was unsuccessful due to a very large false lumen, which was caused by a blunt trauma. However, retrograde guidewire (GW) manipulation was relatively easy to negotiate the occluded lesion. After GW externalization, we deployed two drug eluting stents for this lesion. To our knowledge, this is the first case of retrograde PCI that led to a successful reperfusion therapy for AMI following blunt chest trauma.

Catheter Cardiovasc Interv: 11 Sep 2018; epub ahead of print

Acute myocardial infarction secondary to blunt chest trauma in motorcycle accident: A rare combination where percutaneous coronary intervention and intravascular imaging optimization are needed.

Boi A, Sanna F, Rossi A, Loi B
Blunt chest trauma is a common occurrence in vehicle accident. Cardiac injuries following nonpenetrating thoracic trauma have been reported. ST-elevation myocardial infarction (STEMI) due to coronary artery involvement is a rare but extremely serious condition for the high risk of undetected diagnosis. Blunt thoracic trauma may obscure typical chest pain associated with cardiac ischemia especially in patients with high tolerance of pain or secondary administration of analgesic drugs. We report two consecutive cases of young adults admitted to our emergency department after motorcycle accident and concomitant anterior STEMI due to occlusion of left anterior descending artery. In both cases primary percutaneous coronary intervention with a second generation drug eluting stent implantation was successfully performed. Imaging with intravascular ultrasound and optical coherence tomography showed the mechanisms of coronary occlusion, allowing an optimal stent implantation and avoiding procedural complications in this complex setting.

Catheter Cardiovasc Interv: 11 Sep 2018; epub ahead of print

Fenestrated ASD device \"angioplasty\": How to adjust a \"pop-off\" mechanism when needed.

Tufaro V, Butera G
We report on three cases of atrial septal defect (ASD) closure where a handmade fenestration had to be modified after device implantation. Two patients suffered from left ventricular diastolic dysfunction and one had severe pulmonary arterial hypertension. Amplatzer ASD occluder fenestration was created in all patients. Devices were implanted using an \"over-the-wire\" implantation technique. Due to a sub-optimal hemodynamic result, fenestration was upsized by using a new technique.

Catheter Cardiovasc Interv: 08 Sep 2018; epub ahead of print

Urgent transcatheter aortic valve replacement for severe acute aortic regurgitation following open mitral valve surgery.

Spina R, Khalique O, Kodali S, Bapat VN
Transcatheter aortic valve replacement (TAVR) is not currently approved for pure native valve aortic incompetence, and is typically performed on a compassionate basis in selected patients who are at high risk for conventional surgery. We describe the first use of TAVR to treat iatrogenic severe acute pure aortic incompetence following mitral valve surgery. A 71-year-old gentleman developed life-threatening acute aortic regurgitation (AR) within hours of a very challenging fifth open heart mitral valve replacement. Careful inspection of echocardiographic and computed tomographic imaging identified the cause as a disrupted left coronary cusp at the commissure caused by the surgical mitral annular reconstruction. Medical management with afterload reduction failed with recurrent pulmonary edema, and a sixth open heart surgery was deemed prohibitively high risk. The lack of aortic annular calcium onto which anchors a transcatheter valve was a concern for TAVR. However, we postulated that the struts of the mitral valve bioprosthesis would offer some support to the TAVR valve. We opted for a self-expanding system because of concerns about potential unfavorable interaction between the balloon onto which balloon-expandable bioprosthesis is mounted and the struts of the mitral bioprosthesis, and because the Evolut R system has additional anchoring points at the crown which might enhance transcatheter valve stability in the non-calcified annulus, compared with the Edwards Sapien system. Transfemoral TAVR, performed with a Medtronic Evolut R 34 mm system under general anesthesia and using moderately rapid ventricular pacing, was successful with minimal residual AR. On follow-up 1 month later the patient was asymptomatic, and the aortic and mitral bioprostheses were functioning normally on echocardiogram.

Catheter Cardiovasc Interv: 07 Nov 2018; epub ahead of print

One-stop shop: Simultaneous direct mitral annuloplasty and percutaneous mitral edge-to-edge repair in a patient with severe mitral regurgitation.

Braun D, Näbauer M, Massberg S, Hausleiter J
Percutaneous edge-to-edge repair of severe mitral regurgitation has been established as an alternative treatment option for patients at high risk for cardiac surgery. More recently, the introduction of the Cardioband system enabled percutaneous direct annuloplasty. Here, we present a case of simultaneous percutaneous direct annuloplasty with edge-to-edge repair. Moreover, annuloplasty did facilitate clip implantation bei approximating the anterior and posterior mitral leaflet. In conclusion, the combination of direct annuloplasty with edge-to-edge repair is feasible in a single procedure.

Catheter Cardiovasc Interv: 08 Sep 2018; epub ahead of print

Emergency trans-catheter coronary intervention for left main compression secondary to pulmonary hypertension in a 4-year-old child.

Butera G, Mansour NB, De Marco F
Here, we report on the case of a 4-year-old child with large atrial septal defect (ASD) and severe pulmonary hypertension presenting an ischemic cardiomyopathy secondary to left main (LM) compression by a dilated pulmonary artery trunk. Despite of surgical treatment consisting in ASD closure and coronary artery bypass grafting, the patient was not weanable from ECMO. Control coronarography showed a near-occlusion of the left mammary bypass. A rescue percutaneous LM angioplasty with drug-eluting stent implantation was performed.

Catheter Cardiovasc Interv: 08 Sep 2018; epub ahead of print

Novel approach to coronary artery perforation repair.

Ingrassia J, Youn YJ, Lee J, Azrin M, Khalid S
Coronary artery perforation (CAP) during percutaneous coronary intervention is a rare but serious complication. Treatment options of CAP include prolonged balloon inflation, covered stent, and coil embolization. Although most cases of CAP can be treated with prolonged balloon inflation, some cases, especially Ellis grade III CAP require covered stents or coiling. Covered stents may require a large bore guide catheter and have a high rate of restenosis, which can be a limiting factor in patients with severe peripheral arterial disease. Coil embolization is generally used in distal CAP because coiling in the proximal vessels results in a large territory of infarction. We present a case of an Ellis grade III CAP during rotational atherectomy successfully treated with a novel coiling technique whereby the thrombogenic coil extends through the perforation outside of the vessel, and the intraarterial portion of the coil is excluded from the lumen by drug-eluting stent placement over the proximal portion of the coil.

Catheter Cardiovasc Interv: 08 Sep 2018; epub ahead of print

Cleft mitral leaflets and severe mitral regurgitation: Testing the limits of percutaneous mitral valve repair.

Cheng R, Kar S, Siegel RJ, Nakamura M
Repair of mitral regurgitation (MR) with the MitraClip device (Abbot Vascular, Menlo Park, CA) to treat degenerative MR is associated with improved acute and long-term outcomes. There is an increasing adoption of the device and operators are now testing the limits of the therapy even for unfavorable anatomies. Isolated cleft mitral leaflets are rare but represent a challenge to percutaneous repair. We present two cases of successful repair of severe MR and cleft mitral leaflets. In the first case, a 52-year-old male with a dilated cardiomyopathy and an ejection fraction (EF) of 15% presented in decompensated heart failure. Workup revealed a pseudo-cleft anterior mitral leaflet and a cleft posterior leaflet. A strategy to treat the restricted posterior leaflet lateral of the posterior cleft with a provisional second clip resulted in trace residual MR with only one clip, and an EF improvement to 50% at 2-month follow-up. In the second case, an 80-year-old male with a history of obstructive CAD with a normal EF but severe MR and a restricted anterior leaflet presented with severe shortness of breath. An initial strategy to grasp the middle of the valve was unsuccessful due to the cleft. Instead, two clips were placed side-by-side on either side of the cleft resulting in trivial residual MR. Despite challenging anatomy percutaneous repair can allow for dramatic reduction in MR, resulting in significant left ventricular remodeling and improvement of EF and cardiac output.

Catheter Cardiovasc Interv: 14 Nov 2018; epub ahead of print

Modified delivery of SAPIEN 3 valve in the pulmonary position: Evolution of technique or dire need?

Shahanavaz S, Rockefeller T, Nicolas R, Balzer D
Transcatheter pulmonary valve replacement (TPVR) is now common practice in patients with significant pulmonary regurgitation (PR), stenosis (PS), or mixed pulmonary valve disease. While the Melody valve (Medtronic, Inc.) and its delivery system were specifically designed for use in the right ventricular outflow tract (RVOT), Sapien valves (XT and S3, Edwards Lifesciences, Inc.) and their delivery systems (Novaflex and Commander) were not. As a result, placement of Sapien valves in the RVOT can be challenging secondary to the stiffness of the current delivery system. Manipulating a stiff delivery system within the RV also introduces risk to the tricuspid valve and its chordal attachments. We report a novel delivery technique for the Sapien S3 valve which has greatly simplified valve delivery into the RVOT and may potentially reduce the risk of tricuspid valve injury.

Catheter Cardiovasc Interv: 07 Nov 2018; epub ahead of print

The unmet needs: How future technologies will address current limitations of bioresorbable scaffold technology.

Abizaid A, Ribamar Costa J
First-generation bioresorbable scaffolds (BRS), represented by the three marked-approved devices (Absorb BVS 1.1, DESolve NX, and DREAMS) have demonstrated, in low to moderate angiographic scenarios, similar efficacy to current generation metallic drug-eluting stents. However, a trend toward more device thrombosis have been observed, especially when the scaffolds are used in off-label situations. Among the main shortcomings of this novel technology, we highlight: (1) Increased strut thickness (≥150 μm) and crossing profile; (2) low resistance to overexpansion; (3) lack of radiopacity, and; (4) special storage requirements. In order to overcome these limitations and improve their acute performance and midterm safety, a dozen of novel BRS are currently under research, in different stages of development. In the present review, we address three of these new technologies, pointing out their innovative features and initial clinical results. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 30 Oct 2016; 88:54-59

Hybrid transcatheter tricuspid valve-in-valve placement of an Edwards Sapien XT valve in palliated hypoplastic left heart syndrome.

Ho AB, Kaarne M, Mullen M, Hayes N
Tricuspid regurgitation in the context of hypoplastic left heart syndrome (HLHS) carries a significant burden of both mortality and morbidity. We report successful hybrid trans-atrial implantation of an Edwards Sapien XT valve into a dysfunctional bioprosthetic valve in the tricuspid position of a 9-year-old patient with HLHS. There was an immediate fall in the Fontan pressures combined with significant clinical improvement and the valve continues to function well nearly 3 years post implant. To the best of our knowledge, this is the first described implantation of a transcatheter valve in this specific position and anatomy.

Catheter Cardiovasc Interv: 11 Nov 2018; epub ahead of print

SCAI/SVM expert consensus statement on Carotid Stenting: Training and credentialing for Carotid Stenting.

Aronow HD, Collins TJ, Gray WA, Jaff MR, ... Wayangankar SA, White CJ
Carotid artery stenting (CAS) has become an integral part of the therapeutic armamentarium offered by cardiovascular medicine programs for the prevention of stroke. The purpose of this expert consensus statement is to provide physician training and credentialing guidance to facilitate the safe and effective incorporation of CAS into clinical practice within these programs. Since publication of the 2005 Clinical Competence Statement on Carotid Stenting, there has been substantial device innovation, publication of numerous clinical trials and observational studies, accumulation of extensive real-world clinical experience and widespread participation in robust national quality improvement initiatives [5]. Collectively, these advances have led to substantial evolution in the selection of appropriate patients, as well as in the cognitive, technical and clinical skills required to perform safe and effective CAS. Herein, we summarize published guidelines, describe training pathways, outline elements of competency, offer strategies for tracking outcomes, specify facility, equipment and personnel requirements, and propose criteria for maintenance of CAS competency. © 2015 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 24 Nov 2015; epub ahead of print

Successful retrieval of a firmly stuck rotablator burr by using a modified STAR technique.

Tanaka Y, Saito S
Rotablator burr entrapment occurring during rotational atherectomy is a rare but serious complication that can lead to coronary occlusion and require emergency cardiac surgery. Although several bailout techniques for stuck burrs have been proposed, no definitive methods for removal have been established. We report here a difficult case of a stuck rotablator burr, in which various techniques failed to retrieve the burr. It was ultimately removed using the subintimal tracking and reentry (STAR) technique with a 3-g tapered tip hydrophilic wire. This modified STAR technique, which was originally developed for percutaneous coronary intervention for chronic total occlusion, may be useful as a bailout technique in patients with a firmly stuck rotablator burr that cannot be removed by using standard procedures. © 2015 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 08 Dec 2015; epub ahead of print

Case reports of coronary fibromuscular dysplasia and spontaneous coronary artery dissections.

Lee C, Starovoytov A, Saw J
Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome especially in women. The most common underlying predisposing cause of SCAD is fibromuscular dysplasia (FMD), a non-inflammatory arteriopathy that results in weakening of the affected arteries, and can cause dissection or aneurysm. Coronary FMD (CFMD) was described as rare, and was shown to cause SCAD in histopathological case reports. Unfortunately, CFMD is challenging to diagnose on coronary angiography, as the findings can be similar to other causes of coronary artery disease. Therefore, we illustrate two case examples of CFMD on coronary angiography, and highlight findings on optical coherence tomography to aid diagnosis.

Catheter Cardiovasc Interv: 22 Nov 2018; epub ahead of print

Fracking the Code to Complete Revascularization.

Hira RS, Dean LS
Provisional use of rotational atherectomy (RA) is indicated for procedural success in heavily calcified lesions. In the current study, RA use at three high volume percutaneous coronary intervention (PCI) centers between 2005 and 2013 was 1.4%. MACE rate was 17.8% at median follow-up of 22 months. Peripheral vascular disease (PVD), diabetes mellitus (DM), acute coronary syndrome (ACS), and SYNTAX > 23 were found to be independently associated with MACE. With increasing complexity of disease and SYNTAX score, there is usually an increase in severity of calcification and need for atherectomy. Complete revascularization with residual SYNTAX reduced to < 8 is associated with improved outcomes. Incompleteness of revascularization in patients with SYNTAX > 33 rather than procedural success of the target vessel with atherectomy may have contributed to the adverse outcomes.

Catheter Cardiovasc Interv: 18 Oct 2016; 88:553-554

Edwards Sapien 3 transcatheter aortic valve implantation for management of severe aortic regurgitation in a teenage patient with corrected atrioventricular septal defect and progressive left ventricular dysfunction.

Lehner A, Herrmann FE, Mehilli J, Haas NA
Transcatheter aortic valve replacement is mostly performed in elderly patients with severely calcified aortic valves. There are few reports about its use for pure aortic regurgitation, few reports about its use in adolescent patients and to the best of our knowledge no report about the use of an Edwards Sapien valve in the aortic position in an underage patient after surgically corrected congenital heart disease (CHD). Decompensation of a complex CHD can be difficult to manage and may require unusual solutions. We report a case of a teenage patient presenting with progressive aortic regurgitation and deterioration of left ventricular function after multiple surgical procedures for an atrioventricular septal defect (AVSD). As \"bridge-to-transplant,\" we performed a transcatheter aortic valve implantation using a balloon-expandable Sapien 3 prosthesis. At 6 month follow-up, the patient remained clinically stable with no rehospitalization due to heart failure.

Catheter Cardiovasc Interv: 19 Nov 2018; epub ahead of print

Staged revascularization in patients with acute coronary syndromes due to saphenous vein graft failure and chronic total occlusion of the native vessel: A novel concept.

Xenogiannis I, Tajti P, Burke MN, Brilakis ES
Percutaneous coronary intervention of saphenous vein graft (SVG) lesions can be challenging due to high risk for acute and long-term complications. Treating the corresponding native coronary artery lesion(s) is preferable, but may not be feasible in the acute setting, due to high technical difficulty, especially when the native coronary lesion is a chronic total occlusion (CTO). We describe a novel concept of \"staged revascularization\" in patients presenting with an acute coronary syndrome due to SVG failure, whose native coronary artery supplied by the SVG has a CTO. In the first stage, the culprit SVG lesion is treated restoring flow to the supplied myocardium and minimizing the extent of myocardial injury. During the second stage (typically few weeks later), revascularization of the corresponding native coronary artery lesion(s) is performed, often using the initially treated SVG for retrograde crossing of the native coronary artery CTO. We describe two cases of non-ST segment elevation acute myocardial infarction due to SVG failure that were treated with \"staged revascularization\": the culprit SVG was initially treated followed by staged revascularization of the corresponding native coronary artery CTO. Staged revascularization of SVG lesions causing acute coronary syndromes may allow optimization of both acute and long-term outcomes.

Catheter Cardiovasc Interv: 19 Nov 2018; epub ahead of print

Avoiding hemodynamic collapse during high-risk percutaneous coronary intervention: Advanced hemodynamics of impella support.

Verma S, Burkhoff D, O\'Neill WW
The rate of performing primary percutaneous coronary intervention in patients with complex coronary artery disease is increasing. The use of percutaneous mechanical circulatory support devices provides critical periprocedural hemodynamic support. Mechanical support has increased the safety and efficacy of interventional procedures in this high-risk patient population. Predicting patient response to the selected intervention can be clinically challenging. Here we demonstrate a case where complete hemodynamic collapse during PCI was avoided by mechanical support provided by the Impella device. Further, we employ a comprehensive cardiovascular model to predict ventricular function and patient hemodynamics in response to the procedure. New computational tools may help interventionists visualize, understand, and predict the multifaceted hemodynamic aspects of these high risk procedures in individual patients. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 22 Sep 2016; epub ahead of print

Coronary artery embolism from infectious endocarditis treated with catheter thrombectomy using a GuideLiner catheter.

Oestreich BA, Sommer P, Armstrong EJ
A 27-year-old male with history of IV drug use and recurrent endocarditis necessitating bioprosthetic mitral and tricuspid valve replacements presented with 2 weeks of fevers and chest pain. ECG revealed inferior ST-elevation myocardial infarction and he was taken urgently to the cardiac catheterization laboratory. Coronary angiography revealed thrombotic occlusion of the distal right coronary artery (RCA) with no angiographic evidence of atherosclerotic disease. Aspiration thrombectomy was performed followed by rheolytic thrombectomy. Despite multiple attempts at thrombectomy, significant residual organized thrombus persisted in the distal RCA. Therefore, further thrombectomy was performed by placing a GuideLiner catheter (Vascular Solutions, Minneapolis, MN) deep within the right coronary artery near the bifurcation into the posterior descending and posterior left ventricular arteries. After repeat aspiration, there was significant improvement with thrombolysis in myocardial infarction 3 flow. Intravascular ultrasound of the RCA revealed a normal-appearing vessel without evidence of atherosclerotic disease and mild residual thrombus. The decision was made to not pursue stent placement, given the concern for a likely embolic source. Following the procedure, the patient\'s chest pain resolved and his ST-segments normalized. © 2015 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 15 Apr 2016; 87:E197-E201

Current status of percutaneous right ventricular assist devices: First-in-man use of a novel dual lumen cannula.

Aggarwal V, Einhorn BN, Cohen HA
Ventricular assist devices have become an accepted therapeutic solution for patients with severe left ventricular dysfunction when pharmacology fails to maintain sufficient cardiac output. Despite various technologies that have allowed left ventricular assist devices to become more reliable and versatile in the past decade, comparatively little attention has been applied to right heart assistance which is still in the early stage of its development. The extracorporeal devices developed thus far have been associated with mobility issues and complications common to ventricular assist devices in general, such as infection, bleeding, and thromboembolism. Designed to obviate the problems previously experienced by other right ventricle (RV)-focused devices, the Protek Duo (CardiacAssist, Pittsburgh, PA) is a novel, fully percutaneous, dual lumen cannula for RV support used in conjunction with the paracorporeal TandemHeart(®) (CardiacAssist, Pittsburgh, PA) pump. We describe our initial experience with the Protek Duo cannula in two different clinical scenarios. In addition, we summarize the current percutaneous mechanical support technology for RV assistance and propose modification of current technology to facilitate its application. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 19 Feb 2016; epub ahead of print

MitraClip-induced systolic anterior motion complicated by pericardial effusion: A case report.

Levi A, Sagie A, Kornowski R
Systolic anterior motion (SAM) of the anterior mitral leaflet is a well reported complication of surgical mitral valve repair (MVR). In the current report, we present a case of SAM with left ventricular outflow tract obstruction (LVOTO) which occurred after transcatheter mitral valve repair (TMVR) using the MitraClip device. LVOTO was caused by the combination of protrusion of the MitraClip device into the LVOT and underfilling of the left ventricle due to pericardial effusion and atrial fibrillation. Rapid clinical resolution and marked decline in LVOT pressure gradient occurred following surgical drainage and windowing of the pericardium. We conclude that SAM and LVOTO could occur after TMVR. Seeking and addressing reversible aggravators of LVOTO including pericardial effusion is essential and could potentially make the difference between a successful procedure and a failed one. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 05 Mar 2016; epub ahead of print

Transcatheter aortic valve implantation in degenerative sutureless perceval aortic bioprosthesis.

Landes U, Sagie A, Kornowski R
Sutureless aortic bioprostheses (SAB) are increasingly being used to provide shorter cross-clamp time. Valve-in-valve transcatheter aortic valve replacement (VIV-A) is shown to be effective and safe in the vast majority of patients with degenerated bioprosthetics, yet its\' use in SAB failure is infrequent. We present a case of balloon-expandable VIV-A in an 80-year-old woman who suffered severe symptomatic aortic regurgitation in a failed Perceval S 21-mm valve. Computed tomography scan demonstrated a deformed valve. Our heart team favored a percutaneous VIV-A over reoperation due to the patients\' high surgical risk. An Edwards-Sapien XT 23 mm was successfully deployed with excellent results. The patient remained asymptomatic following 6 months. As other bioprosthesis, some sutureless valves are condemned to structural valve degeneration. Because VIV-A is being established for managing degenerative bioprosthesis in high risk patients, it is cardinal to identify its role in novel degenerative sutureless valves. SAB were introduced to the clinical market only 5-7 years ago. The absence of sutures may theoretically impose risk for valve instability when adding a transcatheter sutureless valve inside the first one. Our successful experience was very reassuring. We report its feasibility because we believe it should provide support for further investigation on VIV-A within novel SAV. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 02 Oct 2016; epub ahead of print

Abnormal distortion of aortic corevalve bioprosthesis with suicide left ventricle, aortic insufficiency, and severe mitral regurgitation during transcatheter aortic valve replacement.

Leya F, Tuchek JM, Coats W
We present a patient with critical degenerative aortic stenosis, mitral annular and aortomitral continuity calcification, and senile sigmoid septal hypertrophy who underwent transcatheter aortic valve replacement using the CoreValve bioprosthesis. Immediately after predilation of the aortic valve (18-mm balloon), the patient developed severe hypotension and dynamic left ventricular outflow tract (LVOT) obstruction with systolic anterior motion of the anterior mitral leaflet, causing severe mitral regurgitation. After deployment of a 26-mm bioprosthesis, a transesophageal echocardiogram and left ventriculogram showed that the frame of the bioprosthesis appeared distorted and underexpanded. On the mitral side of the aorta (side of the aortomitral curtain between 12:00 and 3:00, echo short axis view), we found moderate periprosthetic aortic insufficiency with worse mitral regurgitation. The left ventricle was small and hyperdynamic (ejection fraction >85%). The patient soon developed complete heart block, atrial fibrillation, and ventricular tachycardia. She was resuscitated with aggressive intravenous fluids, vasopressors, and an emergently placed atrioventricular sequential pacemaker. We postdilated the 26-mm bioprosthesis with a 22-mm Z-Med balloon and subsequently with a 25-mm balloon. Each balloon was inflated to its nominal volume and pressure and conformed the nitinol frame of the valve to the net circular shape and expected diameter. However, as soon as each balloon was deflated, the surrounding aortic root anatomy visibly recoiled and the frame returned to its smaller diameter with a distorted shape. A second 26-mm CoreValve bioprosthesis was then deployed in a "valve-in-valve" configuration. Soon after, the patient\'s hemodynamics improved, her clinical condition stabilized, and she completely recovered. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 05 Mar 2016; epub ahead of print

Device-in-device: A transcatheter alternative to surgical explantation of a failing atrial septal defect intracardiac prosthesis.

Chamié F, Maia J, Giuliano LC
A failing intracardiac device is traditionally addressed by open-heart surgery. Surgical explantation of the device, although a simple procedure, carries risks that some patients are not able or willing to cope with. Thus, a nonsurgical option seems desirable in selected cases. We report on four cases of early malfunction of the Polyvinyl Alcohol membrane of Ultrasept II™ CARDIA ASD devices. In all cases, transthoracic echo (TTE) surveillance 4-6 months after the index procedure, depicted significant left-to-right atrial shunts through the center portion of the devices. A second nitinol double disk device with a connecting pin (Lifetech CERA™ Multifenestrated ASD device) was implanted over the CARDIA devices, with excellent results. All procedures were uneventful and all patients are asymptomatic with no residual shunts, in short-term follow-up. This device-in-device technique prevents surgical explantation of failing ASD devices, and may become a less invasive option in selected patients. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 18 Feb 2016; epub ahead of print

Pigtail catheter "propping" for MitraClip percutaneous transcatheter mitral valve repair.

Sandhu K, Butler R, Large A
In recent years percutaneous therapy has emerged as a feasible and effective option for the treatment of mitral regurgitation, particularly in cases where the risks of conventional cardiac surgery are prohibitively high. To date the most widely used percutaneous approach is beating heart, edge-to-edge repair with the MitraClip device (Abbott Vascular-Structural Heart, Menlo Park, CA). The technique requires simultaneous grasping and approximation of both mitral valve leaflets prior to securing and releasing the clip. However, this may be technically challenging or indeed impossible in patients with failure of coaptation, particularly when there is a large coaptation gap. We present an approach for overcoming this relatively common obstacle based on "propping" the anterior mitral valve leaflet toward its posterior counterpart with a diagnostic pigtail catheter to reduce the coaptation gap and to allow grasping of both leaflets without difficulty. © 2015 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 08 Mar 2016; epub ahead of print

A mechanism for stroke complicating thrombus aspiration.

Brown ED, Blankenship JC
We propose a mechanism of how stroke may be caused by thrombus aspiration during primary percutaneous coronary intervention (PPCI), and how it may be technique-dependent. Two recent meta-analyses report increased risk of stroke in patients undergoing routine thrombus aspiration during STEMI and the value of this technique has been controversial. The mechanism of stroke has not been fully explained. This case demonstrates 2 mechanisms by which aspiration might cause thrombus embolization. We recommend that if thrombus aspiration is performed during PPCI for STEMI, it should be done selectively and carefully. It is prudent to make sure the guide catheter tip is not free in the aorta when the aspiration catheter is withdrawn, to maintain suction on the aspiration catheter as it is withdrawn (particularly if the aspiration port seems to be obstructed), and to aspirate the guide catheter after the aspiration catheter is removed to capture any fragments of thrombus that remain in the guide catheter. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 02 Oct 2016; epub ahead of print

Coronary Bioresorbable Vascular Scaffold Use in the Treatment of Coronary Artery Disease.

Testa L, Latib A, Montone RA, Colombo A, Bedogni F
Bioresorbable vascular scaffolds (BVS) represent a promising novel approach for the treatment of coronary artery disease. BVS promise to address some of the well-known limitations of current drug-eluting stents, while providing a transient scaffolding of the vessel to prevent acute vessel closure/recoil. Drug elution by BVS prevents neointimal proliferation in a similar fashion to drug-eluting stents, and complete bioresorption is associated with late vessel lumen enlargement, plaque regression, and restoration of vasomotion. Based on the pathophysiological reasons and on the results derived from clinical studies, BVS are increasingly being used in clinical practice. The aim of this review is to provide an overview of the current evidence supporting the use of BVS in clinical practice. In particular, we will discuss the randomized controlled trials and registries evaluating the clinical outcome of these devices, with a special focus on their application in patients with acute coronary syndrome and in specific lesion subsets (bifurcations, chronic total occlusions, and in-stent restenosis).

Circ Cardiovasc Interv: 13 Jul 2016; 9

Abstract 10613: Symptomatic Human Immunodeficiency Virus Infected Patients Receive Less Aggressive Revascularization Management After Acute Coronary Syndrome, a 5-year Nationwide Analysis.

Huang Lucas C, Wu L, Yue B, Bachoo N, ... Wei X, Herzog E

Cardiovascular disease is a leading cause of morbidity and mortality in human immunodeficiency virus (HIV) infected adults, and should be managed more aggressively.Prior studies highlighted treatment disparities for Acute Coronary Syndrome (ACS) among HIV patients. This study aims at examining these disparities with the latest large cohort data.HIV patient with ACS are as likely to receive cardiac revascularization related procedures compared to control group.We reviewed the Nationwide Inpatient Sample from 2013 to 2016 to identify patients with diagnosis of ACS (ST-elevation and non ST-elevation myocardial infarction, and unstable angina) to compare rates of cardiac procedures (Catheterization, Percutaneous Coronary Intervention - PCI - and Coronary Artery Bypass Graft - CABG) among groups of population of interest (control, asymptomatic HIV, symptomatic HIV).Overall, 515,016 patients with primary diagnosis of ACS where identified and among them 2066 (0.40%) of ACS patients had diagnosis of HIV (asymptomatic and symptomatic). Multivariate regression analysis showed statistically significant lower procedural rates for catheterization (OR: 0.62, 95% CI: [0.52, 0.73]), PCI (OR: 0.80, 95% CI: [0.67, 0.96]) and CABG (OR: 0.70, 95% CI: [0.52, 0.93]) in symptomatic HIV compared to control group. For asymptomatic HIV patient group, no significant change of procedural rates were found compared to control group for catheterization, PCI and CABG (respectively OR: 0.90, 95% CI: [0.78, 1.05], OR: 1.13, 95% CI: [1.00, 1.26] and OR: OR: 0.87, 95% CI: [0.72, 1.04]).Analysis shows a treatment disparity for ACS for symptomatic HIV patients only as symptomatic HIV affected patients received less aggressive catheterization and revascularization management after ACS, compared to control group. However, this effect was not present for the asymptomatic HIV patient group.



Circulation: 18 Nov 2019; 140:A10613

How to deal with atrial septal defect closure from right internal jugular vein: Role of venous-arterial circuit for sizing and over-the-wire device implantation.

Butera G, Lovin N, Basile DP
Secundum atrial septum defect (ASD) is the most common congenital heart disease. It is usually treated by a transcatheter approach using a femoral venous access. In case of bilateral femoral vein occlusion, the internal jugular venous approach for ASD closure is an option, in particular in cases where ASD balloon occlusion test and sizing is needed. Here, we report on a new technique for ASD closure using a venous-arterial circuit from the right internal jugular vein to the femoral artery. Two patients (females, 4 and 10 years of age) had occlusion of both femoral veins because of a previous history of pulmonary atresia and intact ventricular septum, for which they underwent percutaneous radiofrequency perforation and balloon angioplasty. These subjects needed balloon occlusion test of a residual ASD to size the hole and to check for hemodynamic suitability to ASD closure. After performing a venous-arterial circuit, a 24 mm St Jude ASD sizing balloon catheter was advanced over the circuit and the defect closed for 15 min to check hemodynamics and size the defect. ASD was closed is hemodinamically suitable. This technique was safe and reliable. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 16 Jun 2016; epub ahead of print

Successful percutaneous paravalvular leak closure followed by transfemoral aortic lotus valve-in-valve implantation in a degenerated surgical bioprosthesis.

Nerla R, Cremonesi A, Castriota F
Bioprosthesis degeneration is a relevant clinical issue that is increasingly developing with the higher expectancy of life. Its treatment may be further complicated by the presence of paravalvular leaks, which are usually consequence of tissue friability, annular calcification, and infection. The surgical treatment of such complex conditions may be too risky, so percutaneous techniques in selected centers are becoming an attracting option. We report the case of a 65-year-old gentleman with a previous aortic valve replacement (Perimount n.25) who was admitted with worsening heart failure and transoesophageal evidence of severe intraprosthetic regurgitation and a large paravalvular leak. Since he was judged at too high risk for surgery, he was treated by a fully percutaneous approach. First, he had his large paravalvular leak closed by implantation of two plugs from both retrograde and anterograde routes (arterial-venous loop created). After one month, he underwent a "valve-in-valve" transcatheter aortic valve implantation with a fully repositionable Lotus 23 mm valve, which was able to restore a completely normal aortic valve function and let to a dramatic improvement of his functional status at 6-month follow-up (from NYHA IV to NYHA I), when a transthoracic echocardiogram also confirmed the absence of any aortic regurgitation. This case shows how a tailored step-by-step fully percutaneous strategy is safe and feasible in high-risk patients with both bioprosthesis degeneration and large paravalvular leaks. This novel opportunity would need to be better evaluated in properly addressed long-term clinical studies. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 03 May 2016; epub ahead of print

Percutaneous exclusion of a rapidly enlarging left main coronary artery aneurysm using coils and an Amplatzer™ septal occluder.

Aggarwal V, Mishkel G, Goswami N
Coronary artery aneurysms (CAAs) are often an incidental finding amongst patients undergoing coronary angiography. Most CAAs are managed conservatively; rarely a larger CAA can lead to intramural thrombus formation and coronary artery embolization/obstruction even without the presence of significant stenosis. Despite these clinical implications, therapeutic options are limited to case reports and no clearly defined guidelines have been established for treatment. In this article, we present a unique case of a rapidly enlarging left main CAA, with no identifiable etiology that was treated with percutaneous exclusion via coil embolization and an Amplatzer™ septal occluder device. We also discuss existing literature, pathophysiology, and management options for CAAs. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 05 Mar 2016; epub ahead of print

Trans-apical systemic tricuspid valve-in-ring replacement.

Ghobrial J, Reemtsen B, Levi DS, Aboulhosn J
Transcatheter valve replacement offers a safe and effective alternative to traditional surgical techniques in patients with congenital heart disease, especially those at high surgical risk. The most common causes of morbidity and mortality in patients with D-transposition of the great arteries status post Senning or Mustard repair is severe tricuspid valve (TV) regurgitation. Replacement of the systemic TV may be useful in those without severe systemic ventricular dysfunction. We present a case of a patient with D-loop transposition of the great arteries status post Mustard repair and TV ring placement with subsequent severe systemic TV regurgitation, at high surgical risk, who underwent a transcatheter valve replacement via a trans-apical approach using an Edwards Sapien XT valve.

Catheter Cardiovasc Interv: 17 Dec 2018; epub ahead of print

Transcatheter implantation of SAPIEN 3 valve in native right ventricular outflow tract for severe pulmonary regurgitation following tetralogy of fallot repair.

Rockefeller T, Shahanavaz S, Zajarias A, Balzer D
Pulmonary valve replacement (PVR) is indicated in patients with significant pulmonary regurgitation (PR), stenosis (PS), or mixed pulmonary valve disease. While once an exclusively surgical procedure, many patients can undergo transcatheter PVR (TPVR) with excellent early outcomes (Haas et al. 2013, Clin. Res. Cardiol. Off. J. German Cardiac Soc. 102:119-128; Kenny et al. 2011, J. Am. Coll. Cardiol. 58:2248-2256; Cheatham et al. Circulation 2015, 131:1960-1970). The available transcatheter options continue to expand, but the majority of cases performed in the United States involve the use of FDA approved Melody valve (Medtronic; Minneapolis, MN) or the SAPIEN (Edwards Lifesciences; Irvine, CA) family of valves. The SAPIEN 3 valve (S3) recently received FDA approval for transcatheter aortic valve replacement. We report the first S3 implantation in the pulmonary position for treatment of chronic pulmonary regurgitation and progressive right ventricular dilation in an 18 year old male with repaired Tetralogy of Fallot. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 05 Mar 2016; epub ahead of print

Transcatheter Aortic Valve Replacement in Bicuspid Aortic Stenosis Using Lotus Valve System.

Chan AW, Wong D, Charania J
Bicuspid aortic stenosis (BAS) has been excluded in clinical trials on transcatheter aortic valve replacement (TAVR) due to the presumed uneven expansion of the aortic prosthesis, leading to significant paravalvular regurgitation (PVR). There is no transcatheter heart valve (THV) commercially approved for treating BAS. The Lotus Valve System mitigates PVR by possessing an adaptive seal and being fully re-positionable. The latter is also important in preventing embolization, as the location of prosthesis fixation in BAS could be variable due to the presence of less expandable raphe. We report our early experience with the Lotus Valve System in three consecutive TAVR for BAS. They all provide good clinical and hemodynamic results without significant PVR. We conclude that the use of Lotus Valve System for treating BAS is feasible and safe, and may have advantages over the previous generation TAVR systems. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 30 Mar 2016; epub ahead of print

Bioresorbable scaffolds for treatment of coronary bifurcation lesions: Critical appraisal and future perspectives.

Diletti R, Tchetche D, Barbato E, Latib A, ... Fajadet J, van Mieghem NM
Bioresorbable vascular scaffolds have been recently introduced as a novel paradigm for coronary artery disease treatment allowing temporary vessel support and drug delivery without indefinite coronary caging, potentially reducing the long-term limitation of metallic stents. The scientific community has rapidly embraced this concept and bioresorbable devices have been introduced in clinical practice. However, despite the fact that bifurcation lesions represent a large and challenging subset in the field of interventional cardiology, this subgroup of lesions have been avoided in the initial experience with bioresorbable scaffolds and clear recommendations on methodological approaches are lacking. In the present report, we describe the various techniques for bifurcation treatment with bioresorbable scaffolds and the theoretical advantages and disadvantages of this technology in different scenarios, with a glimpse to challenging subsets and possible complications. Therefore, we aim to provide experience based insights and practical guidance for bioresorbable scaffold implantation in bifurcation lesions. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 03 May 2016; epub ahead of print

Left atrial appendage occlusion using a Watchman device in a transplanted heart with biatrial anastomosis.

Poulin MF, Mohamedali B, Kavinsky CJ, Krishnan K
A percutaneous left atrial appendage (LAA) occlusion using a Watchman device was performed in a patient with prior biatrial anastomosis orthotopic heart transplant (OHT). Due to the anatomical changes following biatrial anastomosis, transesophageal echocardiography (TEE) imaging and transseptal puncture become technically challenging. We describe how the standard LAA views on TEE were obtained for device sizing, and how the transseptal puncture was modified to cross the scarred septum. This case demonstrates that LAA occlusion using a Watchman device in biatrial anastomosis OHT is safe and can successfully be done.

Catheter Cardiovasc Interv: 12 Dec 2018; epub ahead of print

Quantification of the Effect of Pressure Wire Drift on the Diagnostic Performance of Fractional Flow Reserve, Instantaneous Wave-Free Ratio, and Whole-Cycle Pd/Pa.

Cook CM, Ahmad Y, Shun-Shin MJ, Nijjer S, ... Sen S, Davies JE
Small drifts in intracoronary pressure measurements (±2 mm Hg) can affect stenosis categorization using pressure indices. This has not previously been assessed for fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and whole-cycle distal pressure/proximal pressure (Pd/Pa) indices. Methods and resultsFOUR HUNDRED FORTY-SEVEN: stenoses were assessed with FFR, iFR, and whole-cycle Pd/Pa. Cut point values for significance were predefined as ≤0.8, <0.90, and <0.93, respectively. Pressure wire drift was simulated by offsetting the distal coronary pressure trace by ±2 mm Hg. FFR, iFR, and whole-cycle Pd/Pa indices were recalculated and stenosis misclassification quantified. Median (±median absolute deviation) values for FFR, iFR, and whole-cycle Pd/Pa were 0.81 (±0.11), 0.90 (±0.07), and 0.93 (±0.06), respectively. For the cut point of FFR, iFR, and whole-cycle Pd/Pa, 34.6% (155), 50.1% (224), and 62.2% (278) of values, respectively, lay within ±0.05 U. With ±2 mm Hg pressure wire drift, 21% (94), 25% (110), and 33% (148) of the study population were misclassified with FFR, iFR, and whole-cycle Pd/Pa, respectively. Both FFR and iFR had significantly lower misclassification than whole-cycle Pd/Pa (P<0.001). There was no statistically significant difference between the diagnostic performance of FFR and iFR (P=0.125).

Circ Cardiovasc Interv: 13 Apr 2016; 9

An alternative treatment strategy for large vessel coronary perforations.

Xenogiannis I, Tajti P, Nicholas Burke M, Brilakis ES
The standard treatment for large vessel coronary perforations is implantation of a covered stent. Antegrade attempts for crossing a right coronary artery chronic total occlusion resulted in guidewire and microcatheter exit with pericardial bleeding. A balloon was inflated proximal to the perforation site to achieve temporary hemostasis. Retrograde crossing of the chronic total occlusion was achieved through an epicardial collateral using the reverse controlled antegrade and retrograde tracking technique. Stent implantation resulted in hemostasis, likely due to creation of a subintimal flap that sealed the perforation site. If technically feasible, subintimal recanalization can be an alternative treatment strategy for coronary perforations occurring during chronic total occlusion percutaneous coronary intervention.

Catheter Cardiovasc Interv: 12 Dec 2018; epub ahead of print

Esophageal perforation caused by an AMPLATZER(TM) vascular plug 4 occlusion device.

Wiegand G, Schlensak C, Hofbeck M
The AMPLATZER(TM) Vascular Plug 4 (AVP4) is a self-expandable, replaceable occluder made of Nitinol wire mesh, which allows the safe and effective interventional occlusion of medium size vessels. This report describes an infant diagnosed with pulmonary atresia, ventricular septal defect, and multifocal collateral lung perfusion through four major aortopulmonary collateral arteries (MAPCAs). A central aorto-pulmonary shunt was performed at 4 months of age. Because of postoperative pulmonary hyperperfusion, one of the MAPCAs was closed interventionally using a 5 mm AVP4. This MAPCA originated from the descending aorta (DAO) near the fifth thoracic vertebra and ran behind the esophagus to the lower lobe of the right lung. The MAPCA was closed near its origin from the DAO. Four weeks later, the patient presented with severe gastrointestinal bleeding, caused by perforation of the AVP4 into the esophagus. The occluder was extracted surgically, the MAPCA was clipped and the esophageal injury was sutured. To date, there have been no reports describing esophageal perforation due to an AVP4. The perforation in this patient may have been due to implantation of the AVP4 near the aorta in a MAPCA segment located directly in front of the spine and behind the esophagus. Another possible factor may have been the requirement for a gastrointestinal feeding tube. Although the occluder is soft and flexible, the spindle-shaped ends may cause trauma if they are located close to other structures. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 02 Jun 2016; epub ahead of print

Ex-vivo percutaneous bypass: Limb perfusion in the setting of occlusive large bore sheath.

Shah Z, Alraies MC, Soud M, Kaki A
Successful cardiac catheterization procedure begins with safe vascular access and ends with effective hemostasis after equipment removal. These new and advanced technologies in the cath lab require large-bore arterial accesses. Large-bore sheaths are associated with blood flow obstruction resulting in limb ischemia. In this case we present a 48-year-old woman was admitted NSTEMI and cardiogenic shock requiring mechanical circulatory support. Selective left common iliac angiography demonstrated obstructive flow at the level of the left CFA (access site). Therefore, ipsilateral bypass circuit was done. The current case illustrates the utility of a temporary ex-vivo bypass circuit to preserve limb perfusion in the presence of an occlusive large bore sheath. The technique permits sufficient hemodynamic support while maintaining limb perfusion and can be used for any occlusive large bore sheath.

Catheter Cardiovasc Interv: 12 Dec 2018; epub ahead of print

Multivessel percutaneous coronary intervention without contrast agents.

Vidi VD, Barseghian A, Garratt KN
Contrast-induced nephropathy (CIN) following coronary angiography is associated with significant morbidity and mortality. Contrast media volume is the key risk factor for CIN in patients with chronic kidney disease undergoing coronary angiography and interventions. Very often, coronary interventions are avoided in such high-risk patients because of possible significant adverse clinical outcomes. We present a case demonstrating use of intravascular ultrasound (IVUS) to guide multivessel percutaneous coronary intervention (PCI) performed without any contrast administration in a patient with extreme risk for CIN. With the availability of advanced imaging of the coronary arteries such as high definition IVUS, contrast free PCI is a feasible approach and is associated with significant advantages of reducing or eliminating the development of CIN following PCI. This case report highlights the key practical aspects of performing contrast-free PCI and the challenges associated with such approach. © 2015 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 27 Dec 2015; epub ahead of print

Left Atrial Appendage and Closure: Who, When, and How.

Holmes DR, Reddy VY
Patients with nonvalvular atrial fibrillation have a 4- to 5-fold increase in strokes and that rhythm may be responsible for 15% to 20% of all strokes, particularly in the elderly. In this setting, thrombus in the left atrial appendage has been found to be the source of stroke in 90% of cases. Although oral anticoagulants have been found effective in reducing stroke rates, for a variety of issues, they may only be used in 40% to 50% of patients at increased risk for stroke. Given pathophysiology of stroke, site-specific therapy directed at left atrial appendage occlusion has been now studied for stroke prevention, and one device is FDA approved (Watchman). A meta-analysis of 2 randomized clinical trials and 2 registries with this device documented the following: (1) patients receiving the device had significantly fewer hemorrhagic strokes (hazard ratio 0.22, P=0.004); (2) a significant reduction in cardiovascular or unexplained death (hazard ratio 0.48, P=0.004); (3) more ischemic strokes in the device group; however, when periprocedural events were excluded, the difference was not significant; and (4) a significant reduction in nonprocedural bleeding with the device (hazard ratio 0.51, P=0.006) versus control. At present, the only device approved in the United States is indicated in patients with nonvalvular atrial fibrillation with acceptable anatomy who are at increased risk for stroke and would be candidates for anticoagulation in whom there is concern about the risk/benefit ratio for chronic anticoagulation. Unresolved issues include optimal patient selection criteria, the role of devices in patients in whom anticoagulation is contraindicated, and the relative role of novel oral anticoagulants versus the device which has not been tested in randomized trials.

Circ Cardiovasc Interv: 02 May 2016; 9

First implantable hemodynamic monitoring device placement in single ventricle fontan anatomy.

Bradley EA, Berman D, Daniels CJ
The Fontan anatomy leads to elevated central venous pressure along with chronic venous congestion and low cardiac output; this is felt to be responsible for deterioration of exercise tolerance and functional capacity over time. Real-time hemodynamic evaluation of the Fontan anatomy has not been evaluated until now. Here, we report the technical aspects of the first two adult Fontan patients to undergo placement of an invasive hemodynamic monitor (IHM). We validate IHM readings with invasive pulmonary artery catheter derived hemodynamics in the Fontan and show successful home transmission of pulmonary artery hemodynamic tracings. This technology has the capacity to change current understanding of Fontan hemodynamics and treatment in patients with complex single-ventricle anatomy. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 24 Mar 2016; epub ahead of print

Circumflex coronary artery injury after mitral valve surgery: A report of four cases and comprehensive review of the literature.

Hiltrop N, Bennett J, Desmet W
As the LCx is closely related to the mitral valve annulus, it is susceptible to perioperative injury. Various underlying mechanisms, predisposing factors, and therapeutic strategies have been suggested but disagreement exists. Using a MeSH terms-based PubMed search, 44 cases of mitral valve surgery-related LCx injury were detected, including our 4 cases. We provide a comprehensive review of current knowledge regarding mitral valve surgery-related left circumflex coronary artery (LCx) injury. Preoperative coronary angiography was performed in 55% (n = 24). Coronary abnormalities were present in 11% (n = 5). Coronary dominance was reported in 73% (n = 32), predominantly showing left (69%, n = 22) or balanced (19%, n = 6) circulations. Right coronary dominance was present in 12% (n = 4). Ischemia was detected in the perioperative or early postoperative phase in 86% (n = 30). Delayed symptoms were present in 14% (n = 5). Echocardiography demonstrated new regional wall motion abnormalities in 80% (n = 24), but was negative in 20% (n = 6) despite coronary compromise. Electrocardiography showed myocardial ischemia in 97% (n = 34), including regional ST-segment elevations in 68% (n = 23). Primary treatment was surgical in 42% (n = 15) and percutaneous in 58% (n = 21), reporting success ratios of 87% (n = 13) and 81% (n = 17), respectively. We confirm an augmented risk of mitral valve surgery-related LCx injury in balanced or left-dominant coronary circulations. Preoperative knowledge of coronary anatomy does not preclude LCx injury. An anomalous LCx arising from the right coronary cusp was identified as a possible specific high-risk entity. Electrocardiographic monitoring and intraoperative echocardiography remain paramount to ensure a timely diagnosis and treatment. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 18 Feb 2016; epub ahead of print

P2Y12 Receptor Antagonists and Morphine: A Dangerous Liaison?

Giannopoulos G, Deftereos S, Kolokathis F, Xanthopoulou I, Lekakis J, Alexopoulos D
P2Y12 receptor antagonists, concurrently administered with aspirin in what has come to be commonly called dual antiplatelet therapy, are a mainstay of treatment for patients with acute coronary syndromes. Morphine, on the contrary, is a commonly used drug in the acute phase of acute coronary syndromes to relieve pain-with the added potential benefit of attenuating acutely raised sympathetic tone. In current guidelines, though, morphine is recommended with decreasing strength of recommendation. One reason is that it raises concern regarding the potentially significant interaction with antiplatelet agents, leading to impaired inhibition of platelet activation. In any case, it is still considered a mandatory part of the inventory of available medications in prehospital acute myocardial infarction management. The goal of the present review is to present published evidence on morphine and its potential interactions with P2Y12 receptor antagonists, as well as on the central issue of whether such interactions may underlie clinically significant effects on patient outcomes.

Circ Cardiovasc Interv: 01 Sep 2016; 9

First-in-human robotic percutaneous coronary intervention for unprotected left main stenosis.

Mahmud E, Dominguez A, Bahadorani J
The safety and feasibility of robotically-assisted percutaneous coronary intervention (PCI) for simple coronary lesions has been demonstrated. The CorPath robotic system (Corpath 200, Corindus, Waltham, MA) consists of a robotic arm mounted on the cardiac catheterization table that consists of a drive housing a single-use sterile cassette, which is connected to the guiding catheter. While sitting in the nonsterile, radiation-shielded cockpit, the operator remotely controls delivery and removal of coronary guidewires, angioplasty balloons, and stents. The database for the ongoing PRECISION registry was queried at a single center and results of unprotected left main robotic PCI procedures are reported. Of 102 robotic PCI procedures performed at this center, 6 were unprotected left main lesions (age 69 ± 14 years; 67% male). All 6 subjects underwent successful PCI (fluoroscopy time 26.8 ± 11.4 min;1.8 stents and 2.2 vessels treated/patient) with three requiring hemodynamic support (two with percutaneous left ventricular assistance using the Impella 2.5 (Abiomed, Danvers, MA) and one with intraaortic balloon pump counterpulsation). This report demonstrates the feasibility of performing robotically assisted unprotected left main PCI with or without hemodynamic support. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 17 May 2016; epub ahead of print

The wise radialist\'s guide to optimal transfemoral access: Selection, performance, and troubleshooting.

Azzalini L, Jolicœur EM
Transradial access (TRA) has reduced vascular access-site complication (VASC) and bleeding rates in patients undergoing coronary angiography and intervention. A "radial-first" approach should be adopted and indications of TRA extended in order to maximize its beneficial effect. However, in certain clinical scenarios, transfemoral access (TFA) is a preferable or a mandatory route to successfully perform the procedure. Since the widespread adoption of TRA, a paradoxical increase in VASC rates has been observed in patients undergoing TFA, which might be attributed to a combination of increased risk profile of both the procedures and the patients, and a loss of skills in securing TFA by those who are now default radial operators. In the present article we provide recommendations on how to optimize patient selection for TRA and TFA, how to manage access site crossover, and how to perform state-of-the-art femoral artery puncture. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 23 May 2016; epub ahead of print

Percutaneous transapical pseudoaneurysm closure following transcatheter aortic valve replacement.

Okuyama K, Chakravarty T, Makkar RR
Left ventricular pseudoaneurysm (LVP) formation is a rare but potentially life-threatening complication of transapical transcatheter aortic valve replacement (TAVR). Conventionally, a pseudoaneurysm has been treated surgically; however, improved transcatheter technique and device technology have made a percutaneous closure of LVP an increasingly viable option, especially in a patient unfavorable for surgery. A TAVR candidate is most likely at increased surgical-risk or inoperable. Therefore a percutaneous closure can be a reasonable strategy for LVP, but its experience following this emerging aortic valve procedure remains limited. We describe a case of LVP formation after TAVR in which it was efficiently treated with a percutaneous closure using a transapical approach via LVP. The first attempt was performed with a transfemoral approach. Pre-closure angiography revealed an eccentric shape of a LVP neck like a "chicken leg". This shape caused serious difficulty to cross LVP with a wire and it was not accomplished. However, the LVP location was at the apex and we could access from a chest wall through the pseudoaneurysm in the second attempt. This approach allowed a close and coaxial wire manipulation and the neck of LVP was finally crossed. After that, a closure device was deployed and the second procedure was successfully completed. An approach selection often contributes to a procedural success. This is the first case of a percutaneous LVP closure following TAVR using a transapical access and may suggest this approach as a possible option for this catheter closure in TAVR candidates. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 12 Sep 2016; epub ahead of print

Hybrid pulmonary artery plication followed by transcatheter pulmonary valve replacement: Comparison with surgical PVR.

Sosnowski C, Matella T, Fogg L, Ilbawi M, ... Caputo M, Kenny D
Objective/Background Historically, the sole option for patients with a dysfunctional native right ventricular outflow tract (RVOT) requiring re-establishment of pulmonary competence has been surgical PVR. We sought to compare early outcomes of hybrid pulmonary valve replacement (PVR) combining surgical plication of the main pulmonary artery followed by transcatheter PVR, with a contemporary cohort of surgical PVR patients. Methods Retrospective chart analysis of all patients with a dilated native RVOT eligible for surgical PVR over 36 months was performed. The cohorts included patients with previous tetralogy of Fallot repair (n = 14), and previous intervention for congenital abnormality of the pulmonary valve (n = 7). Results Twenty-one patients with a dysfunctional native RVOT met criteria for PVR; 8 using the hybrid procedure (group 1: age, 31.5 +/- 17.4 years) and 13 with cardiopulmonary bypass (CPB) (group 2: age, 31 +/- 18.4 years). Valve delivery was successful in all patients with no procedural mortality. Group 1 had a lesser requirement for blood products (P =< 0.001) and a trend toward shorter hospital stay and higher post-operative hemoglobin. No patients in group 1 received inotropic support post-operatively compared to 54% of patients in group 2. Mean follow-up was 3.4 months for group 1 and 13.6 months for group 2 with the average peak gradient across the RVOT of 20.1 and 15.1 mm Hg respectively (P = 0.12), all with no more than mild PI. Conclusions Transcatheter hybrid PVR following RVOT plication provides a reasonable alternative to surgical PVR particularly in higher risk cohorts, reducing possible longer-term consequences of repeated runs of CPB. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 17 Aug 2016; epub ahead of print

Management of Critical Limb Ischemia.

Kinlay S
Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as nonhealing ulcers or gangrene, related to peripheral artery disease. CLI has a high short-term risk of limb loss and cardiovascular events. Noninvasive or invasive angiography help determine the feasibility and approach to arterial revascularization. An endovascular-first approach is often advocated based on a lower procedural risk; however, specific patterns of disease may be best treated by open surgical revascularization. Balloon angioplasty and stenting form the backbone of endovascular techniques, with drug-eluting stents and drug-coated balloons offering low rates of repeat revascularization. Combined antegrade and retrograde approaches can increase success in long total occlusions. Below the knee, angiosome-directed angioplasty may lead to greater wound healing, but failing this, any straight-line flow into the foot is pursued. Hybrid surgical techniques such as iliac stenting and common femoral endarterectomy are commonly used to reduce operative risk. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5-mm diameter. Minor amputations are often required for tissue loss as a part of the treatment strategy. Major amputations (at or above the ankle) limit functional independence, and their prevention is a key goal of CLI therapy. Medical therapy after revascularization targets risk factors for atherosclerosis and assesses wound healing and new or recurrent flow-limiting disease. The ongoing National Institutes of Health-sponsored Best Endovascular Versus Best Surgical Therapy in Patients With Critical Limb Ischemia (BEST-CLI) study is a randomized trial of the contemporary endovascular versus open surgical techniques in patients with CLI.

Circ Cardiovasc Interv: 08 Feb 2016; 9:e001946

Effective percutaneous "edge-to-edge" mitral valve repair with mitraclip in a patient with acute post-MI regurgitation not related to papillary muscle rupture.

Tarsia G, Smaldone C, Costantino MF
A 65-year-old woman was admitted to our institution for rest dyspnea and hypotension. EKG showed sinus tachycardia with signs of infero-posterior STEMI. 2D-echocardiogram showed severe left ventricular systolic dysfunction with a- diskynesia of the inferior and posterior walls and severe functional mitral regurgitation (MR). The patient underwent urgent coronary angiography that showed 3-vessels disease with total occlusion of both first obtuse marginal (OM) branch of the left circumflex artery and right coronary artery (RCA) and critical stenosis of left anterior descending (LAD). Because of extremely high surgical risk, we performed a staged totally percoutaneous approach. First, we reopened the presumed culprit vessels (RCA and OM) and then, after 48 hr, we performed angioplasty of the LAD. Since revascularization provided no significant improvement in respiratory and hemodynamic parameters we performed a percutaneous mitral repair with Mitraclip. MR grade was reduced from severe to trivial with rapid improvement of the respiratory and hemodynamic parameters. The post-procedural course was uneventful and the patient was discharged 7 days later. At the 30-day and 6-month follow-up the patient remained asymptomatic in NYHA I functional class with no recurrence of MR. Acute MR due to post-AMI mechanical complications is generally considered a contraindication to MitraClip implantation for several reasons. However, the present report shows that, in selected cases, the Mitraclip system may be successfully used to reduce the severity of acute MR secondary to AMI and may allow to reverse cardiogenic shock and/or refractory pulmonary congestion related to the acute regurgitation. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 15 Feb 2016; epub ahead of print

Symptomatic right coronary anomaly with dynamic systolic intramural obliteration and isolated right ventricular ischemia.

Angelini P, Uribe C
A 52-year-old man was referred for an anomalous right coronary artery (RCA) originating from the left sinus of Valsalva with an intramural course (R-ACAOS-IM), accompanied by progressive angina and dyspnea. He had been initially advised to have surgical treatment. Computerized axial tomographic angiography showed he had an ectopic origin from the left sinus of a small RCA, with a course between the aorta and pulmonary artery. His negative treadmill nuclear stress test was prematurely terminated because of angina and dyspnea. At our institution, intravascular ultrasound imaging indicated an intramural course and critically severe phasically changing proximal stenosis (80%-100%). The stenosis was resolved with stent-angioplasty of the intramural segment. He had no complications and returned quickly to an asymptomatic state with unrestricted physical activity.

Catheter Cardiovasc Interv: 25 Dec 2018; epub ahead of print

Management of a dissection of matrix P right ventricular-to-pulmonary artery conduit by implanting two pre-stents and a melody valve.

Nozynska J, Stiller B, Grohmann J
Reconstructing the right ventricular outflow tract and pulmonary valve via a bovine-derived valve conduit such as Matrix-P-Xenograft is a common surgical repair technique for pulmonary atresia and ventricular septal defect. After conduit degeneration due to calcification or aneurysmal dilatation, percutaneous transvenous stenting of the right ventricular outflow tract followed by pulmonary valve implantation has become the standard interventional treatment. Applied to stenotic conduits, the method is considered safe and effective. An important but seldom-reported problem is graft failure related to the formation of a Matrix membrane due to inflammation and fibrosis inside the xenograft, which can cause serious problems when dissection and rupture occur during transcatheter intervention. The torn pseudomembrane may cause the complete obstruction of both pulmonary arteries, resulting in a life-threatening situation requiring rapid intervention, as in this case presentation. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 31 May 2016; epub ahead of print

Percutaneous closure of acute aorto-right ventricular fistula following transcatheter bicuspid aortic valve replacement.

Nakamura K, Passeri JJ, Inglessis-Azuaje I
We report a case of acute aorto-right ventricular fistula following transcatheter bicuspid aortic valve replacement and subsequent percutaneous closure. The diagnosis and treatment of this rare complication is illustrated through multi-modality imaging. We hypothesize that the patient\'s heavily calcified bicuspid aortic valve anatomy led to asymmetric deployment of the transcatheter aortic valve replacement (TAVR) prosthesis, traumatizing the right sinus of Valsalva at the distal edge of the TAVR stent and ultimately fistulized to the right ventricle. The patient acutely decompensated with heart failure five days after TAVR and underwent emergent intervention. The aorto-right ventricular fistula was closed using an 18-mm septal occluder device with marked clinical recovery. Transcatheter closure is a viable treatment option for acute aorto-right ventricular fistula. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 21 Aug 2016; epub ahead of print

Adderall induced inverted-Takotsubo cardiomyopathy.

Alsidawi S, Muth J, Wilkin J
Introduction: Takotsubo Cardiomyopathy (TTC), also known as stress-induced cardiomyopathy, was initially described in Japan in 1990. Both illicit and prescription drugs have added to the growing list of insulting stressors. We describe an interesting case of atypical TTC triggered by adderall overdose. Clinical case: A 19-year-old female was brought to the Emergency Department after ingesting 30 Adderall tablets. She was complaining of pressure like chest pain and shortness of breath. Her cardiac enzymes were elevated but the electrocardiogram was unremarkable. Echocardiography identified an ejection fraction (EF) of 25-30% with severe hypokinesis of the base and a preserved apex. Cardiac angiography demonstrated normal coronary arteries with an EF of 35%, hyperkinetic apex and akinetic base consistent with the diagnosis of inverted-TTC. Her symptoms resolved in 24 hrs. Repeat echocardiogram performed 3 days later showed an EF of 60% with no regional wall motion abnormalities. Discussion: TTC can be identified as a rapid development of severe and reversible left ventricular dysfunction extending beyond the territory of a single epicardial coronary artery in the absence of coronary artery disease or pheochromocytoma. Clinical presentation can be challenging and very hard to distinguish from acute myocardial infarction. Medication induced-TTC has been reported. In our case, the patient overdosed on Adderall which is a sympathomimetic medication. Cardiac imaging identified wall motion abnormalities consistent with inverted type TTC. Restoration of left ventricular function within days confirms the diagnosis of TTC. In conclusion, this case offers an interesting insight into the pathophysiology of TTC. © 2011 Wiley-Liss, Inc.

Catheter Cardiovasc Interv: 13 May 2011; epub ahead of print

Successful retrieval of an entrapped rotablator burr using 5 Fr guiding catheter.

Kimura M, Shiraishi J, Kohno Y
Background: Although burr entrapment is a rare complication of the Rotablator, it is extremely difficult to retrieve a fixedly entrapped burr without surgical procedure. Case Report: An 84-year-old male with effort angina had heavily calcified coronary trees as well as severe stenosis in the mid LCx, and moderate stenosis in the proximal LCx, and in the LMT. We planned to perform rotational atherectomy in the LCx lesions. Using 7 Fr Q-curve guiding catheter and Rotawire floppy, we began to ablate using 1.5-mm burr at 200,000 rpm. Because the burr could not pass the proximal stenosis, we exchanged the wire for Rotawire extrasupport and the burr for 1.25-mm burr, and restarted the ablation at 220,000 rpm. Although the burr could manage to pass the proximal stenosis, it had become trapped in the mid LCx lesion. Simple pull on the Rotablator, rotation of the burr, and crossing the Conquest (Confianza) wire could not retrieve it. Thus, we cut off the drive shaft and sheath of the Rotablator, inserted 5 Fr 120-cm straight guiding catheter (Heartrail ST01; Terumo) through the remaining Rotablator system, pushed the catheter tip to the lesion around the burr as well as simultaneously pulled the Rotablator, and finally could retrieve it. Then we implanted stents in the LCx and in the LMT without difficulty. Conclusions: The 5 Fr straight guiding catheter might be useful for retrieving an entrapped burr (1.25-mm burr). © 2011 Wiley-Liss, Inc.

Catheter Cardiovasc Interv: 06 May 2011; epub ahead of print

Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes.

Schüpke S, Neumann FJ, Menichelli M, Mayer K, ... Kastrati A,
Background
The relative merits of ticagrelor as compared with prasugrel in patients with acute coronary syndromes for whom invasive evaluation is planned are uncertain.
Methods
In this multicenter, randomized, open-label trial, we randomly assigned patients who presented with acute coronary syndromes and for whom invasive evaluation was planned to receive either ticagrelor or prasugrel. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. A major secondary end point (the safety end point) was bleeding.
Results
A total of 4018 patients underwent randomization. A primary end-point event occurred in 184 of 2012 patients (9.3%) in the ticagrelor group and in 137 of 2006 patients (6.9%) in the prasugrel group (hazard ratio, 1.36; 95% confidence interval [CI], 1.09 to 1.70; P = 0.006). The respective incidences of the individual components of the primary end point in the ticagrelor group and the prasugrel group were as follows: death, 4.5% and 3.7%; myocardial infarction, 4.8% and 3.0%; and stroke, 1.1% and 1.0%. Definite or probable stent thrombosis occurred in 1.3% of patients assigned to ticagrelor and 1.0% of patients assigned to prasugrel, and definite stent thrombosis occurred in 1.1% and 0.6%, respectively. Major bleeding (as defined by the Bleeding Academic Research Consortium scale) was observed in 5.4% of patients in the ticagrelor group and in 4.8% of patients in the prasugrel group (hazard ratio, 1.12; 95% CI, 0.83 to 1.51; P = 0.46).
Conclusions
Among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups. (Funded by the German Center for Cardiovascular Research and Deutsches Herzzentrum München; ISAR-REACT 5 ClinicalTrials.gov number, NCT01944800.).

Copyright © 2019 Massachusetts Medical Society.

N Engl J Med: 16 Oct 2019; 381:1524-1534

A new strategy for septal ablation with transendocardial ethanol injection using a multifunctional intracardiac echocardiography catheter: A feasibility study in canines?

Guo R, Qian J, Yang Y, Zhu Q, ... Wang Z, Huang J
ObjectiveS: To evaluate the feasibility and safety of a novel multifunctional intracardiac echocardiography catheter for target septal ablation with transendocardial ethanol injection in canines. Background: Percutaneous transluminal septal myocardial ablation has been the primary catheter-based strategy for the treatment of hypertrophic obstructive cardiomyopathy (HOCM). However, inherent limitations of the technique have reduced its therapeutic efficacy. Methods: A new catheter (10 F), integrated with a nitinol needle (29 G) and a 6.5-10- MHz, 32-element, side-fire ultrasound imaging transducer, was delivered into the right ventricle in nine canines and the left ventricle in three canines. A 0.3-ml microbubble and 0.5-1.5 ml absolute ethanol were sequentially injected into the interventricular septum. Electrocardiograph recordings were obtained during the whole procedure. Three hours after this operation, the heart was harvested for gross and histological examination. Results: In all canines, the catheter provided the structural support and helped guide proper needle position within the septum. The microbubble further allowed the confirmation of the needle location through focal echo-density enhancement. Different amounts of ethanol infusion produced a dose-related effect on myocardial ablation. Macroscopic examination showed that the target myocardium became pale with a distinct border between lesions and normal tissue. Hematoxylin and eosin staining further confirmed necrosis within the injection region. Conclusions: Transendocardial ethanol injection at the interventricular septum resulted in controlled myocardial infarction. In addition, the injection depth could be visually followed using this new system, which may provide a safer and more intuitive method for the treatment of HOCM or other cardiomyopathies. © 2011 Wiley-Liss, Inc.

Catheter Cardiovasc Interv: 04 May 2011; epub ahead of print

Transcatheter interventions across fresh suture lines in infants and children: An 8-year experience.

Nicholson GT, Kim DW, Vincent RN, Petit CJ
Objectives The purpose of this study was to examine the outcomes of catheter dilation interventions in general upon surgical anastomotic sites in the immediate postoperative period. Background Early postoperative cardiac catheter intervention is regarded as high-risk, particularly when a dilation intervention across a fresh suture line is performed. Methods All catheter dilation interventions performed upon a fresh suture line within 30 days of congenital heart surgery between August 2005 and December 2013 were reviewed. Values are reported as median and interquartile range (IQR). Primary endpoint was procedural success, which was defined as an increase in vessel diameter of >75% of the adjacent normal vessel or 50% increase over pre-dilation diameter. Secondary endpoints included procedural complications and survival to hospital discharge. Results Forty-five patients, median age 0.15 years (0.03 - 0.51 years), weight 4.1kg (3.1 - 6.4kg), underwent 62 interventional procedures on median postoperative day 7 (3 - 13 days). Among the 62 dilation interventions at surgical anastomotic areas, were 30 stent and 32 balloon angioplasty procedures. There were 2 major complications including: arterial dissection during stent placement and a procedural mortality due to pulmonary artery avulsion during angioplasty. There were 12 deaths (27%) prior to hospital discharge. The median ratio of maximum stent diameter to stenosis diameter was 2.62 (2.27 - 3.73). The median ratio of maximum balloon diameter to stenosis diameter was 2.27 (1.84 - 2.94). Stent placement was more likely to result in procedural success (OR 2.1; 95% confidence interval 1.6 - 2.8). Conclusion Though caution is paramount, early postoperative catheter dilation intervention across fresh suture lines can be performed safely in small, critically ill children. This article is protected by copyright. All rights reserved.

Catheter Cardiovasc Interv: 01 Mar 2015; epub ahead of print

Mid-term follow-up of perventricular device closure of muscular ventricular septal defects.

Bendaly EA, Hoyer MH, Breinholt JP
Background: Surgical and transcatheter management of muscular ventricular septal defects (MVSD) have independent drawbacks. Hybrid procedures are becoming increasingly utilized to manage congenital cardiac lesions including MVSDs. This report describes the mid-term results of perventricular device closure of MVSDs at a single institution. Methods: The cardiology database of patients who underwent attempted perventricular MVSD closure from a single institution was reviewed. Results: Between January 2004 and December 2009, 6 patients underwent attempted perventricular MVSD closure in the operating room. Mean age was 9.8 ± 9.1 months; mean weight was 7.2 ± 3.7 kg. In 5 patients, closure was successful without use of bypass. In 1 patient, the device embolized to the left ventricle after release and patch closure of the MVSD was performed on cardiopulmonary bypass. The mean interval from the procedure to the most recent echocardiogram for the patients with successful perventricular closure was 39.8 ± 25.2 months. Three patients demonstrated no residual shunt at the last echocardiogram. Two patients had mild, hemodynamically insignificant shunting; one had a left ventricular pseudoaneurysm that was embolized during repeat catheterization. Conclusion: Perventricular closure of MVSDs is attractive because it overcomes the limitations of surgery and catheterization. Additionally, it spares the need for cardiopulmonary bypass and its comorbidities. In some instances, however, successful deployment of the device is not possible. Our mid-term results demonstrate overall success but identify possible complications that are not immediately identified in the short-term. © 2011 Wiley-Liss, Inc.

Catheter Cardiovasc Interv: 04 May 2011; epub ahead of print

Outcomes following implantation of the Biolimus A9-eluting BioMatrix coronary stent: Primary analysis of the e-BioMatrix registry.

Urban P, Valdés M, Menown I, Eberli F, ... Xaver Kleber F, e-Biomatrix investigators
Objectives. To assess the safety and efficacy of Biolimus A9-eluting stents (BES, BioMatrix™ and BioMatrix Flex™) in routine clinical practice. Background. The LEADERS randomized trial has documented equivalent efficacy and superior safety of the BES when compared to a first generation Sirolimus-eluting Cypher(TM) stent. Methods. 5,472 patients from 57 centers, treated with BES, were enrolled in an international multicenter registry and followed clinically up to 2 years. Results. Mean patient age was 63.2 ± 11 years, 24% of patients had diabetes, and 49.8% presented with an acute coronary syndrome. 99.3% of patients were discharged on dual antiplatelet therapy [DAPT], 83.3% remained on DAPT at 1 year and 30.6% at 2 years. The incidence of the composite primary endpoint (Major Adverse Cardiac [MACE] at 12 months) was 4.5% (cardiac death 0.9%, myocardial infarction 1.7%, clinically indicated target vessel revascularization [ci-TVR] 2.8%). MACE incidence was 6.8% at 24 months (cardiac death 1.5%, myocardial infarction 2.4%, ci-TVR 4.3%). At 12 months, 32 patients (0.6%) had suffered at least one definite or probable stent thrombosis [ST], and 91 patients (1.7%) a major bleed [MB]. Nine patients with ST (27.3%) and 7 patients with a MB (7.7%) died during the first year after the index procedure. Between 12 and 24 months after implantation, there were 18 (0.4%) additional MB and 8 (0.2%) additional ST. Conclusions. This large international cohort documents a low 12 and 24 months MACE incidence and a very low ST incidence in an unselected patient population undergoing BES implantation. The results are in keeping with those of the randomized controlled LEADERS trial. Even though ST with this stent was a rare event, it was still associated with significant mortality. MB remains a problem, and warrants improved tailoring of DAPT in recipients of drug eluting stents. This article is protected by copyright. All rights reserved.

Catheter Cardiovasc Interv: 15 Feb 2015; epub ahead of print

Cost implications of intraprocedural thrombotic events during PCI.

Plent S, Fan W, Kirtane A, Brener SJ, ... Cohen DJ, Stone GW
Objectives: We sought to estimate the direct costs (in-hospital and 30-day) associated with an intraprocedural thrombotic event (IPTE) among patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) undergoing percutaneous coronary intervention (PCI). Background: Patients with IPTE have higher rates of in-hospital and 30-day major adverse cardiac events than patients without IPTE. The extent to which IPTE also add to medical costs is unknown. Methods: Hospital costs for patients in the ACUITY Trial were compared between patients with and without IPTE. Adjusted comparisons were performed using generalized linear models (GLM). All costs are reported in 2012 US dollars. Results: A total of 1,307 patients with both core laboratory-based angiographic assessment and detailed economic data were included in the final study population. IPTE occurred in 52 patients (4.0%). Median in-hospital costs were higher in patients with IPTE than in those without IPTE ($23,719 vs. $18,419, p=0.01). Thirty-day median costs were also higher for IPTE patients ($23,719 vs. $19,556, p=0.05). After adjusting for baseline differences, IPTE was associated with 19.5% (95% CI: [2.8%-38.8%], p=0.02) and 18.9% (95% CI: [1.2%-39.7%], p=0.04) increases in in-hospital and 30-day costs, respectively. These relative differences represent median increases of $3,592 in initial hospital costs and $3,696in 30-day costs. Conclusions: The occurrence of IPTE during the index PCI in patients with NSTEACS is associated with substantial increases in-hospital and 30-day costs. These findings suggest that strategies to prevent IPTE may be associated with important cost offsets as well as improved clinical outcomes. This article is protected by copyright. All rights reserved.

Catheter Cardiovasc Interv: 01 Mar 2015; epub ahead of print

Percutaneous treatment of a massive saphenous vein graft aneurysm.

Knoery C, Ashcroft M, Smith JA, Leslie SJ
Saphenous vein graft (SVG) aneurysms are a rare, frequently late presenting, potentially fatal complication of coronary artery bypass graft (CABG) surgery. They are often discovered incidentally during radiological tasks such as chest x-ray or CT but can present clinically with symptoms such as worsening angina and breathlessness as well as complications such as rupture or myocardial infarction. Given the risks if left untreated, consideration should be given to treatment either through percutaneous routes or open surgery. However, because of a lack of strong evidence, there are no definitive guidelines on the treatment of SVG aneurysms. We describe a patient with an extensive cardiac surgical history who presented with angina and breathlessness and was found to have a large SVG aneurysm, subsequently successfully treated with percutaneous coronary intervention with covered stents.

Catheter Cardiovasc Interv: 26 Dec 2018; epub ahead of print

The effectiveness of excimer laser coronary atherectomy with contrast medium for under-expanded stent; The findings of optical frequency domain imaging.

Ashikaga T, Yoshikawa S, Isobe M
Stent underexpansion is a risk factor for in-stent restenosis (ISR) and stent thrombosis. Although excimer laser coronary atherectomy (ELCA) with contrast medium was shown to be effective to improve stent underexpansion in undilatable lesions, precise mechanism of this technique was not well understood. We report a case of ISR with stent underoptimal implantation within a circumferential calcified atherosclerotic plaque beneath the stent strut that could not be dilated by repeated high-pressure balloon inflations. After rotational atherectomy, the mechanism of the underexpanded lesion could be obtained by optical frequency domain imaging (OFDI). High-pressure balloon could not dilate the underexpanded stent. Since ELCA with saline flush only gave intimal erosions and minor dissections, additional high-pressure balloon was also ineffective. Finally ELCA with contrast medium could disrupt the calcific lesion beneath the underexpanded stent. The angiographic and OFDI findings confirmed the full stent expansion could be accomplished by further balloon dilatation with an ordinary pressure. ELCA with contrast medium is feasible to improve stent underexpansion by disrupting the calcified plaque behind the stent strut. This article is protected by copyright. All rights reserved.

Catheter Cardiovasc Interv: 09 Mar 2015; epub ahead of print

Novel X-ray imaging technology enables significant patient dose reduction in interventional cardiology while maintaining diagnostic image quality.

Eloot L, Thierens H, Taeymans Y, Drieghe B, ... Lapere R, Bacher K
Objectives The purpose of this study was to quantify the reduction in patient radiation dose during coronary angiography by a new X-ray technology, and to assess its impact on diagnostic image quality. Background Recently, a novel X-ray imaging technology has become available for interventional cardiology, using advanced image processing and an optimized acquisition chain for radiation dose reduction. Methods 70 adult patients were randomly assigned to a reference X-ray system or the novel X-ray system. Patient demographics were registered and exposure parameters were recorded for each radiation event. Clinical image quality was assessed for both patient groups. Results With the same angiographic technique and a comparable patient population, the new imaging technology was associated with a 75% reduction in total kerma-area product (KAP) value (decrease from 47 Gycm(2) to 12 Gycm(2) , P<0.001). Clinical image quality showed an equivalent detail and contrast for both imaging systems. On the other hand, the subjective appreciation of noise was more apparent in images of the new image processing system, acquired at lower doses, compared to the reference system. However, the higher noise content did not affect the overall image quality score, which was adequate for diagnosis in both systems. Conclusions For the first time, we present a new X-ray imaging technology, combining advanced noise reduction algorithms and an optimized acquisition chain, which reduces patient radiation dose in coronary angiography drastically (75%), while maintaining diagnostic image quality. Use of this technology may further improve the radiation safety of cardiac angiography and interventions. This article is protected by copyright. All rights reserved.

Catheter Cardiovasc Interv: 09 Mar 2015; epub ahead of print

Two-year results of a low-dose drug-coated balloon for revascularization of the femoropopliteal artery: Outcomes from the ILLUMENATE first-in-human study.

Schroeder H, Meyer DR, Lux B, Ruecker F, Martorana M, Duda S
Objectives: To assess the safety and effectiveness of the Stellarex™ drug-coated angioplasty balloon (DCB) to inhibit restenosis in the superficial femoral (SFA) and/or popliteal artery. Background: Treatment of peripheral arterial disease is challenged by restenosis, requiring revascularization procedures to maintain patency. DCBs are designed to deliver an anti-proliferative drug to the vessel wall in order to diminish smooth muscle cell proliferation and maintain patency. Methods: This prospective, single-arm, multi-center study enrolled 50 patients with 58 lesions in the first cohort that required pre-dilatation with an uncoated angioplasty balloon prior to inflation of the DCB. The primary effectiveness endpoint was 6-month late lumen loss (LLL). The major secondary endpoint was major adverse event (MAE) rate at 6 months, defined as cardiovascular death, amputation and/or ischemia-driven target lesion revascularization. Results: The mean lesion length was 7.2cm and baseline stenosis was 75.1%. Calcification was present in 62.1% of lesions and 13.8% were occluded. Both endpoints met their pre-specified performance goals; at 6 months, the MAE rate was 4% and the mean LLL was 0.54mm. The primary patency rate was 89.5% at 12 months and 80.3% at 24 months. The freedom from clinically-driven target lesion revascularization rate, per Kaplan-Meier estimate, was 90.0% at 12 months and 85.8% at 24 months. Additionally, there were no amputations or cardiovascular deaths reported through 24 months. Conclusions: The Stellarex DCB provides safe and durable clinical outcomes for treatment of femoropopliteal artery disease through 24 months. This article is protected by copyright. All rights reserved.

Catheter Cardiovasc Interv: 23 Feb 2015; epub ahead of print

Transapical tricuspid valve-in-ring implantation: An alternative approach to a challenging clinical scenario.

Girdauskas E, Lauer B, Kuntze T
We report on a transapical tricuspid valve-in-ring implantation performed via right ventricular apex using the Sapien-XT-prosthesis. A 57-year-old woman with recurrent episodes of right heart failure and three previous sternotomies, including tricuspid valve repair with a 32 mm Carpentier-Edwards-Classic annuloplasty ring was admitted due to recurrent severe tricuspid regurgitation. Given the excessive surgical risk, a 29 mm Sapien-XT-prosthesis was selected for valve-in-ring implantation. Transapical valve-in-ring implantation procedure was uneventful. Predischarge echocardiography showed only trace paravalvular tricuspid regurgitation in the septal region. Transapical approach via right ventricular apex is a viable alternative for tricuspid valve-in-ring implantation in selected high-risk patients. © 2016 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 11 Aug 2016; epub ahead of print

A prospective, post-market study with the MGuard prime embolic protection stent in ST-segment elevation myocardial infarction: The international mguard prime observational study (IMOS Prime).

Amoroso G, Vos NS, Van der Heyden JA, van der Schaaf RJ, ... Herrman JP, Slagboom T
Aims We sought to evaluate the procedural and clinical performances of the MGuard Prime Embolic Protection Stent (EPS) in a "real-world" population with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Methods and results Consecutive STEMI patients meeting the inclusion criteria and undergoing PPCI were enrolled. The primary endpoint was MACE at 30 days, defined as the composite of cardiac death, myocardial infarction (Q wave and non-Q wave) or target lesion revascularization (PCI or CABG). Secondary endpoints included device success, lesion success, and post-procedural reperfusion outcomes: TIMI flow and ST-segment Elevation Resolution (STR). A total of 97 patients (62 years, 77% males) were included. Symptom to cathlab time was 238 min. Device and lesion success were 100%. Final TIMI-3 flow was achieved in 91.8%, and STR>50% in 87% of the patients. MACE at 30 days was 2.2%, which consisted of one case each of target vessel (TV)-myocardial infarction (MI), and non-TV-MI. Conclusions The use of the MGuard Prime EPS stent is feasible, safe and could be also effective in achieving myocardial reperfusion in STEMI patients undergoing PPCI. This article is protected by copyright. All rights reserved.

Catheter Cardiovasc Interv: 09 Mar 2015; epub ahead of print

Prognostic value of cardiac troponin-i or troponin-t elevation following nonemergent percutaneous coronary intervention: A meta-analysis.

Feldman DN, Kim L, Rene AG, Minutello RM, Bergman G, Wong SC
ObjectiveS: The aim of this meta-analysis was to assess the prevalence and prognostic value regarding mortality of cTnT or cTnI elevations after nonemergent percutaneous coronary intervention (PCI) in a large number of cohort/registry studies. Background: Routine cardiac troponin measurement after elective PCI has been controversial among interventionalists. Recent studies have provided conflicting data in regard to predictive value of cardiac troponin-T (cTnT) and troponin-I (cTnI) elevation after non-emergent PCI. Methods: Electronic and manual searches were conducted of all published studies reporting on the prognostic impact of cTnT or cTnI elevation after elective PCI. A meta-analysis was performed with all-cause mortality at follow-up as the primary endpoint. Results: We identified 22 studies, involving 22,353 patients, published between 1998 and 2009. Postprocedural cTnT and cTnI were elevated in 25.9% and 34.3% of patients, respectively. Follow-up period ranged from 3 to 67 months (mean: 17.7 ± 14.9 months). The results showed no heterogeneity among the trials (Q-test: 25.39; I(2) : 17%; P = 0.23). No publication bias was detected (Egger\'s test: P = 0.16). The long-term all-cause mortality in patients with cTnI or cTnT elevation after PCI (5.8%) was significantly higher when compared to patients without cTnI or cTnT elevation (4.4%); OR 1.45 (95% CI: 1.22-1.72), P < 0.01. In addition, the postprocedural composite adverse clinical events of all-cause mortality or myocardial infarction (MI) in patients with cTnI or cTnT elevation after PCI (9.2%) was significantly higher when compared to patients without cTnI or cTnT elevation (5.3%); OR 1.77 (95% CI: 1.48-2.11), P < 0.01. Conclusions: The current meta-analysis indicates that cTnI or cTnT elevation after nonemergent PCI is indicative of an increase in long-term all-cause mortality as well as the composite adverse events of all-cause mortality and MI. Efforts to routinely monitor periprocedural cTn levels along with more intensive outpatient monitoring/treatment of patients with cTn elevations may help to improve the long-term adverse outcomes in these patients following non-emergent PCI. © 2011 Wiley-Liss, Inc.

Catheter Cardiovasc Interv: 16 May 2011; epub ahead of print

Percutaneous transcatheter closure of a large systemic to pulmonary venous fistulae in an adult patient after extracardiac fontan.

Healan S, Varga P, Shah AP
Vascular fistulae are frequent complications in patients who have undergone a Fontan operation for palliation of single ventricle physiology. Fistulae involving the pulmonary vasculature may result in progressive hypoxemia, pulmonary hemorrhage and clinical symptoms. These are commonly managed by percutaneous transcatheter embolization utilizing coils, and more recently, vascular plugs and septal occluders. We present a clinical case of an adult patient who underwent an extracardiac Fontan procedure in childhood for univentricular physiology and presented with symptoms of systemic desaturation ten years after his surgery. The patient was found to have a large fistula from the inferior vena cava to the right inferior pulmonary vein. The fistula was attempted to be closed with a 12mm Amplatzer Septal Occluder (St. Jude Medical, St. Paul MN). Angiography showed continued flow across the fistula, which was then successfully occluded with an 18mm Amplatzer "Cribriform" Septal Occluder (St. Jude Medical, St. Paul MN). The patient experienced immediate improvement in his systemic saturation, and demonstrates continued resolution of his symptomatic hypoxia on follow-up. This case illustrates an uncommon systemic to pulmonary vein fistula after Fontan, and a unique, successful embolization with two septal occluders, resulting in sustained symptomatic improvement. This article is protected by copyright. All rights reserved.

Catheter Cardiovasc Interv: 23 Feb 2015; epub ahead of print