Percutaneous Closure of an Iatrogenic Aorta to Right Ventricle Fistula Acquired Following Intracardiac Repair

Iatrogenic aortocardiac fistulae have been described rarely following intracardiac repair. This 28 year-old-male presented to our facility with dyspnea going on 20 days after closure of ventricular septal defect (VSD) and resection of subaortic membrane. A communication was noticed between the aorta and the right ventricle (RV) upon transthoracic echocardiography. Cardiac catheterisation revealed a significant shunt and an aortogram revealed a 6 mm communication between aorta and right ventricle. Percutaneous closure of this defect was attempted under local anaesthesia through right femoral access. An alpha arteriovenous loop was formed despite repeated attempts, hence a retrograde approach for device delivery was considered. An 8 mm Amplatzer muscular VSD occluder device was deployed across the defect achieving a complete closure through an 8F delivery sheath. To the best of our knowledge this is the first report of an iatrogenic aorta to RV fistula occurring in a patient following an intracardiac repair which has been successfully treated percutaneously.

Left main PCI: An observational analysis from large single-centre experience

BACKGROUND

Although trials have shown efficacy of unprotected left main percutaneous coronary intervention (uLMPCI), data from Indian subcontinent are lacking. Hence, we planned this observational analysis of single-center uLMPCI data.

OBJECTIVES

To study long-term outcome after uLMPCI and identify predictors of adverse outcome.

METHODS

Case details of 62 consecutive patients of uLMPCI between 2006 and 2013 were retrieved from a computerized database wherein detailed records were maintained.

RESULTS

Mean follow-up duration was 669.8±404.2 days. Procedural success rate was 98.4%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat intervention (RI) at three years. MACCE occurred in 13 (20.9%) patients. Cardiac death (CD), (including possible stent thrombosis), RI, and CVA occurred in 6 (9.7%), 5 (8%), and 2 (3.2%) patients, respectively. Overall three-year MACCE-free survival rate was 76.7%. Event-free survival rate was similar among patients who underwent uLMPCI alone and patients who underwent uLMPCI along with additional one-vessel PCI [(88.9% vs 81.8%), p=0.492], while survival rate was lower in patients who underwent uLMPCI along with PCI of additional two or more vessels (40%, p=0.036). Patients with syntax score ≤32 had higher event-free survival rate than those with syntax score >32 [(87.1% vs 33.3%), p=0.001]. Syntax score >32 was the only independent predictor of adverse outcome.

CONCLUSION

uLMPCI is safe and effective alternative to CABG for LM alone and LM plus single-vessel disease with syntax score ≤32.

Bypass Grafting Versus Percutaneous Intervention-Which Is Better in Multivessel Coronary Disease: Lessons From SYNTAX and Beyond

The landmark Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) Trial has aided in reducing the area of uncertainty in decision-making between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in patients with complex coronary artery disease. As part of the SYNTAX Trial, quantification of the coronary artery disease burden was prospectively undertaken by the Heart Team - consisting of at least an interventional cardiologist and cardiac surgeon - utilising the anatomical SYNTAX Score (www.syntaxscore.com) as a clinical tool in order to agree that equivalent anatomical revascularisation could be achieved. The anatomical SYNTAX Score is now advocated in both European and US revascularisation guidelines to guide decision-making between CABG and PCI as part of the SYNTAX pioneered Heart Team approach. In addition, the SYNTAX Trial has lead to the development and validation of the SYNTAX Score II, in which the anatomical SYNTAX Score was augmented with clinical variables, to allow for more objective and tailored decision making for the individual patient. Prospective validation of the SYNTAX Score II tool is currently ongoing in the SYNTAX II (ClinicalTrials.gov Identifier: NCT02015832) and EXCEL (ClinicalTrials.gov identifier: NCT01205776) trials. The present paper presents lessons learned from SYNTAX, including the development and/or validation of several SYNTAX based clinical tools, and the potential implications for current and future clinical practice.

Mustard baffle obstruction and leak - How successful are percutaneous interventions in adults?

Atrial switch operations for D-Transposition of the great arteries (D-TGA) were performed until the late 20th century. These patients have substantial rates of re-operation, particularly for baffle related complications. This study sought to analyze the efficacy of percutaneous transcatheter intervention (PTI) for baffle leak and/or stenosis in adult atrial switch patients. Adult patients with a prior atrial switch operation who underwent heart catheterization (2002-2014) at a tertiary adult congenital heart disease referral center were retrospectively analyzed. In 58 adults (30 ± 8 years, 75% men, 14% New York Heart Association (NYHA) functional class ≥2) who underwent 79 catheterizations, PTI was attempted in 50 (baffle leak (n = 10, 20%), stenosis (n = 27, 54%), or both (n = 13, 26%)). PTI was successful in 45 and 5 were referred for surgery due to complex anatomy. A total of 40 bare metal stents, 18 covered stents, 16 occlusion devices, 2 angioplasties, and 1 endovascular graft were deployed. In isolated stenosis, there was improvement in NYHA functional class after PTI (8 vs. 0 patients were NYHA FC > 2, p = 0.004), which was matched by improvement in maximal oxygen consumption on exercise testing (VO₂) (25.1 ± 5.4 mL/kg/min vs. 27.9 ± 9 mL/kg/min, p = 0.03). There were no procedure-related deaths or emergent surgeries in this cohort. This single-center cohort is the largest reported series of adult atrial switch operation patients who have undergone PTI for baffle stenosis and/or leak. We demonstrate that PTI with an expert multi-disciplinary team is a safe and effective alternative to surgery in adult patients with an atrial switch operation.

Late device embolization in a persistent mitral paravalvular leak

An 83-year-old man with severe organic mitral regurgitation underwent mitral valve surgery with implantation of a biologic prosthesis. Four months later he presented with hemolytic anemia and heart failure due to severe paravalvular regurgitation. Since the patient refused surgery, the paravalvular leak was closed percutaneously using two Amplatzer devices, with angiographic and clinical success. Two months after the intervention he developed heart failure again and embolization of one of the devices was documented, with significant worsening of paravalvular regurgitation. A redo percutaneous closure was attempted but although initially promising, was ultimately unsuccessful as heart failure symptoms and hemolytic anemia persisted. Surgical correction was the final solution for this case. This is the second case of late device embolization reported in the literature and highlights the importance of careful long-term follow-up of such patients, as late complications, although rare, may occur.

Percutaneous closure of secundum type atrial septal defects: More than 5-year follow-up

AIM: To investigate long-term efficacy of two different devices more than five years after percutaneous atrial septal defect (ASD) closure in adults.

METHODS: All patients who underwent percutaneous closure of an ASD in the St. Antonius Hospital, Nieuwegein, The Netherlands, between February 1998 and December 2006 were included. Percutaneous closure took place under general anaesthesia and transesophageal echocardiographic monitoring. Transthoracic echocardiography (TTE) was performed 24 h post-procedure to visualize the device position and to look for residual shunting using color Doppler. All complications were registered. All patients were invited for an outpatient visit and contrast TTE more than 5-years after closure. Efficacy was based on the presence of a residual right-to-left shunt (RLS), graded as minimal, moderate or severe. The presence of a residual left-to-right shunt (LRS) was diagnosed using color Doppler, and was not graded. Descriptive statistics were used for patients’ characteristics. Univariate analysis was used to identify predictors for residual shunting.

RESULTS: In total, 104 patients (mean age 45.5 ± 17.1 years) underwent percutaneous ASD closure using an Amplatzer device (ASO) in 76 patients and a Cardioseal/Starflex device (CS/SF) in 28 patients. The mean follow-up was 6.4 ± 3.4 years. Device migration occurred in 4 patients of whom two cases occurred during the index hospitalization (1 ASO, 1 CS/SF). The other 2 cases of device migration occurred during the first 6 mo of follow-up (2 CS/SF). The recurrent thrombo-embolic event rate was similar in both groups: 0.4% per follow-up year. More than 12 mo post-ASD closure and latest follow-up, new-onset supraventricular tachyarrhythmia’s occurred in 3.9% and 0% for the ASO and CS/SF group, respectively. The RLS rate at latest follow-up was 17.4% (minimal 10.9%, moderate 2.2%, severe 4.3%) and 45.5% (minimal 27.3%, moderate 18.2%, severe 0%) for the ASO- and CS/SF groups, respectively. There was no residual LRS in both groups.

CONCLUSION: Percutaneous ASD closure has good long-term safety and efficacy profiles. The residual RLS rate seems to be high more than 5 years after closure, especially in the CS/SF. Residual LRS was not observed.

Treatment strategies in the left main coronary artery disease associated with acute coronary syndromes

Significant left main coronary artery (LMCA) stenosis is not rare and reported 3 to 10% of patients undergoing coronary angiography. Unprotected LMCA intervention is a still clinical challenge and surgery is still going to be a traditional management method in many cardiac centers. With a presentation of drug eluting stent (DES), extensive use of IVUS and skilled operators, number of such interventions increased rapidly which lead to change in recommendation in the guidelines regarding LMCA procedures in the stable angina (Class 2a recommendation for ostial and shaft lesion and class 2b recommendation for distal bifurcation lesion). However, there was not clear consensus about the management of unprotected LMCA lesion associated with acute myocardial infarction (MI) with a LMCA culprit lesion itself or distinct culprit lesion of other major coronary arteries. Surgery could be preferred as an obligatory management strategy even in the high risk patients. With this review, we aimed to demonstrate treatment strategies of LMCA disease associated with acute coronary syndrome, particularly acute myocardial infarction (MI). In addition, we presented a short case series with LMCA lesion and ST elevated acute MI in which culprit lesion placed either in the left anterior descending artery or circumflex artery. We reviewed the current medical literature and propose simple algorithm for management.

A new device for paravalvular leak closure

Percutaneous closure of a prosthetic paravalvular leak (PVL) is a challenging procedure. Operators must use devices constructed for other applications. We present the use of a device which is specifically designed for PVL closure. To the best of our knowledge, there is no publication in MEDLINE reporting the use of the device.

Resistant hypertension due to unilateral renal artery occlusion as the first presentation of antiphospholipid syndrome

Resistant hypertension in the setting of renal artery occlusion should prompt further investigation for secondary causes in a young patient. We present renal artery occlusion in the setting of antiphospholipid syndrome as the initial presentation successfully treated with percutaneous intervention. This case is followed by review of the literature.

[Instent rupture of a saphenous vein graft during percutaneous intervention successfully treated with a covered stent]

Percutaneous coronary interventions of saphenous vein grafts are associated with an increased risk of periprocedural complications; among these, the rupture of the vein graft is probably the less common and the most dangerous; it is even more exceptional when it occurs on a stented portion of the graft. We report the case of a 75-year-old man who presented during a balloon angioplasty of intent restenosis of a saphenous vein graft a spectacular graft rupture at the level of the previously stented site and who was ultimately successfully treated with a covered stent.

Drug-eluting stents versus coronary artery bypass grafting in diabetic patients with multi-vessel disease: a meta-analysis

BACKGROUND

Data comparing long-term results after percutaneous intervention with drug-eluting stents (DES/PCI) and coronary artery grafting (CABG) in diabetic patients (pts) with multi-vessel disease is conflicting. We have conducted a systematic review and meta-analysis to help answer this issue.

METHODS

MEDLINE, WoS, and Scopus were systematically analysed to yield observational studies (OBS) or randomised controlled trials (RCT) fulfilling search criteria. Odds ratio (OR) for studied end-points were obtained with inverse variance random effects analysis. Results are presented with 95% confidence intervals with significance at p<0.05.

RESULTS

A total of 14 studies (5 RCT; 9 OBS) including more than 5000 pts were selected for review. Early/30-day was lower in the DES/PCI cohort [OR 0.49(0.27, 0.88); p=0.02; I(2)=0%]. Post-procedural stroke was higher in the CABG (1.8%) cohort compared to DES/PCI (0.17%; p<0.01). A pooled analysis of RCT demonstrated that stroke rate was similar in both cohorts at the end of one year [OR 0.84(0.19, 3.74); p=0.82; I(2) =67%]. During a follow-up of three to five years, repeat intervention was much higher in the DES/PCI cohort [OR 3.02(2.13, 4.28; p<0.01]. The odds of suffering an adverse cardiovascular /cerebrovascular event were 1.71 (1.27, 2.3) times higher in the DES/PCI cohort compared to CABG.

CONCLUSION

In diabetic patients with multivessel disease, early mortality is lower in the DES/PCI cohort. While peri-procedural stroke rates are lower with PCI, they are, however, comparable at the end of one year. Use of drug-eluting stents leads to a higher rate of re-intervention and major cardiovascular/cerebrovascular events at three to five years.

Transcatheter mitral paravalvular leakage closure: A beautiful last resort

We describe a case of a 54-year-old patient with rheumatic heart valve disease who was treated with double valve replacement (both aortic and mitral) twice. Two months after the second operation she developed a severe mitral paravalvular leakage (PVL) leading to cardiogenic shock for which she was hospitalized in the intensive care unit. Multiple weaning efforts proved to be unsuccessful because of persistent hemodynamic instability caused by the severe PVL. Since re-redo cardiac surgery would have meant an unacceptable high peri-operative risk it was decided in the heart team to close the PVL by a transcatheter technique. This was done successfully and led to a spectacular hemodynamic improvement. Just 24 h after closure of the PVL she could be discharged from the intensive care unit and the day after the procedure she came walking into the echocardiography laboratory for an echocardiographic evaluation. This case demonstrates not only the feasibility of transcatheter closure of a PVL but also that this can be a true life-saving act. <Learning objective: This case emphasizes that refractory heart failure can be a hard indication for closure of a PVL given the fast and complete clinical recovery after closure of the defect. Furthermore, it demonstrates the feasibility and the efficacy of transcatheter PVL closure, even when multiple devices have to be used to close the leak properly avoiding the risks inherent to redo cardiac surgery.>.

Drug-eluting stents versus coronary artery bypass grafting in diabetic patients with multi-vessel disease: a meta-analysis

BACKGROUND

Data comparing long-term results after percutaneous intervention with drug-eluting stents (DES/PCI) and coronary artery grafting (CABG) in diabetic patients (pts) with multi-vessel disease is conflicting. We have conducted a systematic review and meta-analysis to help answer this issue.

METHODS

MEDLINE, WoS, and Scopus were systematically analysed to yield observational studies (OBS) or randomised controlled trials (RCT) fulfilling search criteria. Odds ratio (OR) for studied end-points were obtained with inverse variance random effects analysis. Results are presented with 95% confidence intervals with significance at p<0.05.

RESULTS

A total of 14 studies (5 RCT; 9 OBS) including more than 5000 pts were selected for review. Early/30-day was lower in the DES/PCI cohort [OR 0.49(0.27, 0.88); p=0.02; I(2)=0%]. Post-procedural stroke was higher in the CABG (1.8%) cohort compared to DES/PCI (0.17%; p<0.01). A pooled analysis of RCT demonstrated that stroke rate was similar in both cohorts at the end of one year [OR 0.84(0.19, 3.74); p=0.82; I(2) =67%]. During a follow-up of three to five years, repeat intervention was much higher in the DES/PCI cohort [OR 3.02(2.13, 4.28; p<0.01]. The odds of suffering an adverse cardiovascular /cerebrovascular event were 1.71 (1.27, 2.3) times higher in the DES/PCI cohort compared to CABG.

CONCLUSION

In diabetic patients with multivessel disease, early mortality is lower in the DES/PCI cohort. While peri-procedural stroke rates are lower with PCI, they are, however, comparable at the end of one year. Use of drug-eluting stents leads to a higher rate of re-intervention and major cardiovascular/cerebrovascular events at three to five years.

Orbital atherectomy system in treating calcified coronary lesions: 3-Year follow-up in first human use study (ORBIT I trial)

BACKGROUND/PURPOSE

The ORBIT I trial evaluated the safety and performance of an orbital atherectomy system (OAS) in treating de novo calcified coronary lesions. Severely calcified coronary arteries pose ongoing treatment challenges. Stent placement in calcified lesions can result in stent under expansion, malapposition and procedural complications. OAS treatment may be recommended to facilitate coronary stent implantation in these difficult lesions.

MATERIALS/METHODS

Fifty patients with de novo calcified coronary lesions were enrolled in the ORBIT I trial. Patients were treated with the OAS followed by stent placement. Our institution treated 33/50 patients and continued follow-up for 3 years.

RESULTS

Average age was 54.4 years and 90.9% were males. Mean lesion length was 15.9mm. The average number of OAS devices used per patient was 1.3. Procedural success was achieved in 97% of patients. Angiographic complications were observed in five patients (two minor dissections, one major dissection and two perforations). The cumulative major adverse cardiac event (MACE) rate was 6.1% in-hospital, 9.1% at 30 days, 12.1% at 6 months, 15.2% at 2 years, and 18.2% at 3years. The MACE rate included two in-hospital non Q-wave myocardial infarctions (MI), one additional non Q-wave MI at 30 days leading to target lesion revascularization (TLR), and three cardiac deaths.

CONCLUSIONS

The ORBIT I trial suggests that OAS treatment may offer an effective method to modify calcified coronary lesion compliance to facilitate optimal stent placement in these difficult-to-treat patients with acceptable levels of safety up to 3 years post-index procedure.

In vivo feasibility study of ultrasound potentiated collagenase therapy of chronic total occlusions

Arterial chronic total occlusions (CTOs) pose considerable challenges for percutaneous interventions, due primarily to the presence of stiff proximal fibrous caps (PFCs) which act as a barrier to the penetration of guide wires. A new approach under development for improving the success rate of guide wire crossing in CTOs is to employ collagenase to degrade the mechanical integrity of the PFCs. This has been shown to be feasible in preclinical work and in a Phase 1 clinical trial. In a recent study we demonstrated using ex vivo experimental CTO specimens that ultrasound-stimulated microbubbles (USMBs) could potentiate the effects of collagenase and result in increased mechanical degradation of the PFCs of CTOs. Here we report the results of the first in vivo study examining the feasibility of this approach, which demonstrates that the force required to puncture through the PFCs of CTOs is reduced with combined USMB+collagenase treatments relative to collagenase only treatments. This approach has the potential to further improve the efficacy of the emerging technique of collagenase facilitation of percutaneous interventions for CTO.

Percutaneous options for heart failure in adults with congenital heart disease

In the context of congenital heart disease (CHD), the complex biochemical and physiologic response to the pressure- or volume-loaded ventricle can be induced by stenotic and shunt/regurgitant lesions, respectively. A range of transcatheter therapies have recently emerged to expand the therapeutic potential of the more traditional surgical and medical interventions for heart failure in patients with CHD. Together, these complementary interventions aim to treat the growing patient population with adult CHD (ACHD). In this article, the most commonly used transcatheter interventions for heart failure in patients with ACHD are reviewed.

Guiding-catheter thrombectomy combined with distal protection during primary percutaneous coronary intervention of a saphenous vein graft

Primary percutaneous intervention of saphenous vein grafts is associated with a high risk of distal embolization and no reflow. We report a case of acute myocardial infarction with a large intragraft thrombus, successfully treated with a technique combining thrombectomy with a 6 Fr guiding catheter and distal protection with the FilterWire EZ.

Left bundle branch block without concordant ST changes is rarely associated with acute coronary occlusion

BACKGROUND

The Sgarbossa score has been used to identify acute myocardial infarction on ECG in the presence of LBBB but has relied on elevated CK-MB for validation rather than angiographic evidence of vessel occlusion.

METHODS

We determined (a) the presence or absence of Sgarbossa criteria with concordant (S-con) or discordant (S-dis) ST changes, (b) the presence of acute coronary occlusion or likely recent occlusion on angiography and (c) the biochemical evidence of myocardial infarction (Troponin T >0.10 μg/L, Troponin I >1.0 μg/L) in patients field-triaged with suspected AMI and LBBB.

RESULTS

Between April 2004 and March 2009, 102 patients had field ECGs transmitted by paramedics for triage--8 with S-con, 26 with S-dis and 68 with LBBB alone. Acute coronary occlusion was present in 8/8 with S-con but none of the S-dis or LBBB alone patients, and in all 8 S-con patients reperfusion resulted in resolution of S-con changes. Likely culprit lesions with TIMI 3 flow were found in 3 S-dis patients but stenting did not result in resolution of S-dis. LBBB did not resolve in any patient. Troponin was elevated in 26 patients--11 with occlusion or likely culprit lesions, 15 with non-ischaemic causes.

CONCLUSIONS

In the absence of S-con, LBBB is not associated with acute coronary occlusion and should not be used as criteria for reperfusion therapy in myocardial infarction.

The evolving role of cardiac imaging in percutaneous valvular intervention

Surgical therapies have represented the primary evidence-based intervention to alter the natural history of valvular heart disease (VHD), however, the increasing incidence of patients at high surgical risk due to age and related co-morbid conditions has given rise to the need for alternative strategies. Thus, percutaneous approaches to VHD therapy have emerged as an important therapeutic option. Cardiovascular imaging plays a critical role in patient screening for percutaneous valvular interventions, during the procedure itself, and as part of follow-up for the identification of implant success/failure and complications. The technical demands on imaging in this context are highly specific. Although imaging has a significant role in the broader evaluation of valvular heart disease mechanism and severity, the purpose of this paper is to summarise the particular goals of cardiovascular imaging in the work-up for, during, and in the follow-up of percutaneous valvular intervention.

Drug-Eluting Stents Versus Bare Metal Stents in Saphenous Vein Graft Intervention

Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with higher adverse event rates, lower procedural success, and inferior longterm patency rates compared with native vessel PCI. The ability to comply with dual antiplatelet therapy, and whether the patient will need an interruption in dual antiplatelet therapy, should be considered when deciding whether to implant a drug-eluting stent (DES) or bare metal stent (BMS) in an SVG. DES should be used for SVG PCI because they seem to reduce target vessel revascularization. This article reviews the evolution and contemporary evidence regarding use of DES versus BMS in SVG PCI.

Uncertainties in managing myocardial infarction associated with infective endocarditis

Embolic myocardial infarction is an uncommon but increasingly recognised complication of infective endocarditis. This complication has a high mortality rate and is deemed a relative contraindication to thrombolytic therapy. The present article describes an episode of acute myocardial infarction associated with infective endocarditis. Systemic thrombolytic therapy was administered, which resulted in resolution of cardiac ischemia but was complicated by a fatal intracerebral bleed. There are a number of published cases describing the use of systemic thrombolysis, primary percutaneous intervention and early valvular surgery in this circumstance, but the optimal course of treatment for myocardial infarction in the context of infective endocarditis remains to be elucidated. Additional guidance for those who are likely to encounter this condition in clinical practice would be welcomed.

Real World Application of Stenting of Unprotected Left Main Coronary Stenosis: A Single-Center Experience

BACKGROUND

The aim of this study was to summarize our single-center real-world experience with percutaneous coronary intervention (PCI) stenting of unprotected left main coronary artery (ULMCA). PCI-stenting of the ULMCA, while controversial, is emerging as an alternative to coronary artery bypass graft (CABG) surgery in select patients and clinical situations.

METHODS

Between January 2005 and December 2008, PCI-stenting was performed on 125 patients with ULMCA lesions at our institution. Clinical and procedural data were recorded at the time of procedure, and patients were followed prospectively (mean 1.7 years; range 1 day-4.1 years) for outcomes, including death, myocardial infarction (MI), and target vessel revascularization (TVR).

RESULTS

The majority of cases were urgent or emergent (82.5%), 50.4% of patients were non-surgical candidates, and 63.2% had 3 vessel disease. Many emergent patients presented in shock (62.1%), were not surgical candidates (89.7%), and had high mortality (20.7% in-hospital, 44.8% long-term). Mortality in the elective group was 6.3%. Cumulative death and TVR rates were 28.8% and 13.6%, respectively. Independent predictors of mortality were ejection fraction (EF) ≤ 35% (HR 2.4, CI 1.1 - 5.4) and left main bifurcation (HR 2.7, CI 1.2 - 5.7).

CONCLUSIONS

PCI-stenting is a viable option in patients with LMCA disease and extends options to patients who are poor candidates for CABG. Elective PCI in low-risk CABG patients results in good long-term survival. Cumulative TVR is 13.6%. EF ≤ 35% and left main bifurcation are independently associated with increased mortality.