ECG-Gated CCTA in the Assessment of Post-Procedural Complications

INTRODUCTION

The aim of our study was to assess the role of ECG-gated coronary CT angiography (CCTA) in the diagnosis, imaging follow-up, and treatment guidance in post-procedural/surgical interventions in the heart and thoracic aorta (PTCA, TAVI, PMK/ICD placement, CABGs).

MATERIALS AND METHODS

We retrospectively evaluated 294 ECG-gated CCTA studies performed in our center from January 2020 to January 2023. CCTA studies were acquired to detect/exclude possible complications related to the endovascular or surgical procedure.

RESULTS

There were 27 cases (9.2%) of post-procedural complications. Patients enrolled in the study were 18 males and 9 females (male/female ratio: 2), with age ranging from 47 to 86 years (mean age, 68.3 years). Among percutaneous coronary intervention (PCI) complications, coronary intimal dissection with ascending aorta involvement was found to be the most frequent complication after PTCA (22.2%). Vascular wall pseudoaneurysm formation (11.1%) and coronary stent misalignment or displacement (14.8%) were complications less frequently encountered after PTCA. Right atrial or ventricular perforation with associated hemopericardium were the most common complications (18.5%) after pacemaker implantation. Complications encountered after aortic valve interventions were loosening and dislocation of the prosthesis associated with aortic root pseudoaneurysm (7.4%), para-valvular leak (11.1%), and hemopericardium (7.4%). In one patient who underwent transcatheter repair of patent foramen ovale (3.7%), CTTA detected the dislocation of the Amplatzer septal occluder.

CONCLUSIONS

ECG-gated CCTA is a fundamental diagnostic tool for the detection of post-procedural endovascular/surgical complications to enable optimal patient management. Radiologists must be familiar with the use of cardiac synchronization in the course of CT and must be aware of all possible complications that can occur in the context of acute settings or routine follow-up studies.

Bilateral Opposing Loop Technique for Securing Air Knots

Incompletely seated knots (air knots) during surgical aortic valve replacement can be potentially difficult to repair in anatomically challenging areas around the aortic root. That is especially true with mechanical protheses as subvalvular areas are inaccessible once the valve is seated. In this report, we present a novel and simple technique of tightening air knots from within the aortic root without removing the prosthesis.

Utility of Real-Time 3-Dimensional Transesophageal Echocardiography in the Assessment of Mitral Paravalvular Leak

BACKGROUND

Mitral paravalvular leak (PVL) is a potential complication of surgical valve replacement procedures. Real-time 3D transesophageal echocardiography (RT-3DTEE) has emerged as an efficient tool for providing essential information about the anatomy of mitral PVLs compared with 2DTEE findings. The purpose of this study was to evaluate the utility of RT-3DTEE in the assessment of mitral PVLs.

METHODS AND RESULTS

The 3D characteristics of PVLs were recorded and compared with 2D findings. We included 34 consecutive patients with clinical suspicion of mitral PVL in the study. Mitral PVLs were detected in 26 patients (76%); 26 PVLs were identified by 2DTEE and 37 by RT-3DTEE. Moderate or severe mitral regurgitation was present in 23 patients (88%). The most common PVL locations were the septal and posterior regions. The median PVL size measured by RT-3DTEE was 7 mm long×4 mm wide. The median vena contracta of defect measured by 2DTEE and RT-3DTEE was 5 mm and 4 mm, respectively. The median effective regurgitant orifice area of defect measured by RT-3DTEE was 0.36 cm(2). The defect types were "oval" (54%), "round" (35%), "crescentic" (8%) and highly irregular (3%).

CONCLUSIONS

Compared with 2DTEE, RT-3DTEE provided detailed descriptions of the number, location, size and morphology of PVLs, which is essential for planning and guiding the potential corrective techniques. (Circ J 2016; 80: 738-744).

Sequential percutaneous closure of mitral prosthetic paravalvular leak and complex communicating pseudoaneurysms of the ascending aorta and subvalvar left ventricular outflow tract

Ascending aortic and subvalvar left ventricular outflow tract (LVOT) pseudoaneurysms are rare complications following aortic valve or root replacement surgery. Clinically important paravalvular leaks are rare complications following any valve replacement surgery. We report an unusual case of sequential percutaneous closure of mitral prosthetic paravalvular leak and complex communicating ascending aortic and subvalvar LVOT pseudoaneurysms, which demonstrates the importance of multimodal imaging assessment surrounding percutaneous closure. © 2015 Wiley Periodicals, Inc.

Balloon-expandable valves for degenerated mitral xenografts or failing surgical rings

AIMS

Transcatheter mitral valve-in-valve implantation (TMViVI) for the treatment of failing mitral xenografts or recurrent mitral regurgitation after surgical ring implantation is an emerging therapy for patients in need of repeated mitral valve surgery. Despite the fact that these procedures have been shown to be feasible and effective, haemodynamic data after TMViVI are still limited in the literature.

METHODS AND RESULTS

Twelve patients (logES: 39.2±23.5%) were treated either by transapical (n=7) or transseptal (n=5) TMViVI, as a valve-in-valve (ViV, n=8) or valve-in-ring (ViR, n=4) implantation. Left atrial pressures (LAP), transmitral gradients and right heart haemodynamics (Swan-Ganz catheterisation) were studied before and after TMViVI. Procedural success was 100%, mitral regurgitation after TMViVI was mild in one, trace in five and absent in six patients. Thirty-day mortality was 0%. Left atrial pressures decreased significantly after valve implantation (before LAPmean/v-wave: 24.3/44.1 mmHg; after LAP/v-wave 15.9/22.1 mmHg; p<0.001) and cardiac output increased significantly. Transmitral gradients corresponded to mitral surface areas between 1.7 and 3.5 cm2, and were thus very acceptable in terms of the high surgical risk population.

CONCLUSIONS

In conclusion, TMViVI with the balloon-expandable SAPIEN XT valve for ViV or ViR implantation is feasible with promising acute transmitral haemodynamic data. Nevertheless, sustained long-term performance remains to be demonstrated in the future.

Paravalvular leak closure with the Amplatzer Vascular Plug III device: immediate and short-term results

INTRODUCTION AND OBJECTIVES

Percutaneous paravalvular leak closure is a complex procedure with varying success rates; the lack of closure devices specifically designed for this purpose has hampered this technique. The characteristics of the Amplatzer Vascular Plug III appear to be well suited for paravalvular leak closures; however, the available data are limited to case reports or small series of patients. The aim of this study was to analyze the feasibility and efficacy of paravalvular leak with this device.

METHODS

The immediate and 90-day safety and efficacy of mitral and aortic paravalvular leak closures performed with this device at our hospital were analyzed.

RESULTS

Percutaneous repair of 34 paravalvular leaks (27 mitral, 7 aortic) was attempted in 33 patients. The device was successfully implanted in 93.9% (in 2 patients, a second planned procedure was needed), and successful closure (defined as regurgitation reduction ≥ 1 grade) was achieved in 90.9% of patients. Complications included emergency surgery due to disc interference (n=1) and blood transfusion (n=3). There were no reports of procedure-related death, myocardial infarction, or stroke. At 90 days, survival was 100%, and 90.3% of patients showed significant clinical improvement; 4 patients developed vascular complications (pseudoaneurysm).

CONCLUSIONS

Mitral and aortic paravalvular leak closure with the Amplatzer Vascular Plug III is feasible and safe, with high clinical and echocardiographic success rates.

Percutaneous closure of tricuspid paravalvular leak

While transcatheter closure of mitral and aortic paravalvular leaks has been well-described, there are no prior reports of such procedures for prosthetic tricuspid valves. We describe our experience with percutaneous closure of a tricuspid paravalvular leak in a 34-year-old patient with a history of tricuspid atresia. He had previously undergone repair with placement of a right atrium-to-right ventricle conduit and most recently, placement of a bio-prosthetic tricuspid valve. He subsequently developed significant tricuspid paravalvular leak with symptoms of severe right heart failure. His clinical status was improved following successful transcatheter closure of the defect.

Transcatheter recanalization of totally occluded proximal pulmonary arteries and major systemic veins in patients with congenital heart disease

The purpose of the present study was to assess the results and technical aspects of attempted transcatheter recanalization of occluded pulmonary arteries or major systemic veins from our center. Occluded pulmonary arteries or major systemic veins are often not considered amenable to transcatheter treatment and can be a cause of significant hemodynamic compromise for patients. The records of patients with occluded pulmonary arteries or major systemic veins who underwent cardiac catheterization from April 1997 to February 2011 were reviewed. We identified 18 patients, of whom, 9 had occluded pulmonary arteries and 9 occluded systemic veins. Recanalization was achieved in 17 of the 18 patients (94%). At a median follow-up of 35 months (range 6 months to 12 years), all vessels remained patent. The freedom from reintervention rate in the entire cohort was 61% at 6 months, 35% at 1 year, and 35% at 5 years. Freedom from an unplanned reintervention was 67% at 6 months. Procedural adverse events occurred in 2 patients. One death occurred within 24 hours of the catheterization procedure and 2 late deaths occurred, all unrelated to the procedure. In conclusion, both acute and chronic success at recanalizing the occluded pulmonary arteries and major systemic veins can be achieved using percutaneous techniques. Careful follow-up is needed, because reintervention can be necessary to maintain long-term vessel patency without stenosis.

Repair of prosthetic mitral valve paravalvular leak using an off-pump transapical approach

Patients who present with significant paravalvular regurgitation after mitral valve replacement remain a difficult patient population and high-risk surgical candidates. We present 3 cases of transapical closure of mitral valve paravalvular leak (PVL) after mitral valve replacement using Amplatzer closure devices (AGA Medical Corp, Plymouth, MN). All 3 patients experienced decreased regurgitation at the site of the closure as well as symptomatic improvement in their heart failure.

Two-stage percutaneous closure of mitral periprosthetic valvular leak

Periprosthetic valve leak can develop as a complication of valve replacement surgery and may manifest as symptomatic valvular regurgitation, heart failure, or haemolysis. We report a case of severe mitral periprosthetic valve leak requiring a two-stage percutaneous closure technique with multiple Amplatzer® III vascular plugs.

Techniques for transcatheter recanalization of completely occluded vessels and pathways in patients with congenital heart disease

Occlusions of major vessels in patients with congenital heart disease may occur due to a variety of factors. These occlusions are often felt to be best addressed surgically; however, we and others have been successful in recanalizing most of these vessels in the catheterization laboratory. Most of these patients will require multiple procedures in the catheterization laboratory to ensure vessel patency and to facilitate vessel growth. Physicians performing the procedure should have a thorough understanding of the anatomic considerations for the intended procedure and have access to a variety of devices and equipment to optimize the result of the procedure. In this article, we review some of the technical aspects that are vital for the success of the procedure.