Quality control in treating patients with patent foramen ovale: 7-year-experience of the Heart and Brain team of the Careggi University Hospital

BACKGROUND

The right comprehension of ischemic stroke pathogenesis guarantees the best prevention therapy. The term "patent foramen ovale (PFO) related stroke" has been proposed for those events where PFO is supposed to be pathogenetic, but their definition is challenging. A multidisciplinary evaluation in a "Heart & Brain" team (HBteam) including stroke neurologists and interventional cardiologists was therefore highly recommended in the recent guidelines of secondary stroke prevention.

OBJECTIVE

We aimed at describing the organization of the HBteam of Careggi-University-Hospital of Florence (Italy), and the results of the first seven years of activity.

METHODS

In 2016 Interventional Cardiologists and Stroke Neurologists set up an outpatient clinic for the joined evaluation of patients with PFO and other cardio/neurological conditions. A specific diagnostic-therapeutic hospital plan was produced for PFO patients. Patient empowerment was guaranteed by a hospital explicative webpage, a booklet regarding risks/benefits of PFO closure and a 3D heartmodel to simulate the intervention. Data were collected in a dedicated registry.

RESULTS

We evaluated 594 patients for PFO, 40 for left atrial appendage closure and 38 for other conditions. In 20% of PFO-patients, HBteam diagnosis was discordant from that of referring physicians, 14% were stroke misdiagnoses. We advised against closure in 53% of patients. At follow-up 94% of closed patients had no/minimum residual shunt; 3 patients had a cerebral ischemic event.

CONCLUSIONS

A dedicated HBteam represents a unique opportunity to share decisions with patients after a thorough empowerment process. The joining of cardioneurological skills allows a better classification of PFO-patients, reducing futile interventions.

279 LAYERED PLAQUES: NOT ALL ARE HEALED

Layered plaques are the effect of a previous plaque event. They are associated with coronary spasm and found in more than 50% of patients with stable angina and a quarter of those with an acute coronary syndrome. Nevertheless, it is not clear whether their presence is indicative of a healing process or rather is predictive of an increased risk of future events. A 71-year-old male, heavy smoker and hypertensive, presented with episodes of angina at rest that resolved spontaneously in less than 5 minutes, with evidence of ST-segment elevation (STE) in the lower leads during one of these episodes. Coronary angiography showed an intermediate stenosis at the end of the mid segment of the dominant right coronary artery (RCA) (Figure A). Optical coherence tomography (OCT) revealed a layered plaque, consisting of high backscattering layers alternated with low reflection layers (Figures A1-3). Given the minimum luminal area of 3.65 mm2 and the absence of other criteria for plaque instability (erosion, thin-cap, etc.), we treated the patient conservatively with medical therapy alone, consisting of a single antiplatelet agent and a high-dose statin with ezetimibe. A non-dihydropyridine calcium antagonist and a long-acting nitrate were started given the suspicion of coronary spasm. Four months later the patient returned to the emergency department for persistent oppressive chest pain unresponsive to sublingual nitrates with evidence of STE in the lower leads. Emergency coronary angiography showed an acute occlusion of RCA with TIMI 0 flow in correspondence to the layered plaque highlighted 4 months earlier on OCT (Figure B). Antegrade flow was restored with manual thrombus aspiration (Figure C) and OCT showed lesion progression with many new layers, together with a cavity suggestive of plaque rupture (Figures C1-3). A 3.5×38 mm everolimus eluting stent was deployed – based on OCT sizing – and post-dilated with a 4.0×8 mm non-compliant balloon, obtaining an excellent angiographic result with TIMI 3 flow (Figure D). Low-reflecting layers within layered plaques are generally considered to be lipid deposits, but they could also represent intraplaque haemorrhages, generated by coronary spasm. The haematoma can be reorganised within the plaque to create a new layer, leading to lesion progression without necessarily requiring a loss of endothelial integrity. The progressive increase of the haematoma may lead to plaque rupture when the pressure exceeds the resistance of superficial layers. This case reveals a new possible mechanism of plaque progression in patients with coronary spasm and explains how layered plaques can be ambivalently considered to be either stable or vulnerable. Their treatment should be meticulously tailored not only based on classical criteria of plaque instability but also according to the underlying trigger mechanism.

547 AN UNUSUAL CONSERVATIVE STRATEGY FOR ACUTE AORTIC RUPTURE AFTER TAVI POST-DILATATION

Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for symptomatic severe aortic stenosis in patients deemed to be at high operative risk for the surgery. Despite its high success, TAVI is associated with rare life-threatening complications. The frequency of aortic annular rupture (AAR) has been reduced by advances in pre-procedural screening and patient selection but, when occurs, often requires emergency surgery with a very high mortality. We described an unusual case managed conservatively.

A 86-year-old female patient with NYHA Class III and STS score for mortality of 4.8% underwent TAVI via a transfemoral approach. At preprocedural MDCT the aortic annular area was 293 mm2 with severe calcification of the valve leaflets extending in the outflow tract and in the sinotubular junction with effacement of the coronary sinuses (Fig. 1A-B). Following deployment of a 23-mm self-expanding valve (Medtronic Evolut Pro+) without predilatation, moderate-to-severe residual aortic regurgitation (AR) was observed (Vid. 1). After balloon post-dilatation using a 20×40mm noncompliant (NC) OSYPKA - VACS III balloon, mild-to-moderate AR still persisted (Fig. 1C, Vid. 2). Accordingly, we decided to perform a second post-dilatation using a 22×40mm NC balloon which reduced AR to mild but caused a contained AAR was observed (Fig. D&E, Vid. 3). The patient remained hemodynamically stable with no chest pain and had no pericardial effusion on echo. The risk of a Bentall operation in such a frail elderly patient was judged prohibitive and a conservative strategy was recommended. Postprocedural MDCT confirmed the presence of a pseudoaneurysm with the maximum dimensions of 24×15 mm (Fig. 1F). Patient was followed-up for 23 days first in hospital keeping a low blood pressure with iv nitrates and then in a rehabilitation centre. An MDCT control on day 10 showed no growth of the pseudoaneurysm with a reduction of the brisk filling initially observed. She was discharged without additional problems, and scheduled for a three month control MDCT.

Established risk factors for AAR include valve and balloon oversizing, bicuspid valve, small annulus, shallow Valsalva sinuses, and massive annular or sub/supra-annular calcification. When these recognized risk factors are present, a conservative strategy for valve postdilatation is strongly recommended. Early recognition and prompt surgical management of AAR are essential but occasionally also a conserative strategy can prove successful.

Optical coherence tomography and artificial intelligence for calcium quantification in coronary disease of diabetic patients

Background

Diabetes mellitus (DM) is associated with increased cardiovascular morbidity and mortality. Coronary artery disease in diabetic patients is characterized by a greater burden of lipidic plaques and calcifications. Little is known on the quantitative and qualitative characteristics of calcific plaques in diabetics vs non diabetics. The recent application of Artificial Intelligence (AI) to optical coherence tomography (OCT) enables unique evaluation of coronary calcification.

Purpose

To compare qualitative and quantitative characteristics of coronary calcified plaques in diabetic and non-diabetic patients using AI-OCT.

Methods and material

We recruited 78 patients admitted for chronic coronary syndrome (CCS) or acute coronary syndrome (ACS) undergone intracoronary imaging with OCT between January 2019 to October 2021. Differences in plaques characteristics assessed by Artificial Intelligence applied at OCT runs were compared in DM and non-DM population using generalized estimating equations. To estimate the burden of calcification we classified the calcific lesions according to the Fujino score, an OCT based calcium scoring system.

Results

A total of 78 patients were included (54 non-DM lesions, 29 DM lesions). The culprit lesion was examined by OCT in all patients without any peri- or postprocedural complications. The population was homogeneous for cardiovascular risk factors even if we observed a higher prevalence of peripheral arterial disease (PAD) in the DM cohort (22.2% vs 2% p value 0.003). There were no statistical differences in previous PCI or CABG but we observed more multivessel PCI in the history of DM patients if compared with non-diabetic ones (33.3% vs 11.8% p value 0.021). The clinical presentation in DM groups was more often unstable angina (22.2% vs 0% p value <0.001) while STEMI, NSTEMI or CCS had the same prevalence in the two cohorts. At baseline angiography, patients with diabetes had more often multivessel disease (29.6% vs 17.6% p=0.014) with all the vessels equally involved. There were no qualitative differences in plaque morphology but using the Fujino score to estimate the calcium burden in the two population we found hardest calcific plaques expressed by higher Fujino score more frequently in DM patients compared to non-DM ones (50% vs 26.9%, p=0.04 of Fujino score 4).

Conclusion

DM has an impact on atherosclerotic process and plaque remodeling. Applying AI methods at OCT plaque analysis, we can extract important and standardized information on calcium burden in diabetic. This might help the interventional cardiologist in image interpretation, therapeutic strategy decision, improving workflow and clinical outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University of Florence

The role of calcification in cardiovascular outcome after left main bifurcation revascularization: a single centre experience

Introduction

Left main bifurcation (LMB) disease represents a high-risk subset of advanced coronary artery disease, often associated with severe calcification. Different stenting techniques have been evaluated to overcome challenges of the LMB anatomy, but the role of the calcific burden on cardiovascular (CV) outcome after LMB revascularization is unclear.

Purpose

We sought to evaluate the CV hospitalization predictors during follow-up of patients who underwent LMB revascularization (LMBR) in a high-volume center in Italy.

Methods

We performed a retrospective analysis of LMBR patients between 2018 and 2021. Patients were treated with different techniques in the acute or chronic settings and followed-up by telephone or outpatient visit. Coronary calcification (CC) was visually judged as absent, mild, moderate or severe. Predictors of CV hospitalizations were assessed.

Results

The median follow-up was 511 days. Among 129 patients who underwent LMBR during the study period, 32 (24.8%) were female, with a mean age of 72 (±10.6) years. 105 (81.4%) patients were hypertensive and 49 (38%) diabetics. The mean eGFR value was 66.3 (± 21.8) ml/min/m2. The majority of patients had three vessel disease (79, 61.3%), while only a small minority had one vessel disease (5, 3.9%). The mean SYNTAX score I was 27.1 (± 8.6), with most patients at intermediate risk (65, 50.4%) followed by patients at low (37, 28.7%) and high (27, 20.9%) risk. A provisional technique was used in most cases (79, 61.2%), followed by double-kissing crush (37, 28.7%) and T-stent/T-and-protrusion (13, 10.1%). Intravascular imaging was used in 84 (65.1%) cases. Most patients had no angiographic demonstration of CC (73, 57.9%), while when present, they were mild in 14 (11.1%), moderate in 29 (23%) and severe in 10 (7.9%) patients. Preparation of the CC was performed only with non-compliant (NC) balloons in mild CC (10, 71.4%) and with NC balloons (14, 48.3%) or intravascular lithotripsy (IVL) (13, 44.8%) in case of moderate CC. In the presence of severe CC, lesion preparation was carried out with IVL (4, 40%) or NC balloons (6, 60%). CC were associated with a more unfavorable outcome and, when present in a severe grade, resulted in a statistically significant risk of CV hospitalizations (HR 1.652; 95% CI 1.723–15.793; p=0.003) (Figure 1). After univariate and multivariate Cox regression analysis (Figure 2), only the presence of severe CC was associated with an increased risk of CV hospitalizations (HR 1.9; 95% CI 1.76–19.63; p=0.002), whereas aspirin therapy was a protective factor (HR −1.34; CI 0.07–0.86; p=0.02).

Conclusions

The presence of severe calcification is associated with a higher risk of CV hospitalizations, despite preparation of calcific lesions was always performed and intravascular imaging use was extensive. There were no differences in outcomes regardless to clinical presentation at admission, different stenting techniques and SYNTAX score I.

Funding Acknowledgement

Type of funding sources: None.

Telemedicine: Benefits for Cardiovascular Patients in the COVID-19 Era

The recent pandemic with SARS-CoV-2 raises questions worldwide regarding telemedicine for housebound patients, including those with cardiovascular conditions. The need for further investigation, monitoring and therapeutic management are advancing practical issues which had not been identified for consideration prior to the pandemic. Using the marketing assessment, we identified the needs of the patients and evaluated the future steps necessary in the short term to meet them. The research found progress made via telemedicine in monitoring and conducting minor decisions (like up-titrating the doses of different medication regimens) in patients with several cardiovascular diseases (heart failure, atrial fibrillation, high blood pressure), as there is a worldwide trend to develop new telemonitoring biosensors and devices based on implantable delivered transcatheter. The worldwide telemedicine trend encourages a switch from small and hesitating steps to a more consistent assessment of the patients, based on high technology and Interventional Cardiology. Cardiovascular telemedicine, although made a sustainable effort in managing patients' health, has many obstacles to overcome before meeting all their needs. Data security, confidentiality and reimbursement are the top priorities in developing remote Cardiology. The regulatory institutions need to play an integrative role in leading the way for defining the framework of future telemedicine activities. The SARS-CoV-2 outbreak with all its tragedy served to reinforce the message that telemedicine services can be life-saving for cardiovascular patients. Once the Covid-19 era will fade away, telemedicine is likely to remain a complementary service of standard care. There is still room to improve the remote identification and investigation of heart disease, provide an accurate diagnosis and therapeutic regimen, and update regulations and guidelines to the new realities of technological progress in the field.

Current lipid-lowering approach and LDL target achievement in very high-risk patients: in-hospital results of a high-volume primary percutaneous coronary intervention tertiary center

Funding Acknowledgements

Type of funding sources: None.

Background

Low-density lipoprotein-cholesterol (LDL-C) is a well-accepted causal risk factor for atherothrombotic cardiovascular disease. Several randomized controlled trials and meta-analyses have shown that lipid-lowering therapies reduce cardiovascular events and have a positive effect in reducing vulnerable plaques. In particular, the recommended target for LDL-C has become more and more stringent, moving to 1.4 mmol/l (55 mg/dl) for very high-risk patients. According to the 2019 ESC/EAS Guidelines, the current paradigm for lipid management favors a stepwise approach consisting of early initiation of high-intensity statin, followed by subsequent addition of ezetimibe, and ultimately a consideration of PCSK9 inhibitor treatment if LDL-C levels remain elevated.

Methods

We recruited 307 patients admitted for acute coronary syndrome (ACS) during the COVID-19 pandemic from March 2020 to December 2020. Baseline LDL-C concentration and prescribed hypolipemiant treatment at hospital admission and discharge were registered. Therefore, we included all consecutive patients identified as very-high cardiovascular risk, according to 2019 ESC guidelines. We stratified our population through variables independently associated with non-attainment of LDL-cholesterol such as hypertension, diabetes, peripheral arterial disease, clinical manifestations of ACS, number of main vessels treated, and complexity of the atherosclerotic disease.

Results

274 patients were included. Mean age was 69,9 years (SD 11,4), 20,8 % were women, 23,7 % had diabetes, 16,4 % had PAD and 32,1 % suffered from valvular disease, mainly with mitral regurgitation or aortic stenosis no more than mild or moderate. Of 25.1% with a previous history of acute myocardial infarction, the 33,3% of whom didn’t have statin therapy pre-ACS index (p =0,001). At admission, medium cholesterol levels of patients that underwent previous coronary revascularization (25,5% of the total population) were 84,21 ± 31,2 mg/dL, not in range according to both 2016 and 2019 ESC guidelines. At discharge, 77,37 % of all the patients included received only statin therapy VS 22,63% with statin plus ezetimibe. In the subpopulation of patients with recurring ACS events with LDL pre-admission > 100 mg/dL,despite high dose statin, only 25% of this population were discharged adding ezetimibe (VS 75% who kept on the treatment of high dose statin without up-titration).

Conclusions

Management of dyslipidemia is frequently suboptimal and the gap between guidelines and clinical practice for lipid management across Europe has been exacerbated by the 2019 guidelines. A greater utilization of non-statin lipid-lowering therapies is likely needed to reach the LDL-C optimal target. A correct stratification of the risk class would help to identify, in a personalized perspective of treatment, patients at very high risk that would take advantage of more aggressive therapy to reach the lowest target of LDL-C ("the lower is better").

Percutaneous closure of a ‘whale tail’ left atrial appendage with a Watchman FLX device and pre-procedural FEops HEARTguide patient-specific computational simulation: a case report

Background

Percutaneous left atrial appendage closure (LAAC) is an emerging alternative to oral anticoagulation for stroke prevention in atrial fibrillation (AF) in patients with AF, elevated stroke risk and contraindications to long-term anticoagulation treatment. Optimal pre-procedural planning is essential to ensure optimal procedural results.

Case summary

We report the case of a 62-year-old man with a history of right cerebellar haematoma referred for LAA closure. We describe the first use of FEops HEARTguide patient-specific computational simulation in the planning of LAAC with the Watchman Flex device (Boston Scientific, Marlborough, MA, USA) in an unusual ‘whale tail’-like LAA anatomy.

Discussion

Percutaneous left atrial appendage (LAA) closure is feasible in the majority of patients. However, certain LAA anatomies may pose substantial technical challenges. This case shows the crucial role of a pre-procedural assessment based on patient-specific computational simulations for LAA closure in difficult scenarios resulting in a more efficient procedure with the optimal result and good clinical outcomes.

Peripheral intravascular lithotripsy for transcatheter aortic valve implantation: a multicentre observational study

BACKGROUND

The presence of severe calcific atherosclerosis at the iliofemoral axis may preclude transcatheter aortic valve implantation (TAVI) by the transfemoral (TF) approach. Intravascular lithotripsy (IVL) is a novel technology that fractures intimal/medial calcium and increases vessel compliance allowing TF TAVI in selected patients with peripheral artery disease (PAD).

AIMS

The aim of this study was to report on the safety and efficacy of IVL-assisted TF TAVI in an all-comers population.

METHODS

Clinical, imaging and procedural data on all consecutive patients treated by IVL-assisted TF TAVI in six high-volume European centres (2018-2020) were collected in this prospective, real-world, multicentre registry.

RESULTS

IVL-assisted TF TAVI was performed in 108 patients, increasing from 2.4% to 6.5% of all TAVI from 2018 to 2020, respectively. The target lesion was most often localised at the common and/or external iliac artery (93.5% of cases; average TL-MLD 4.6±0.9 mm with 318 degrees of calcium arc). Transfemoral aortic valve delivery was successful in 100% of cases; final procedural success in 98.2% (two conversions to cardiac open surgery for annular rupture and valve migration). Complications of the IVL-treated segments consisted of 1 perforation and 3 major dissections requiring stent implantation (2 covered stents and 2 BMS). Access-site-related complications included 3 major bleedings. Three in-hospital deaths were recorded (2.8%, 1 failed surgical conversion after annular rupture, 1 cardiac arrest after initial valvuloplasty, 1 late hyperkalaemia in renal dysfunction).

CONCLUSIONS

IVL-assisted TF TAVI proved to be a safe and effective approach, which helps to expand the indications for TF TAVI in patients with severe calcific PAD. However, these patients continue to have a higher-than-average incidence of periprocedural complications.

680 Peripheral intravascular lithotripsy of ILEO-femoral arteries to facilitate transfemoral TAVI: a multicentric prospective registry

Aims

The presence of severe calcific atherosclerosis at the iliofemoral axis may preclude transcatheter aortic valve implantation (TAVI) by transfemoral (TF) approach. Intravascular lithotripsy (IVL) is a novel technology that fractures intimal/medial calcium and increases vessel compliance allowing TF-TAVI in selected patients with peripheral artery disease (PAD). To report on the safety and efficacy of IVL-assisted TF-TAVI in an all-comers population.

Methods and results

Clinical, imaging and procedural data on all consecutive patients treated by IVL-assisted TF-TAVI in six high-volume European centres (2018–2020) were collected in this prospective, real-world, multicentre registry. IVL-assisted TF-TAVI was performed in 108 patients, increasing from 2.4% to 6.5% of all TAVI in 2018 to 2020, respectively. The target lesion was most often localized at the common and/or external iliac artery (93.5% of cases; average TL-MLD 4.6 ± 0.9 mm with 318 degrees of calcium arc). Transfemoral aortic valve delivery was successful in 100% of cases; final procedural success in 98.2% (two conversion to cardiac open surgery for annular rupture and valve migration). Complications of the IVL-treated segments consisted of one perforation and three major dissections requiring stent implantation (two covered stents and two BMS). Access site related complication included three major bleedings. Three in-hospital deaths were recorded (2.8%, one failed surgical conversion after annular rupture, one cardiac arrest after initial valvuloplasty, one late hyperkalaemia in renal dysfunction).

Conclusions

IVL-assisted TF-TAVI proved to be a safe and effective approach, which helps expanding the indications for TF-TAVI in patients with severe calcific PAD. Still, these patients maintain a higher than average incidence of peri-procedural complication.

Peripheral intravascular lithotripsy to facilitate transfemoral TAVR: a multicentric prospective registry

Background

The presence of severe calcific atherosclerotic disease at iliac artery level is a contraindication to transfemoral (TF) TAVI procedures, challenging TF delivery in 15–20% of cases. Many case reports described the efficacy of Intravascular lithotripsy (IVL) to facilitate TF access but only one prospective registry has been reported in literature and dates back 2018. For this reason a new multicenter prospective registry was ideated to confirm the role of IVL technology in facilitating TF TAVR.

Aims

The aims of this study were 1)to analyze the trend of TF TAVR compared to alternative approaches in the last 5 years and 2)to evaluate the prevalence of IVLassistedTAVR since it was introduced in this specific setting in 2018 3) to evaluate the success rate in terms of valve performance and procedural success of TF-TAVR system delivery after IVL lesion preparation.

Materials and methods

We prospectively collected data from all consecutive TAVRprocedures performed between Jan2016 andDec2020 at 4Italian and 1 Denmark centres. All patients underwent CT angiography of lower extremity before the procedure in order to assess the severity of aorto-iliac-femoral calcification and to select those patients who required specific lesion preparation to preserve TF access. For each target calcified lesion we measured length, diameter and %of stenosis, circumferential extension and minimal cross-sectional area. Angiographic IVL-related and access site complications (dissection, perforation, major bleeding) were examined.

Results

Between 2016 and 2020, a total of 3710 TAVR were performed, 3428 (92%) via TF route while the remaining 240 (8%) included alternative approaches mainly represented by subclavian and transapical access. IVL-assisted TAVR were 0 in 2016 and 2017, 13 (2%) in 2018 when the first IVL-assisted aortic valve implantation was performed and doubled in 2019, reaching a total of 112 in the whole 5-year period considered. The number of IVL-facilitated TAVR has been increased in the 5-year period, achieving 7% of the TF procedures while non-TF TAVR decreased considerably from 10% to 6%. Common and external iliac axis was the target lesion in the majority of cases (54%) followed by common iliac artery alone. lesion minimum diameter 4.7mm, with average stenosis of 50%. The maximum calcium angle was 332°. The majority of IVL was performed with a 7-mm catheter (78.6%). 1 balloon per lesion was employed. 1 perforation and 2 severe dissections occurred, that required stent placement. In 55% of cases the aortic regurgitation was absent or minimal.

Conclusions

TF approach remained the first choice for TAVR procedure in the majority of cases compared to non-TF thanks to the progressive increase of IVLassistedTAVR that allowed operators to preserve TF route. Peripheral IVL appeared feasible, safe and effective in patients with severe peripheral artery disease, with high success rate in terms of valve performance and low rate of complications.

Funding Acknowledgement

Type of funding sources: None.

Predictive factors of Permanent Pacemaker Implantation following Transcatheter Aortic Valve Replacement: membranous septum length and implantation depth evaluated with preoperative computed tomography

Background/Introduction

In the last decades, transcatheter aortic valve replacement (TAVR) revolutionized the treatment of symptomatic severe aortic stenosis. Cardiac conduction disturbances (CD) and the need for permanent pacemaker implantation (PPMI) remain the most frequent drawback of TAVR.The efficacy and safety of TAVR is proven not only in inoperable and high-risk patients, but TAVR use is increasing rapidly among intermediate- and low-risk populations, including progressively younger patients. In these prospective the risk of new-onset CD becomes increasingly important in clinical management. Several pre-procedural nonmodifiable factors (e.g., right bundle branch block [RBBB]) and modifiable factors (such as valve type and implantation depth) have been associated with conduction disturbances post-TAVR.

Purpose

The His bundle passes through the membranous septum (MS) and it is therefore not surprising that deeper valve implantation increases the likelihood of mechanical damage of the His bundle, leading to a transient or persistent CD. To date, it remains uncertain whether the association between valve type and CD relates primarily to a valve class effect or it is mainly secondary to differences in valve positioning accuracy and implantation depth between valve types. The aim of this study is to evaluate the length of the membranous septum (MS) and the implant depth (ID) in relation to the risk of permanent pacemaker (PPM) with both balloon-expandable (BE) and self-expanding (SE) transcatheter heart valves.

Methods

Of the 104 patients in the study, 79 patients underwent TAVIs with BE (44) and SE valves (35). Using preoperative computed tomography (CT) and angiography, MS length and implantation depth (ID) were retrospectively assessed. 14 patients were excluded for the presence of pre-TAVI PPM, 3 for the presence of congenital bicuspid aortic valve, 8 due to the presence of non-evaluable CT angiography.

Results

In the study population, out of the total of 79 patients, PPMs were implanted in 8 patients (10.12%), of which 7 in 35 (20%) patients undergoing TAVI with SE and 1 in 44 (2.27%) with BE valves. The measurements of MS was 4±2.1 mm for BE vs 3.3±2 mm for SE valves (p=0.141) and ID was 4.9±1.7 mm for BE vs 5.9±3.2 mm for SE valves (p=0.046). At multivariate logistic regression, two significant variables related to the post-TAVI PPMI were identified: MS (p=0.029) and ID (p=0.009), moreover the MS / ID ratio represents an additional predictor for PPMI regardless of the type of valve used (p=0.002).

Conclusion(s)

The study confirms the importance of the pre-TAVI MS length measurement for both types of valves. The only modifiable factor is the implantation technique which, knowing the PPMI's preoperative risk must be modified according to the patient's septum. Therefore it will be possible to modify the valve ID according to the patient's septum, looking for higher implants in higher-risk cases, particularly with self-expanding valves.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): No fundings

Long-term echocardiographic findings after TAVR: 5-year follow-up in 400 consecutive patients

A little is known about long-term hemodynamic performance of the transcatheter heart valves (THVs). The aim of the present study was to assess hemodynamic outcome, structural valve deterioration (SVD) and bioprosthetic valve failure (BVF) in patients treated with transcatheter aortic valve replacement (TAVR) five or more years ago. All consecutive patients treated at Bologna and Florence University Hospitals with TAVR between January 2008 and December 2013 were analyzed in a retrospective registry with regards to demographic, procedural and outcome data as well as follow-up data on mortality and echocardiographic characteristics. Standardized definitions were used to define outcomes and durability of the THVs. 400 patients were included in the study, mostly treated with transfemoral TAVR (71.8%), using first generation balloon-expandable (37%) or self-expanding (63%) devices. The 1-year mortality was 21.8% (87 patients) and 5-year mortality was 53.8% (215 patients). Median follow-up was 45.5 months (14.0-68.9) totaling 1516.7 patient/years, with the longest follow-up being 10.25 years. At least one follow-up echocardiogram was available for 320 patients (80%), SVD occurred in 19 of these patients (5.94%): moderate in 17 patients (5.31%) and severe in two patients (0.63%). The hemodynamic presentation was stenosis in most of the cases (12 patients). Late BVF was registered in 10 patients (3.13%) and this was mainly driven by transcatheter paravalvular leak closure (six patients) with subsequent good long-term outcome. Our results confirm that TAVR appears to be a long-lasting treatment strategy with low rates of structural valve degeneration and valve failure.

Advancements in Transcatheter Aortic Valve Implantation: A Focused Update

Transcatheter aortic valve implantation (TAVI) has become the leading technique for aortic valve replacement in symptomatic patients with severe aortic stenosis with conventional surgical aortic valve replacement (SAVR) now limited to patients younger than 65-75 years due to a combination of unsuitable anatomies (calcified raphae in bicuspid valves, coexistent aneurysm of the ascending aorta) and concerns on the absence of long-term data on TAVI durability. This incredible rise is linked to technological evolutions combined with increased operator experience, which led to procedural refinements and, accordingly, to better outcomes. The article describes the main and newest technical improvements, allowing an extension of the indications (valve-in-valve procedures, intravascular lithotripsy for severely calcified iliac vessels), and a reduction of complications (stroke, pacemaker implantation, aortic regurgitation).

Relation between the size of patent foramen ovale and the volume of acute cerebral ischemic lesion in young patients with cryptogenic ischemic stroke

Background

Patent foramen ovale (PFO) closure is superior to medical therapy alone to prevent stroke recurrence in selected patients. Small cortical infarcts and large right to left shunts seem to identify patients who will benefit most from closure. We aimed to study the correlation between the size of the PFO and the volume of cerebral ischemic lesions in young patients with cryptogenic ischemic stroke.

Methods

PFO dimensions and acute ischemic lesion volume of 20 patients, aged<55 years, were analyzed with transesophageal echocardiography and brain magnetic resonance imaging, respectively. The association between the volume of ischemic lesions with the length of PFO, maximum separation between septum primum and septum secundum, and the combination of the twos was explored.

Results

A direct statistically significant correlation was found between cerebral lesion volume and maximum separation of septum primum and septum secundum (p=0.047). Length of PFO showed a non-significant trend towards an inverse correlation with lesion volume (p=0.603). Multiple linear regression analysis showed that cerebral lesion volume was dependent directly on maximum separation and inversely on length of PFO (regression coeff. −0,837; p= 0.057; 2,536, p=0.006, respectively).

Conclusions

These data suggest that even small PFO might be pathogenetic in case of small cerebral infarcts and that large cerebral infarcts might be PFO related if the shunt is large. If confirmed, the combination of detailed characteristics of PFO with the volume of cerebral infarct could be integrated in a new score to select patients who would take real advantage from a percutaneous closure.

The DESolve® novolimus bioresorbable scaffold

A longtime aspiration of interventional cardiologists remains to improve the long-term impact of stent permanence in coronaries to restore original vessel patency and physiological endothelium response. Bioresorbable vascular scaffolds were considered revolutionary in coronary devices, but several trials were disappointing; thus, the challenge in this field remains. DESolve is a novolimus-eluting poly-L lactide-based polymer scaffold that dissolves through a bio-reabsorption mechanism, vanishing completely in 2 years. Its ability to supply the necessary radial strength to support the vessel for the critical early months after delivery is an important feature showing a unique self-correction property, which reduces incomplete stent apposition. Overexpansion has a good, safe margin with DESolve. This review aims to provide an overview of this controversial topic.

[Prosthesis embolization during transcatheter aortic valve implantation]

Transcatheter aortic valve implantation (TAVI) has been a revolution in the treatment of severe aortic stenosis evolving to a high procedural success rate and low rate of complications. Embolization of the percutaneous device is a rare but potentially life-threatening complication. The spectrum of clinical manifestations ranges between incidental finding on cardiac imaging to cardiogenic shock or cardiac arrest. Data about predictors and management of transcatheter heart valve embolization are scarce and mostly anecdotical. Management strategies are related to the type, the size, the location of the embolized device, the timing of diagnosis, and the clinical presentation of the patient. According to recent data from TRAVEL registry, device embolization and migration occur in approximately 1% of the patients and is responsible for increased morbidity and mortality. However, in a considerable proportion of cases it could have been prevented, hence structural interventionalists should plan the procedures carefully and know thoroughly the risk factors for device embolization. Increased awareness of predisposing factors, preventive measures, and appropriate bail-out options and techniques are strongly advisable. This paper is a review of the incidence, and outcomes of percutaneous prosthesis embolization during TAVI. It also suggests an integrated algorithmic approach for the management of device embolization incorporating both percutaneous and surgical techniques.

Supra-Aortic Vessel Stenting to Stabilize an Embolized Acurate NEOTranscatheter Heart Valve: The Chandelier Technique

THV aortic embolization can be managed percutaneously by snaring the prosthesis in a stable position in ascending aorta. We report two cases of embolized Acurate NEO with extreme mobility of devices in ascending aorta in which a bailout supra-aortic trunk stenting with consistent aortic protrusion were performed stabilizing the devices.

Atrial Fibrillation and Resistant Stroke: Does Left Atrial Appendage Morphology Matter? A Case Report

Introduction: Patients with atrial fibrillation (AF) can experience ischemic stroke despite adequate anticoagulant therapy. The secondary prevention strategy of these so-called “resistant strokes” is empirical. Since about 90% of patients with ischemic stroke due to atrial fibrillation have thrombus in left atrial appendage (LAA) we sought to explore the possibility that resistant stroke could have a LAA morphology resistant to anticoagulants.

Case Report: A 77 years old man affected by AF experienced two cardioembolic ischemic stroke while on anticoagulants. The study of LAA showed a windsock-like morphology in the proximal part while distally the LAA presented a cauliflower morphology with a large amount of pectinate muscles and blood stagnation. The precise characteristics of LAA were properly understood integrating images obtained by cardiac CT, transesophageal echocardiography, and selective angiography. A high risky LAA for thrombus formation was diagnosed and its occlusion (LAAO) as an add-on therapy to anticoagulants was proposed and performed. Six month follow-up was uneventfully.

Conclusion: The systematic study of LAA in patients with resistant-stroke could help to identify LAA malignant morphology. The efficacy on stroke recurrence of the combined therapy (anticoagulants plus LAAO) is worthy to be tested in randomized trials.

Intravascular imaging to guide lithotripsy in concentric and eccentric calcific coronary lesions

Background

Calcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure.

Purpose

The study aimed at the evaluation of the immediate procedural outcome of a novel treatment algorithm based on IVUS and/or OCT and including lithotripsy into a real-world consecutive based on intravascular imaging assessment by IVUS or OCT.

Methods and results

Thirty-one calcified stenoses (28 patients) out of a total of 455 lesions in 370 patients treated between November 2018 and May 2019 met the clinical and angiographic criteria for treatment with IVL under intravascular imaging guidance. Patients were divided into two subgroups depending on the calcium arc measured with intravascular imaging. Twenty lesions showed a calcium arc greater than 180 degrees (289±53 degrees) and 11 lesions smaller than 180 (140±24 degrees). The following parameters were assessed with OCT and/or IVUS: post stent minimal lumen area (MLA) and area stenosis (AS), incomplete strut apposition (ISA), eccentricity index, strut fracture, and edge dissection. After optimization a satisfactory lumen enlargement (acute gain 1.28±0.46 mm; minimal stent area 7.09±2.77 mm2) was observed with good stent expansion (residual area stenosis &lt;20% in 29 lesions, 93.5%) and OCT calcium fractures in 71% of cases. Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no in-hospital coronary perforations, no pericardial effusions, no stent failure or thrombosis, no deaths.

Conclusions

A standardized algorithm applying multimodality imaging to guide selection and application of IVL facilitated second generation DES implantation with final post-dilatation delivers excellent immediate procedural results and patient outcome, both in concentric or eccentric calcifications.

Funding Acknowledgement

Type of funding source: None

Deep sedation vs femoral block anesthesia: beat-by-beat hemodynamic impact on TAVI procedure

BACKGROUND

In spite of the increased use of Trans-catheter Aortic Valve Implantation (TAVI) due to the better patient selection, well-trained operators and improved technology, the choice of the best anesthesia regimen remains an open question. In particular, it remains to be clarified whether deep sedation (DS) in spontaneous breathing or femoral local anesthesia (LA) is best.

OBJECTIVE

This study compared the hemodynamic variations determined by deep sedation (DS) with spontaneous breathing and local femoral anesthesia (LA) in 2 groups of patients submitted to TAVI with two different kinds of anesthesia, using a beat-by-beat pulse contour method (MostCare^®-UP).

METHODS

82 patients with severe aortic stenosis and similar baseline characteristics and indications underwent trans-femoral TAVI: 50 with LA and 32 with DS. All patients were submitted to minimally invasive hemodynamic monitoring. The following parameters were measured: pressure indexes: systolic, diastolic, mean (SysP, DiaP, MAP) and dicrotic (DicP) pressures; flow indexes: cardiac output (CO), stroke volume (SV); ventriculo-arterial coupling indexes (VAC): peripheral arterial elastance (Ea_P), systemic vascular resistance (SVR); cardiovascular system performance: cardiac cycle efficiency (CCE), dP/dt_{max_rad}.

RESULTS

The TAVI procedure was successful in 89% of patients (VARC-2 criteria) with no difference between the 2 groups. Anesthesia induction determined a higher decrease of pressures in DS than in LA (P<0.01) with no differences in CO. The VAC parameters (Ea_P, SVR) decreased (P<0.01) in DS with an improvement in CCE (P<0.001); these parameters did not change in LA. The post-TAVI flow and VAC parameters, especially Ea, increased (P<0.05) more significantly in the LA group than in the DS group (P<0.001). Using logistic regression, the occurrence of the post-TAVI aortic regurgitation was correctly associated with the pressure gradient MAP-DicP in 63% of the study population (P=0.033). This association was more effectively detected in the LA group (78%, P=0.011) with a ROC AUC=0.779, than the DS group.

CONCLUSION

The use of the pulse contour method to track the fast-hemodynamic changes during the TAVI procedure proved suitable for the aim. As expected, LA and DS induced different pre-TAVI hemodynamic conditions, which influenced the post-TAVI hemodynamic changes. The hemodynamic conditions induced by LA, enabled the occurrence of post-TAVI aortic regurgitation to be detected more effectively.

Transcatheter aortic valve implantation (TAVI) in cardiogenic shock: TAVI-shock registry results

OBJECTIVES

Aim of this study is to evaluate safety, feasibility, and mid-term outcome of transcatheter aortic valve implantation (TAVI) in cardiogenic shock (CS).

BACKGROUND

Balloon aortic valvuloplasty in patients with severe aortic valve stenosis (SAS) complicated by CS is indicated but associated with a grim prognosis. TAVI might be a more reasonable treatment option in this setting but data are scant.

METHODS

From March 2008 to February 2019, 51 patients with severe aortic valvulopathy (native SAS or degenerated aortic bioprosthesis) and CS treated by TAVI in 11 European centers were included in this multicenter registry. Demographic, clinical, and procedural data were collected, as well as clinical and echocardiographic follow-up.

RESULTS

The mean age of our study population was 75.8 ± 13, 49% were women, and mean Society of Thoracic Surgeons (STS) score was 19 ± 15%. Device success was achieved in 94.1%, with a 5% incidence of moderate/severe paravalvular leak. The 30-day events were mortality 11.8%, stroke 2.0%, vascular complications 5.9%, and acute kidney injury 34%. Valve Academic Research Consortium-2 early safety endpoint was reached in 35.3% of cases. At 1-year of follow-up, the mortality rate was 25.7% and the readmission for congestive heart failure was 8.6%.

CONCLUSIONS

TAVI seems to be a therapeutic option for patients with CS and SAS or degenerated aortic bioprosthesis in terms of both safety and efficacy at early and long-term follow-up.

Intravascular Imaging to Guide Lithotripsy in Concentric and Eccentric Calcific Coronary Lesions

BACKGROUND

Calcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure.

PURPOSE

The study aimed at the evaluation of the immediate procedural outcome in a real-world consecutive population of a selective use of lithotripsy based on the intravascular imaging assessment with IVUS or OCT.

METHODS AND RESULTS

Thirty-one calcified stenoses (28 patients) out of a total of 455 lesions (370 patients) treated between November 2018 and May 2019 received IVL under intravascular imaging guidance. The majority of the IVL lesions had angiographically severe calcifications and were selected after intravascular imaging. A smaller group was identified by poor expansion after high-pressure balloon dilatation, in one case despite preliminary small burr Rotablation. After IVL, when OCT was performed calcium fractures were observed in 71% of cases. After OCT/IVUS guided stent optimization a satisfactory lumen enlargement (minimal stent area 7.09 ± 2.77 mm²) was observed with good stent expansion (residual area stenosis<20% in 29 lesions, 93.5%) Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no periprocedural coronary perforations or pericardial effusions, and no in-hospital or 30 days stent thrombosis. When patients were divided into two subgroups according to a calcium arc ≤180° (Group A: 10 lesions, calcium arc 140 ± 24°; Group B: 21 lesions, calcium arc 289 ± 53°), at OCT Group B presented also a higher number of calcium fractures post IVL than group A (group A: 38% vs group B: 92%, p = 0.03). The in-stent minimum lumen diameter (MSD), the in stent minimal lumen area (MSA) and the acute gain, however, were similar between the two groups (acute gain group A: 1.22 ± 0.29 mm; group B: 1.31 ± 0.52 mm, p = 0.63).

CONCLUSIONS

A standardized algorithm applying intravascular imaging guidance of IVL facilitated second generation DES expansion delivers excellent immediate lumen expansion and patient outcome, both in concentric and eccentric calcifications.

Percutaneous Trans-septal Mitral Valve-in-Ring Implantation Using a Transcatheter Balloon-Expandable Transcatheter Heart Valve With Elective Intra-Procedural Artero-Venous ECMO in a Patient With Severely Reduced Left Ventricular Ejection Fraction

Percutaneous mitral valve-in-valve implantation is an emerging option in patients with surgical bioprosthesis failure or failing mitral annuloplasty and increased surgical risk. We present a case of transcatheter transvenous trans-septal mitral valve-in-ring (TMVinR) procedure, in a patient with severe left ventricular dysfunction and severe mitral regurgitation, after surgical mitral annuloplasty, managed with periprocedural mechanical circulatory support (MCS) with VA-ECMO.

Intracardiac Versus Transesophageal Echocardiographic Guidance for Left Atrial Appendage Occlusion: The LAAO Italian Multicenter Registry

OBJECTIVES

This study sought to evaluate the feasibility, safety, and efficacy of intracardiac echocardiography (ICE)-guided versus transesophageal echocardiography (TEE)-guided left atrial appendage occlusion (LAAO) by the use of Amplatzer Cardiac Plug or Amulet devices included in a large Italian registry.

BACKGROUND

TEE is widely used for LAAO procedure guidance. ICE may be a potential alternative imaging modality in LAAO.

METHODS

Data from 604 LAAO procedures performed in 16 Italian centers were reviewed. ICE-guided LAAO was performed in 187 patients, whereas TEE was used in 417 patients. Procedural success was defined as LAAO without occurrence of pericardial tamponade, stroke, systemic embolism with end organ damage, major bleeding, and device embolization. Stroke, transient ischemic attack, major bleeding, overall and cardiovascular death were analyzed.

RESULTS

CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65 to 74 years, sex category) and HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol) scores were similar between the ICE and TEE groups. TEE implied lower procedural (delta 12 min) and fluoroscopy time (delta 5 min) when compared with ICE. Procedural success was similarly high (≥94%) between the TEE and ICE groups with a complication rate of 6.5% for TEE versus 4.2% for ICE (odds ratio: 1.468; 95% confidence interval: 0.681 to 3.166; p = 0.327). At median follow-up of 451 days (interquartile range: 162 to 899 days), the rate of cerebral ischemic events was similar between TEE-guided and ICE-guided procedures.

CONCLUSIONS

ICE-guided LAAO by means of Amplatzer devices may represent a second alternative imaging modality after an appropriate learning curve and bearing in mind that pre-procedural computed tomography imaging is mandatory. When comparing ICE with TEE, TEE remains the gold standard.

One more option in heart failure: correction of mitral regurgitation with MitraClip®

Degenerative mitral regurgitation in elderly patients and functional mitral regurgitation secondary to severe left ventricular dysfunction are not easy options for conventional surgery. Recently, a new percutaneous approach has been proposed with the MitraClip^®, based on the Alfieri edge-to-edge repair technique. The aim of the study is to report, compare and discuss the results of two multicenter randomized trials: MITRA.FR and COAPT in light of the current practice. In both trials patients with functional mitral regurgitation grade 3/4+ or 4/4+ were randomly assigned, in 1:1 ratio, to undergo percutaneous repair and optimal medical therapy or optimal medical therapy alone. Other baseline characteristics reflecting severity of mitral regurgitation and of left ventricular impairment were statistically different, such as the effective regurgitant orifice area (0.31 cm² in MITRA.FR vs 0.41 cm² in COAPT) and the indexed LVEDV (135 ± 37 ml/m² in MITRA.FR vs 101 ± 34 ml/m² in COAPT). A 24 months follow-up and a 12 months follow-up have been completed, respectively, in COAPT and MITRA.FR. Out of the 307 patients enrolled in the MITRA.FR, 152 were randomized to percutaneous treatment but only in 138 (95.8%) the MitraClip^® was actually implanted. At the end of the follow-up a residual mitral regurgitation of at least grade 3+ has been observed in 17% of the patients. A composite of death from any cause or unplanned hospitalizations for heart failure at 12 months respectively occurred in 83 patients (54.6%) treated percutaneously and 78 patients (51.3%) treated with medical therapy only. A total of 614 patients have been enrolled in the COAPT and 293 underwent transcatheter treatment. A successful implantation of the MitraClip^® was achieved in 287 patients (98.0%). Hospitalization for heart failure at 24 months occurred in 160 patients in the device group and in 283 in the control group, with an annualized ratio of 35.8% and 67.9%, respectively (p > 0.001). The conflicting results of the two trials may have many explanations, but probably the main cause is the most stringent inclusion criteria in COAPT. The effective reduction of mitral regurgitation and improvement in exercise capacity already observed in registries including more than 70,000 patients was confirmed in a randomized trial with improvement observed in hard end-points. This has already led to an extension of FDA approval to functional regurgitation and a more liberal use across the world.

[Tips and tricks for using extracorporeal life support devices in the intensive cardiac care unit]

In patients with severe cardiac dysfunction refractory to conventional therapies, extracorporeal membrane oxygenation used in veno-arterious modality can provide temporary circulatory assistance (extracorporeal life support, ECLS). Since it is an invasive and complex technique, its use is potentially burdened by severe complications, thus requiring careful nursing and medical care during intensive cardiac care unit stay. The use of ECLS requires specific skills such as knowledge of protective mechanical invasive ventilation, specific echocardiographic evaluation, accurate monitoring of hemodynamics and laboratory tests. A patient on ECLS is at high risk of thrombotic and hemorrhagic complications that could be fatal, hence specific pro- and anti-hemostatic therapy is needed. Moreover, the knowledge of some peculiar aspects of ECLS system and management can help doctors to avoid several complications such as limb ischemia, left ventricular overload and regional perfusion discrepancy. In conclusion, careful management by adequately trained personnel is required.

Left atrial appendage occlusion for stroke despite oral anticoagulation (resistant stroke). Results from the Amplatzer Cardiac Plug registry

INTRODUCTION AND OBJECTIVES

Despite the efficacy of oral anticoagulant (OAC) therapy, some patients continue to have a high residual risk and develop a stroke on OAC therapy (resistant stroke [RS]), and there is a lack of evidence on the management of these patients. The aim of this study was to analyze the safety and efficacy of left atrial appendage occlusion (LAAO) as secondary prevention in patients with nonvalvular atrial fibrillation who have experienced a stroke/transient ischemic attack despite OAC treatment.

METHODS

We analyzed data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients with nonvalvular atrial fibrillation undergoing LAAO. Patientes with previous stroke on OAC therapy as indication for LAAO were identified and compared with patients with other indications.

RESULTS

A total of 115 patients (11%) with RS were identified. The CHA₂DS₂-VASc and the HAS-BLED score were significantly higher in the RS group (respectively 5.5±1.5 vs 4.3±1.6; P <.001; 3.9±1.3 vs 3.1±1.2; P <.001). No significant differences were observed in periprocedural major safety events (7.8 vs 4.5%; P=.1). With a mean clinical follow-up of 16.2±12.2 months, the observed annual stroke/transient ischemic attack rate for the RS group was 2.6% (65% risk reduction) and the observed annual major bleeding rate was 0% (100% risk reduction).

CONCLUSIONS

Patients with RS undergoing LAAO showed similar safety outcomes to patients without RS, with a significant reduction in stroke/transient ischemic attack and major bleeding events during follow-up. Adequately powered controlled trials are needed to further investigate the use of LAAO in RS patients.

[Patent foramen ovale closure: how to choose the right device for the right patient]

Percutaneous patent foramen ovale (PFO) closure is an intervention aimed to prevent cardioembolic stroke. It recently proved to be superior to antiplatelet therapy in preventing recurrent strokes in a well-selected population of patients with a previous cryptogenic cerebral ischemic event. A large part of the clinical advantage of PFO transcatheter therapy derives from the very high efficacy and safety of the maneuver. Various types of devices with different characteristics are currently available for the use of the interventionists. Recently, a direct PFO suture device has been added to the device list, allowing for PFO closure without implanting any prosthesis. This article describes the procedure of PFO closure with a particular focus on the main characteristics of the various devices available. A road-map of choice among the various prostheses is also provided, keeping in mind the patient's clinical features and the various PFO anatomies.