Cross-Seal IDE Trial: Prospective, Multicenter, Single-Arm Study of the Cross-Seal Suture-Mediated Vascular Closure Device System

BACKGROUND

An increasing number of interventional procedures require large-sheath technology (>12F) with a favorable outcome with endovascular rather than open surgical access. However, vascular complications are a limitation for the management of these patients. This trial aimed to determine the effectiveness and safety of the Cross-Seal suture-mediated vascular closure device in obtaining hemostasis at the target limb access site following interventional procedures using 8F to 18F procedural sheaths.

METHODS

The Cross-Seal IDE trial (Investigational Device Exemption) was a prospective, single-arm, multicenter study in subjects undergoing percutaneous endovascular procedures utilizing 8F to 18F ID procedural sheaths. The primary efficacy end point was time to hemostasis at the target limb access site. The primary safety end point was freedom from major complications of the target limb access site within 30 days post procedure.

RESULTS

A total of 147 subjects were enrolled between August 9, 2019, and March 12, 2020. Transcatheter aortic valve replacement was performed in 53.7% (79/147) and percutaneous endovascular abdominal/thoracic aortic aneurysm repair in 46.3% (68/147) of subjects. The mean sheath ID was 15.5±1.8 mm. The primary effectiveness end point of time to hemostasis was 0.4±1.4 minutes. An adjunctive intervention was required in 9.2% (13/142) of subjects, of which 2.1% (3/142) were surgical and 5.6% (8/142) endovascular. Technical success was achieved in 92.3% (131/142) of subjects. Freedom from major complications of the target limb access site was 94.3% (83/88).

CONCLUSIONS

In selected patients undergoing percutaneous endovascular procedures utilizing 8F to 18F ID procedural sheath, Cross-Seal suture-mediated vascular closure device achieved favorable effectiveness and safety in the closure of the large-bore arteriotomy.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03756558.

Artificial Intelligence in Cardiovascular Medicine: Historical Overview, Current Status, and Future Directions

Artificial intelligence and machine learning are rapidly gaining popularity in every aspect of our daily lives, and cardiovascular medicine is no exception. Here, we provide physicians with an overview of the past, present, and future of artificial intelligence applications in cardiovascular medicine. We describe essential and powerful examples of machine-learning applications in industry and elsewhere. Finally, we discuss the latest technologic advances, as well as the benefits and limitations of artificial intelligence and machine learning in cardiovascular medicine.

Artificial Intelligence for Education, Proctoring, and Credentialing in Cardiovascular Medicine

Artificial intelligence and machine learning are rapidly gaining popularity in every aspect of cardiovascular medicine. This review discusses the past, present, and future of artificial intelligence in education, remote proctoring, credentialing, research, and publication as they pertain to cardiovascular procedures. This review describes the benefits and limitations of artificial intelligence and machine learning and the exciting potential of integrating advanced simulation, holography, virtual reality, and extended reality into disease diagnosis and patient care, as well as their roles in cardiovascular research and education. Nonetheless, much of the available data resides in electronic medical records or within industry-sponsored proprietary programs that are not compatible or standardized for current clinical application. Many areas in cardiovascular medicine would benefit from the introduction or increased use of artificial intelligence. Web-based artificial intelligence applications could be used to address unmet needs for education, on-demand procedural proctoring, credentialing, and recredentialing for interventionists and physicians in remote locations. Further progress in artificial intelligence will require further collaboration among computer scientists and researchers in order to identify and correct the most relevant problems and to implement the best data-based approach to achieving this goal. The future success of artificial intelligence in cardiovascular medicine will depend on the degree of collaboration between all pertinent experts in this field. This will undoubtedly be a prolonged, stepwise process.

Hemodynamic outcomes after valve-in-valve transcatheter aortic valve replacement: a single-center experience

Background

Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has emerged as a safe, effective alternative to redo aortic valve surgery in high-risk patients with degenerated surgical bioprosthetic valves. However, ViV-TAVR has been associated high postprocedural valvular gradients, compared with TAVR for native-valve aortic stenosis.

Methods

We performed a retrospective study of all patients who underwent ViV-TAVR for a degenerated aortic valve bioprosthesis between January 1, 2013 and March 31, 2019 at our center. The primary outcome was postprocedural mean aortic valve gradient. Outcomes were compared across surgical valve type (stented versus stentless), surgical valve internal diameter (≤19 versus >19 mm), and transcatheter aortic valve type (self-expanding vs. balloon-expandable).

Results

Overall, 89 patients underwent ViV-TAVR. Mean age was 69.0±12.6 years, 61% were male, and median Society of Thoracic Surgeons Predicted Risk of Mortality score was 5.4 [interquartile range, 3.2-8.5]. Bioprosthesis mode of failure was stenotic (58% of patients), regurgitant (24%), or mixed (18%). The surgical valve was stented in 75% of patients and stentless in 25%. The surgical valve's internal diameter was ≤19 mm in 45% of cases. A balloon-expandable transcatheter valve was used in 53% of procedures. Baseline aortic valve area and mean gradients were 0.87±0.31 cm² and 36±18 mmHg, respectively. These improved after ViV-TAVR to 1.38±0.55 cm² and 18±11 mmHg at a median outpatient follow-up of 331 [67-394] days. Higher postprocedural mean gradients were associated with surgical valves having an internal diameter ≤19 mm (24±13 versus 16±8, P=0.002) and with stented surgical valves (22±11 versus 12±6, P<0.001).

Conclusions

ViV-TAVR is an effective option for treating degenerated surgical aortic bioprostheses, with acceptable hemodynamic outcomes. Small surgical valves and stented surgical valves are associated with higher postprocedural gradients.

MANTA versus Perclose for large-bore vessel closure: The evidence continues to grow

The MANTA is a new, easy-to-use, collagen plug-based vascular closure device specifically designed for large-bore arteriotomy closure. The authors report on their experience comparing the MANTA device with the Perclose ProGlide technique in patients undergoing transcatheter aortic valve replacement. They found similar rates of success and vascular complications with both devices, suggesting that MANTA is a suitable option for these patients. It remains to be determined whether one device will emerge as the ideal choice for most patients. Device cost is a significant barrier to widespread adoption, but price has decreased recently.

"Simple" Transcatheter Aortic Valve Replacement With Conscious Sedation: Safety and Effectiveness in Real-World Practice

Transcatheter aortic valve replacement (TAVR) is a well-established alternative to open surgical replacement. Strictly selecting low-risk patients and using conscious sedation during TAVR has enabled hospital stays to be safely shortened. We evaluated the safety and effectiveness of a less rigorous patient-selection process involving multidisciplinary case discussions, percutaneous procedures with the use of conscious sedation, and postprocedural care outside an intensive care unit, with the goal of discharging patients from the hospital early. We call this "simple TAVR." We retrospectively reviewed the records of patients who underwent TAVR from March 2015 through February 2020 at our center. The procedures were performed by 2 high-volume operators. Of 524 total procedures, 344 (65.6%) qualified as simple TAVR. All 344 procedures were successful. The highest 30-day complication rate was associated with new permanent pacemaker implantation (7.3%, 25 patients); the rates of major vascular complications, stroke, and all-cause death were less than 3% each. Of note, 252 patients (73.3%) were discharged from the hospital the day after TAVR, and 307 (89.2%) within 48 hours. Simple TAVR is safe, economical, and feasible in real-world practice, and it does not necessitate a rigorous perioperative protocol or patient-selection process.

"Simple" Transcatheter Aortic Valve Replacement With Conscious Sedation: Safety and Effectiveness in Real-World Practice

Transcatheter aortic valve replacement (TAVR) is a well-established alternative to open surgical replacement. Strictly selecting low-risk patients and using conscious sedation during TAVR has enabled hospital stays to be safely shortened. We evaluated the safety and effectiveness of a less rigorous patient-selection process involving multidisciplinary case discussions, percutaneous procedures with the use of conscious sedation, and postprocedural care outside an intensive care unit, with the goal of discharging patients from the hospital early. We call this "simple TAVR." We retrospectively reviewed the records of patients who underwent TAVR from March 2015 through February 2020 at our center. The procedures were performed by 2 high-volume operators. Of 524 total procedures, 344 (65.6%) qualified as simple TAVR. All 344 procedures were successful. The highest 30-day complication rate was associated with new permanent pacemaker implantation (7.3%, 25 patients); the rates of major vascular complications, stroke, and all-cause death were less than 3% each. Of note, 252 patients (73.3%) were discharged from the hospital the day after TAVR, and 307 (89.2%) within 48 hours. Simple TAVR is safe, economical, and feasible in real-world practice, and it does not necessitate a rigorous perioperative protocol or patient-selection process.

Clinical impact of calcified nodules in patients with heavily calcified lesions requiring rotational atherectomy

Coronary atherectomy has been around for many years, and the body of evidence for its use in complex calcified lesions has grown. Calcific coronary disease presents a particularly challenging clinical scenario in PCI, having poorer outcomes than noncalcified lesions. This study is the first to identify calcified nodules as an independent predictor of worse outcomes after atherectomy and PCI. Continued study of lesion characteristics will improve our understanding of PCI outcomes and help manage patients in the long-term after PCI and stenting.

Effect of concomitant aortic regurgitation on early hypoattenuated leaflet thickening after transcatheter aortic valve replacement in patients with symptomatic severe aortic stenosis

Identification of hypoattenuated leaflet thickening (HALT) and subacute leaflet thrombosis has become widely recognized. Patients with anatomical changes associated with moderate or greater aortic regurgitation (larger sinus of Valsalva and eccentric left ventricular remodeling) appear to have less HALT early postprocedure compared with those without. Further research on the risk factors including anatomical and hemodynamic variables should further our knowledge of these entities so we can better manage patient both pre and post TAVR.

Transcatheter aortic valve replacement after chest radiation: A propensity-matched analysis

BACKGROUND

Chest radiation therapy (CRT) for malignant thoracic neoplasms is associated with development of valvular heart disease years later. As previous radiation exposure can complicate surgical treatment, transcatheter aortic valve replacement (TAVR) has emerged as an alternative. However, outcomes data are lacking for TAVR patients with a history of CRT.

METHODS

We conducted a retrospective study of all patients who underwent a TAVR procedure at a single institution between September 2012 and November 2018. Among 1341 total patients, 50 had previous CRT. These were propensity-matched in a 1:2 ratio to 100 patients without history of CRT. Thirty-day adverse events were analyzed with generalized estimating equation models. Overall mortality was analyzed with stratified Cox regression modelling.

RESULTS

Median clinical follow-up was 24 months (interquartile range [IQR], 12-44 months). There was no difference between CRT and non-CRT patients in overall mortality (hazard ratio [HR] 0.84 [0.37-1.90], P = 0.67), 30-day mortality (HR 3.1 [0.49-20.03], P = 0.23), or 30-day readmission rate (HR 1.0 [0.43-2.31], P = 1). There were no differences in the rates of most adverse events, but patients with CRT history had higher rates of postprocedural respiratory failure (HR 3.63 [1.32-10.02], P = 0.01) and permanent pacemaker implantation (HR 2.84 [1.15-7.01], P = 0.02).

CONCLUSIONS

For patients with aortic valve stenosis and previous CRT, TAVR is safe and effective, with outcomes similar to those in the general aortic stenosis population. Patients with history of CRT are more likely to have postprocedural respiratory failure and to require permanent pacemaker implantation.

Thoracic aortic disease: Can we safely cover the branches?

Thoracic aortic disease has usually been treated with surgery. Thoracic endovascular aortic repair is challenging if supra-aortic vessels are involved. In situ fenestration of the main graft from a retrograde approach while using bare-metal stents as bridge stents appears to be a safe and practical technique.

Preventing tricuspid valve injury during transcatheter pulmonary valve replacement

The transcatheter pulmonary valve replacement technique has evolved over the past decade. There is risk of injuring the tricuspid valve if the transcatheter device is advanced uncovered across the right heart. Advancing a long sheath past the landing zone and uncovering the device can help mitigate this risk, at the expense of requiring larger-caliber sheaths. Additional refinements of the technique such as the one reported here, along with improvements in device design, are likely to further reduce complications.

Assessing atherothrombotic burden with optical coherence tomography analysis may facilitate post-PCI prognostication and antiplatelet therapy

Atherothrombotic burden (ATB) correlates with myocardial blush grade (MBG), a known predictor of mortality and outcome after ST-elevation myocardial infarction. Quantitative or semiquantitative analysis of ATB with optical coherence tomography may assist interventional cardiologists in post-PCI prognostication and, perhaps, in rendering more aggressive antiplatelet therapy. Future studies comparing treatment strategies for post-PCI patients with elevated ATB or depressed MBG may identify best practices after acute coronary syndromes.

Peripheral arterial disease and transcatheter valve replacement outcomes

Patients with PAD have worse outcomes after TAVR. The extent and distribution of PAD are important considerations in determining TAVR feasibility and choosing an access site. Further research is needed to establish the best approaches to treating patients with aortic and iliofemoral disease severe enough to limit device delivery.

Editorial for: Outcomes after endovascular mechanical thrombectomy in occluded vascular access used for dialysis purposes

Multimodality interventions, including both percutaneous and surgical approaches, are paramount in maintaining vascular fistula and graft patency in hemodialysis patients. Mechanical thrombectomy with Angiojet AVX or Solent Proxi of AVFs and AVGs achieved acceptable technical and clinical success rates (>90%) in combination with adjuvant percutaneous transluminal angioplasty and stenting. Future prospective studies using intravascular imaging before therapy may be useful when deciding which treatment modalities to use for AVFs and AVGs.

Clinical and economic outcomes of ProGlide compared with surgical repair of large bore arterial access

Aim: This study compared real-world complication rates, hospitalization duration and costs, among patients undergoing arterial repair using the Perclose ProGlide (ProGlide) versus surgical cutdown (Cutdown). Materials & methods: Retrospective study of matched patients who underwent transcatheter aortic valve replacement/repair, endovascular abdominal aortic aneurysm repair, thoracic endovascular aortic repair or balloon aortic valvuloplasty with arterial repair by either ProGlide or Cutdown between 1 January 2013 and 24 April 2017. Results: Infections and blood transfusions were lower in the ProGlide cohort. Patients in the ProGlide cohort had a 42.5% shorter index hospitalization, which corresponded to US$14,687 lower costs. Conclusion: The use of ProGlide for arterial repair was associated with significantly lower transfusion rates, shorter index hospitalization and lower hospitalization costs compared with surgical cutdown.

Comparison of perioperative costs with fast-track vs standard endovascular aneurysm repair

Background

Perioperative health care utilization and costs in patients undergoing elective fast-track vs standard endovascular aneurysm repair (EVAR) remain unclear.

Methods

The fast-track EVAR group included patients treated with a 14 Fr stent graft, bilateral percutaneous access, no general anesthesia or intensive care monitoring, and next-day hospital discharge. The standard EVAR group was identified from Medicare administrative claims using a matching algorithm to adjust for imbalances in patient characteristics. Hospital outcomes included operating room time, intensive care monitoring, hospital stay, secondary interventions, and major adverse events (MAEs). Perioperative outcomes occurring from hospital discharge to 30 days postdischarge included MAE, secondary interventions, and unrelated readmissions.

Results

Among 1000 matched patients (250 fast-track; 750 standard), hospital outcomes favored the fast-track EVAR group, including shorter operating room time (2.30 vs 2.83 hrs, P<0.001), shorter hospital stay (1.16 vs 1.69 d, P<0.001), less need for intensive care monitoring (4.4% vs 48.0%, P<0.001), and lower secondary intervention rate (0% vs 2.4%, P=0.01). Postdischarge outcomes also favored fast-track EVAR with a lower rate of MAE (0% vs 7.2%, P<0.001) and all-cause readmission (1.6% vs 6.8%, P=0.001). The total cost to the health care system during the perioperative period was $26,730 with fast-track EVAR vs $30,730 with standard EVAR. Total perioperative health care costs were $4000 (95% CI: $3130–$4830) lower with fast-track EVAR vs standard EVAR, with $2980 in savings to hospitals and $1030 savings to health care payers.

Conclusion

A fast-track EVAR protocol using a 14 Fr stent graft resulted in shorter procedure time, lower intensive care utilization, faster discharge, lower incidence of MAE, lower readmission rates, and lower perioperative costs compared to standard EVAR.

Delivery catheters: Do they truly make a difference in transcatheter pulmonary valve replacement?

Transcatheter pulmonary valve replacement (TPVR) is a safe and feasible procedure for treating pulmonary stenosis, failed right ventricular conduits, or failed bioprosthetic valves. The medtronic melody valve and the Edwards Sapien XT and S3 valves have been the main prosthetic valves used in TPVR. Using the GORE DrySeal sheath helps valve delivery and facilitates TPVR.

Pivotal Clinical Study to Evaluate the Safety and Effectiveness of the MANTA Percutaneous Vascular Closure Device

Background:

Open surgical closure and small-bore suture-based preclosure devices have limitations when used for transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, or percutaneous thoracic endovascular aortic aneurysm repair. The MANTA vascular closure device is a novel collagen-based technology designed to close large bore arteriotomies created by devices with an outer diameter ranging from 12F to 25F. In this study, we determined the safety and effectiveness of the MANTA vascular closure device.

Methods and Results:

A prospective, single arm, multicenter investigation in patients undergoing transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, or thoracic endovascular aortic aneurysm repair at 20 sites in North America. The primary outcome was time to hemostasis. The primary safety outcomes were accessed site-related vascular injury or bleeding complications. A total of 341 patients, 78 roll-in, and 263 in the primary analysis cohort, were entered in the study between November 2016 and September 2017. For the primary analysis cohort, transcatheter aortic valve replacement was performed in 210 (79.8%), and percutaneous endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic aneurysm repair was performed in 53 (20.2%). The 14F MANTA was used in 42 cases (16%), and the 18F was used in 221 cases(84%). The mean effective sheath outer diameter was 22F (7.3 mm). The mean time to hemostasis was 65±157 seconds with a median time to hemostasis of 24 seconds. Technical success was achieved in 257 (97.7%) patients, and a single device was deployed in 262 (99.6%) of cases. Valve Academic Research Consortium-2 major vascular complications occurred in 11 (4.2%) cases: 4 received a covered stent (1.5%), 3 had access site bleeding (1.1%), 2 underwent surgical repair (0.8%), and 2 underwent balloon inflation (0.8%).

Conclusions:

In a selected population, this study demonstrated that the MANTA percutaneous vascular closure device can safely and effectively close large bore arteriotomies created by current generation transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, and thoracic endovascular aortic aneurysm repair devices.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02908880.

EndoAnchors Minimize Endoleaks in Chimney-Graft Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysms

Juxtarenal abdominal aortic aneurysms (AAAs) are difficult to treat because they often have little or no proximal aortic neck. Patients with this complex anatomy are not usually candidates for an endovascular aneurysm repair (EVAR). Chimney-graft EVAR has been introduced, but type Ia endoleak is a typical risk. We have begun using EndoAnchors to determine whether this risk can be reduced. From July 2013 through July 2014, we used the chimney-graft EVAR technique in 5 patients whose juxtarenal AAAs had a short or no proximal aortic neck. During the procedure, we implanted EndoAnchors as needed. Postprocedurally, at 30 days, and through end of follow-up (duration, 11-18 mo), all patients had patent endografts without type Ia endoleak (our primary endpoint), visceral stent-graft thrombosis, or renal complications. One patient who received 4 chimney grafts had a postprocedural type II endoleak, which was treated with embolization. We found it feasible to use EndoAnchors with the chimney-graft technique to prevent type Ia endoleaks in the treatment of juxtarenal AAAs. Further studies are needed to validate this adjunctive technique and to determine its durability.