Recently, subintimal angioplasty has been introduced as a bailout strategy to improve the success rate of PCI for vessels with CTO. However, the long-term outcome of subintimal angioplasty has not been determined, and a limitation of subintimal angioplasty is the uncertainty in making the re-entry point. We report two cases, where occlusive in-stent restenosis occurred in a stent implanted in the subintimal space of the RCA that had CTO. These two cases were successfully treated with bypass restenting across the struts of an occluded subintimal stent using a retrograde approach. A retrograde wire crossed the occluded segment through the lumen along the outside of the stent and reentered the inside of the stent across the stent struts. The reverse CART technique followed by multiple restenting across the stent struts restored antegrade flow. Follow-up angiography demonstrated the patency of the RCA. © 2013 Wiley Periodicals, Inc.

We report the first case of mitral stenosis following Mitra-Clip insertion in a patient with symptomatic NYHA IV heart failure, secondary to severe mitral regurgitation (MR). A 79 year old female with a history of prior aortic valve replacement underwent percutaneous mitral valve repair. A single clip was advanced coaxially down onto the mitral valve under TOE guidance, with the anterior and posterior leaflets clipped together between A2 and P2. TOE confirmed a significant reduction in MR (grade 4 to grade 1). Despite initial symptomatic relief, she represented 3 months later with similar symptoms. Repeat TOE confirmed a well positioned Mitra-Clip with mild residual MR. However, the possibility of significant mitral stenosis was raised due to the presence of significant turbulence through the bi-orifice valve, with a peak gradient of 25 mmHg. In addition there was evidence of severe functional tricuspid valve (TV) regurgitation with elevated pulmonary artery (PA) pressures (PA 90mmHg), confirmed on subsequent right heart catheterization. After repeated heart team discussions and a failure of optimal medical therapy, and despite a logistic EuroScore of 35.5, minimally invasive surgical replacement of the MV and simultaneous TV repair was undertaken via a right thoracotomy. Despite procedural success and initial good post -operative response, the patient died subsequently from a combination of hospital-acquired pneumonia and significant gastrointestinal bleeding (post operative day 35). Mitra-Clip is a promising novel approach to mitral valve repair. The establishment of further clinical and echocardiographic based selection criteria will help identify the correct patients for this treatment. © 2013 Wiley Periodicals, Inc.

Objectives:

We sought to evaluate the pathologic findings of the percutaneous Parachute device implanted in patients with severe heart failure (HF).

Background:

Currently most treatments of HF rest on optimal medical therapy with adjunctive interventional or surgical palliative treatments. One such treatment is the Parachute device, which partitions the left ventricle excluding the scarred myocardium from functioning myocardium, and has shown promise in clinical studies.

Methods:

We have examined histopathologically 7 cases [6 males (age range 43-74 years; mean 56 years) and one female (55 years)] of Parachute device that were either retrieved at autopsy (n=4) or during transplantation (n=3); implant duration, 15 to 1,533 days.

Results:

Three patients died of cardiac causes and none died from complications. Histologic early changes (<30 days, n=1) included adherent thrombus, with focal neutrophil infiltration and degenerating inflammatory cells. Over time (31 to 300 days, n=4) there was organized thrombus and development of neoendocardial thickening especially at the free-edge of the device and its contact with the adjacent endocardium while the base of the device showed varying degrees of fibrin thrombus. The greatest organization of thrombus was observed in devices removed at >300 days (680 and 1533 days); both had fractures of the foot along with strut fracture and one had tearing of the ePTFE.

Conclusions:

The percutaneous Parachute device appears as a promising adjunctive treatment for patients suffering from severe HF. The pathologic changes are those of organizing thrombus with and without inflammation with minor complications of foot and strut fracture. © 2013 Wiley Periodicals, Inc.

Background:

The number of low birth weight infants with congenital heart disease is increasing and catheterizations may have an increased risk for mortality and morbidity.

Objectives:

We investigate the outcome and complications of cardiac catheterizations in infants weighing < 2.5 kilograms.

Methods:

Retrospective review of catheterization records from 1995 to 2010 in infants weighing < 2.5 kilograms. The demographics, procedure, outcome and follow-up data were collected.

Results:

Of 101 catheterizations performed in 88 patients, 45 (45%) catheterizations were interventional. Balloon atrial septostomy (n=23), pulmonary valvuloplasty (14), aortic valvuloplasty (4), stent placement (3), balloon angioplasty (2) and temporary pacemaker insertion (1) were successfully performed. Balloon atrial septostomy was performed with pulmonary or aortic valvuloplasty in 2 catheterizations. Infants < 2.5 kilograms had higher significant adverse event rate that those 2.5 - 3.5 kilograms (13% versus 6.6%, p < 0.05). No procedural death was noted. Significant adverse events (n=13) included cardiopulmonary resuscitation 3, vascular 6, arrhythmia 3 and apnea requiring intubation 1. On median follow-up of 3 years (0.03 to 14), n=69, mortality rate was 36%. In 6 patients with valvar pulmonary stenosis with median follow-up of 6 years (0.75 to 13), 4 (67%) did not require re-intervention. Of 2 patients with aortic stenosis, 1 did not require repeat intervention for 6 years (last follow-up).

Conclusion:

Interventional catheterization is feasible with low procedural morbidity and mortality in high risk infants < 2.5 kilograms. Catheterization primarily serves as a palliative procedure to stabilize infants for definitive treatment. Balloon valvuloplasty may be effective for isolated valvar pulmonary stenosis in infants < 2.5 kilograms. © 2013 Wiley Periodicals, Inc.

Objectives:

To compare the discriminatory value of differing risk scores for predicting clinical outcomes following PCI in routine practice.

Background:

Various risk scores predict outcomes after PCI. However, these scores consider markedly different factors, from purely anatomical (SYNTAX risk score [SRS]) to purely clinical (ACEF, modified ACEF [ACEFmod], NCDR), while other scores combine both elements (Clinical SYNTAX score [CSS], NY State Risk Score [NYSRS]).

Methods:

Patients with triple vessel and/or LM disease with 12 month follow-up were studied from a single center PCI registry. Exclusion criteria included STEMI presentation, prior revascularization and shock. Clinical events at 12 months were compared to baseline risk scores, according to score tertiles and area under receiver-operating-characteristic curves (AUC).

Results:

We identified 584 eligible patients (69.8±12.3yrs, 405 males). All scores were predictive of mortality, with the SRS being least predictive (AUC=0.66). The most accurate scores for mortality were the CSS and ACEF (AUC=0.76 for both: p=0.019 and 0.08 vs. SRS, respectively). For TLR, while the SRS trended toward being positively predictive (p=0.075), several scores trended towards a negative association, which reached significance for the NCDR (p=0.045). The SRS and CSS were the only scores predictive of MI (both p<0.05). No score was particularly accurate for predicting MACE (death+MI+TLR), with AUCs ranging from 0.53 (NCDR) to 0.63 (SRS).

Conclusions:

Competing factors influence mortality, MI and TLR after PCI. An increasing burden of comorbidities is associated with mortality, whereas anatomical complexity predicts MI. By combining these outcomes to predict MACE, all scores show reduced utility. © 2013 Wiley Periodicals, Inc.

Background:

Stent thrombosis (ST) is associated with a significant burden of coronary thrombus and potential microvascular obstruction. Aspiration thrombectomy may decrease the extent of microvascular obstruction in patients with acute myocardial infarction but its role in the treatment of ST is uncertain. The present study sought to evaluate the association between aspiration thrombectomy, procedural success and long-term outcomes among patients presenting with ST.

Methods:

In a multicenter cohort of patients with definite ST, procedural success, long-term mortality and major adverse cardiovascular events (death, stroke, re-infarction, revascularization) were ascertained. Propensity weighting was used to determine the association between aspiration thrombectomy and long-term outcomes.

Results:

A total of 205 patients with ST were identified. Among these, 115 (56%) patients underwent adjunctive aspiration thrombectomy during percutaneous coronary intervention. Patients undergoing aspiration thrombectomy were more likely to present with ST-elevation myocardial infarction (75% vs. 52%, P<0.003) and require hemodynamic support (19% vs. 10%, P=0.07). Aspiration thrombectomy was associated with improved procedural outcomes including post-procedural TIMI 3 flow, resulting in higher angiographic and procedural success (each 96% vs. 83%, P<0.001). Despite improved angiographic outcomes, the use of aspiration thrombectomy was not associated with a difference in long-term mortality (adjusted HR 0.99, 95% CI 0.44-2.24) or major adverse cardiovascular events (adjusted HR 1.06, 95% CI 0.45-2.48).

Conclusions:

Aspiration thrombectomy is associated with improved coronary flow and procedural success but is not associated with improved long-term outcomes among patients undergoing percutaneous intervention for definite ST. © 2013 Wiley Periodicals, Inc.

This report describes the first use of a new paravalvular leak (PVL) device designed specifically to close paravalvular mitral and paravalvular aortic leaks. The first patient had severe paravalvular mitral leak that was closed using the transapical route with a rectangular designed PVL device which has an oval waist for self-centering and the second patient had moderate paravalvular aortic leak that was closed with a square designed device which has a round waist for self-centering. Both patients had complete closure. © 2013 Wiley Periodicals, Inc.

OBJECTIVES:

In transcatheter aortic valve replacement (TAVR), the influence of aortic annular assessment with either multidetector computed tomography (MDCT) or conventional transesophageal echocardiography (TEE) on the incidence of post-procedural paravalvular aortic regurgitation (PAR) was evaluated.

BACKGROUND:

PAR remains a major limitation in TAVR. Appropriate selection of transcatheter heart valve (THV) size is crucial to prevent PAR.

METHODS:

Outcomes following TAVR with a balloon-expandable THV were compared in two retrospective cohorts identified according to whether THV size selection was based on TEE (study group 1, n = 80) or MDCT (study group 2, n = 58).

RESULTS:

The two study groups were comparable with regard to baseline clinical, risk score and echocardiographic characteristics. The incidence of moderate/severe PAR was lower in study group 2 than in group 1, 8.6% versus 28.8% (p <0.01). The difference between the THV nominal diameter and MDCT annular diameter was predictive of moderate/severe PAR (AUC 0.84; 95% CI: 0.72-0.92). Neither age, gender, body mass index, annular eccentricity index, aortic valve calcification nor the difference between the THV diameter and the TEE annular diameter predicted post-procedural PAR. Increased THV oversizing relative to the MDCT mean annular diameter was associated with reduced severity of PAR. No difference in per-procedural complications between two study groups was observed.

CONCLUSION:

MDCT-based annular sizing in TAVR significantly reduces post-procedural PAR, and THV oversizing appears pivotal in this aspect. Further delineation of the optimal degree of THV oversizing is needed. © 2013 Wiley Periodicals, Inc.

OBJECTIVES:

To describe the initial world experience and mid-term follow-up of perimembranous ventricular septal defect (pmVSD) closure with a newly designed occluder.

BACKGROUND:

Transcatheter closure of pmVSDs has been associated with a substantial risk of complete heart block, prompting many centers to abandon this intervention.

METHODS:

A prospective multicenter cohort study was conducted on patients with pmVSD undergoing catheter closure using the Amplatzer(®) Membranous VSD Occluder 2 in the initial 4 pilot centers.

RESULTS:

Nineteen patients, median age 6 years (range 1.4-62 years), were enrolled and followed for 14±3 months (range 8 to 20 months). The median weight was 26 kg (range 9.3-96 kg) and the mean Qp/Qs ratio was 1.8±0.7. The defect on left ventricular side measured 9.9±3.5 mm and the orifice on right ventricular side was 8.1±2.8 mm by echocardiography. Mean device size was 9.4±2.4 mm (range 5-14 mm). An eccentric device was employed in 9 patients (47%) and a concentric device in 10 (53%). Overall, 18 patients (95%) had successful device implants. Procedural time was 122±39 min. There were no procedural complications. Mild residual shunting was initially observed in 14 (78%) patients. At last follow-up, mild residual shunting persisted in only 3 (17%) patients. There was no significant increase in aortic or tricuspid regurgitation. No patient had any degree of AV block, although one developed a transient left anterior fascicular block. Holter evaluation, obtained in all patients, was unremarkable in all.

CONCLUSIONS:

This early cohort experience using a novel adapted transcatheter closure device for pmVSD suggests that the procedure is feasible, safe, and effective. © 2013 Wiley Periodicals, Inc.

Objectives:

To compare iliofemoral arterial complications with transfemoral transcatheter aortic valve replacement (TF-TAVR) utilizing surgical cutdown versus percutaneous access with closure devices in a randomized trial.

Background:

Major vascular complications following TAVR are a significant risk of the procedure. There are no randomized data comparing whether access method in TF-TAVR influences the risk of such complications.

Methods:

From June to December 2011, thirty consecutive patients undergoing TF-TAVR were randomized to either surgical cutdown (C) or percutaneous (P) access. Subjects underwent preoperative CT scans, pre- and postoperative bilateral femoral arterial ultrasound and angiography. The primary endpoint was the composite of major and minor vascular complications at 30 days, as defined by the Valve Academic Research Consortium-2. Multivariate predictors of vascular complications were identified.

Results:

Of the 30 subjects enrolled, 27 were treated with the randomized method of access as randomized. Iliofemoral complications were observed in eight patients (26.7%; C=4, P=4), all of which were dissections and/or stenoses that required percutaneous and/or surgical intervention. There were 2 (13.3%) major and 2 (13.3%) minor complications in each group. Two covariates that were significantly associated with vascular complications included female sex and baseline femoral arterial velocity on ultrasound.

Conclusions:

While surgical cutdown in TF-TAVR is the recommended access for new centers initiating a TAVR program, this small randomized pilot study suggests the lesser invasive percutaneous method in an experienced center is equivalent in safety to the surgical method. Doppler ultrasound may be useful in predicting complications prior to the procedure. © 2013 Wiley Periodicals, Inc.