ABSTRACT
An 82-year-old patient experienced symptomatic intra-prosthetic aortic regurgitation 5 years after self-expandable transcatheter heart valve (THV) implantation. Redo-transcatheter aortic valve replacement was initially considered at high risk of coronary obstruction. Using a systematic computed tomography-based approach planning a low implantation with a SAPIEN 3 Ultra THV, we effectively mitigated risks.
ABSTRACT
Background: Left atrial appendage (LAA) thrombus is a contraindication for LAA closure (LAAC). However, in selected cases, oral anticoagulants are strictly contraindicated because of a history of life-threatening bleeding, and LAAC remains the only possible therapy to avoid systemic and especially cerebral embolization. Case summary: We report a case of LAAC despite a massive proximal thrombus in a patient who had an absolute contraindication to anticoagulant therapy, with thorough pre-planning using CT scan, device modelling and thrombus trapping techniques to reduce the risk of systemic embolic events and perform LAAC safely. Discussion: Although LAAC remains at high risk in this setting, the use of cautious techniques and tools, from pre-procedure planning to systemic embolization prevention systems associated to a precise transoesopheageal echocardiography guiding throughout the procedure, allows it to be performed as safely as possible when no other option is available.
ABSTRACT
BACKGROUND: Real-time cardiac magnetic resonance generates spatially and temporally resolved images of cardiac anatomy and function, without the need for contrast agent or X-ray exposure. Cardiac magnetic resonance-guided right heart catheterization (CMR-RHC) combines the benefits of cardiac magnetic resonance and invasive cardiac catheterization. The clinical adoption of CMR-RHC represents the first step towards the development of cardiac magnetic resonance-guided therapeutic procedures. AIM: To describe the feasibility, safety and diagnostic yield of CMR-RHC in consecutive all-comer patients with clinical indications for right heart catheterization. METHODS: From December 2018 to May 2021, 35 consecutive patients with prespecified indications for right heart catheterization were scheduled for CMR-RHC via the femoral route under local anaesthesia in a 1.5T cardiac magnetic resonance suite equipped for interventional cardiac magnetic resonance. The duration of various procedural components and safety data were recorded. Success rate (defined by the ability to record all prespecified haemodynamic measurements and imaging metrics), adverse events and patient/physician perprocedural comfort were assessed. RESULTS: One patient withdrew his consent before the study, and scanner troubleshooting occurred in one case. Among the 33 remaining patients, prespecified cardiac magnetic resonance imaging metrics were obtained in all patients, whereas full CMR-RHC measurements were obtained in 30 patients (91%). A dedicated cardiac magnetic resonance-compatible wire was used in 25/33 procedures. CMR-RHC was completed in 29±16minutes, and the total duration of the procedure, including conventional cardiac magnetic resonance imaging, was 62±20minutes. There were no adverse events and no femoral haematomas. Procedural comfort was deemed good by the patients and operators for all procedures. CMR-RHC significantly impacted diagnosis or patient management in 28/33 patients (85%). CONCLUSIONS: CMR-RHC seems to be a feasible and safe procedure that can be used in routine daily practice in consecutive adults with an impactful clinical yield.
