Ventricular Pseudoaneurysm and Free Wall Rupture After Acute Myocardial Infarction: JACC Focus Seminar 4/5.

Postinfarction ventricular free-wall rupture is a rare mechanical complication, accounting for <0.01% to 0.02% of cases. As an often-catastrophic event, death typically ensues within minutes due to sudden massive hemopericardium resulting in cardiac tamponade. Early recognition is pivotal, and may allow for pericardial drainage and open surgical repair as the only emergent life-saving procedure. In cases of contained rupture with pseudo-aneurysm (PSA) formation, hospitalization with subsequent early surgical intervention is warranted. Not uncommonly, PSA may go unrecognized in asymptomatic patients and diagnosed late during subsequent cardiac imaging. In these patients, the unsettling risk of complete rupture demands early surgical repair. Novel developments, in the field of transcatheter-based therapies and multimodality imaging, have enabled percutaneous PSA repair as a feasible alternate strategy for patients at high or prohibitive surgical risk. Contemporary advancements in the diagnosis and treatment of postmyocardial infarction ventricular free-wall rupture and PSA are provided in this review.

Ventricular Septal Rupture After Myocardial Infarction: JACC Focus Seminar 3/5.

Ventricular septal rupture remains a dreadful complication of acute myocardial infarction. Although less commonly observed than during the prethrombolytic era, the condition remains complex and is often associated with refractory cardiogenic shock and death. Corrective surgery, although superior to medical treatment, has been associated with high perioperative morbidity and mortality. Transcatheter closure techniques are less invasive to surgery and offer a valuable alternative, particularly in patients with cardiogenic shock. In these patients, percutaneous mechanical circulatory support represents a novel opportunity for immediate stabilization and preserved end-organ function. Multimodality imaging can identify favorable septal anatomy for the most appropriate type of repair. The heart team approach will define optimal timing for surgery vs percutaneous repair. Emerging concepts are proposed for a deferred treatment approach, including orthotropic heart transplantation in ideal candidates. Finally, for futile situations, palliative care experts and a medical ethics team will provide the best options for end-of-life clinical decision making.

Transition to heart transplantation in post-myocardial infarction ventricular septal rupture: a systematic review.

Post-myocardial infarction ventricular septal rupture (MI-VSR) remains a dreadful complication with dismal prognosis. Surgical repair is the primary treatment strategy, whereas the role of heart transplantation (HT) as a primary option in MI-VSR is limited to case reports (CRs). We performed a systematic review of CRs to describe in-hospital mortality, and survival at 6 and 12 months in adult patients with MI-VSR treated with HT as a primary or bailout strategy. We performed a comprehensive search of Web of Science, PubMed, and Ovid Medline. The last search was completed on March 10, 2020. An aggregated score based on the CARE case report guideline was used to assess the quality of the CRs. We included CRs that described adult patients with MI-VSR treated with HT as a primary or bailout strategy. A total of 14 CRs between 1994 and 2015 were included, retrieving and analyzing the characteristics of 17 patients. A total of 12 patients underwent HT, with HT being the primary strategy in 8 patients and a bailout strategy for 4 patients following initial surgical repair, while 5 patients died awaiting HT under mechanical circulatory support (MCS), accounting for the total in-hospital mortality of this series (29%). Regarding long-term outcomes, 6 patients were reported to be alive at 6 months and 1 year after HT, while information was missing in the remaining 6 patients. In conclusion, HT supported by the use of temporary and durable MCS as a bridge to HT could be a feasible primary or bailout strategy to reduce the high in-hospital mortality of patients with MI-VSR.

Cardioform Septal Occluder for the Closure of a Peri-Device Leak After Initial Watchman Implantation.

Left atrial appendage occlusion has become a safe and effective alternative for stroke-risk reduction among patients with non-valvular atrial fibrillation (AF). Although complete closure is ideal, residual peri-device leaks (PDL) are not uncommon and have been associated with an increased residual risk of stroke. PDL closure has been proposed as an alternate strategy to allow for the safe discontinuation of oral anticoagulation. We describe the safety and feasibility of successful PDL closure using a non-fenestrated Cardioform (Gore Medical, Flagstaff, Arizona) septal occluder after initial Watchman (Boston Scientific, Marlborough, Massachusetts) implantation.

Mechanical tricuspid balloon 'valvuloplasty' in a prohibitive risk patient with cardiogenic shock: a case report.

BACKGROUND: We present a complex case of a failing tricuspid mechanical valve prosthesis in a patient with refractory cardiogenic shock at prohibitive risk for surgery in whom balloon 'valvuloplasty' resulted in immediate haemodynamic improvement in valve function. CASE SUMMARY: A 67-year-old woman with remote history of endocarditis s/p tricuspid valve repair and mechanical aortic valve replacement was referred for second opinion and management of new severe symptomatic tricuspid valve stenosis resulting in progressive debilitating congestive heart failure (HF). The patient was approved by the heart team to undergo redo open heart for surgical repair of the tricuspid valve. Intraoperative technical challenges were met to repair the tricuspid valve. In turn, the native valve was resected and a 33 mm On-X mechanical valve prosthesis. The patient's post-operative course was complicated by recurrent haemoptysis, prolonged mechanical respiratory support, acute kidney injury, and cardiogenic shock. Surgical re-exploration to address the dysfunctional mechanical tricuspid valve was felt to be prohibitive. Structural heart team was consulted. Cardiac catheterization was recommended to ascertain and confirm findings. The patient was transferred to the cardiac catheterization laboratory. Initial fluoroscopic examination of the heart confirmed the echocardiographic results of an immobile septal leaflet of the recently implanted mechanical tricuspid valve. An 8 × 40 mm Mustang OTW angioplasty balloon was then advanced across the mechanical valve and inflated gradually at nominal pressure. A single inflation resulted in successful restoration of valve leaflet function. DISCUSSION: To the best of our knowledge, this is the first balloon 'valvuloplasty' on a mechanical On-X valve in the tricuspid position.

First Experience Using a Nonfenestrated Cardioform Septal Occluder for Closure of Giant Mitral Paravalvular Leak.

A variety of fenestrated vascular plugs have been used to seal paravalvular leaks with meaningful success; however, incomplete closure and refractory hemolysis remains a common problem. We describe the feasibility and rationale of their first experience using a nonfenestrated Cardioform Septal Occluder (Gore Medical, Flagstaff, Arizona) to treat a giant mitral paravalvular leak. (Level of Difficulty: Advanced.).

The utility of pulmonary function testing in the preoperative risk stratification of patients undergoing transcatheter aortic valve replacement.

BACKGROUND: The role of pulmonary function testing (PFT) as a predictor of clinically relevant endpoints in transcatheter aortic valve replacement (TAVR) is unclear. OBJECTIVE: To determine the utility of PFT in the preoperative risk stratification of patients undergoing TAVR. METHODS: An evaluation of PFT (i.e., FEV1), arterial blood gases (i.e., PO2), the diagnosis of chronic obstructive lung disease (COPD) by the Global Initiative for COPD (GOLD), and the diagnosis of chronic lung disease (CLD) by the Society of Thoracic Surgeons (STS) was performed to determine whether a relationship exists among these parameters and clinically relevant outcomes, including all-cause 30-day and 1-year mortality. RESULTS: A total of 513 patients underwent TAVR between March 2013 and December 2016. Per STS criteria, 269/513 (52%) had CLD with a mean FEV1 of 55.4 ± 12%. Per GOLD criteria, 158/513 (30%) of patients had COPD with a mean FEV1/forced vital capacity of 61.8 ± 8.2%. The severity of CLD was affected by changes in ejection fraction, albumin, creatinine, and B-type natriuretic peptide levels (p = .009, p < .001, p < .001, and p < .001, respectively), whereas the severity of COPD was not affected by these same variables, (p = .302, .079, .137, and .102, respectively). An increased A-a gradient (p = .035), increased PCO2 (p = .016), and decreased PO2 (p = <.001) demonstrated increased risk of 30-day mortality. Neither classification (COPD or CLD), nor PFT changes, showed association with 30-day and 1-year mortality (p = NS). CONCLUSION: This study suggests that isolated abnormalities in spirometry are a poor indicator of clinically relevant outcomes in TAVR. When classified correctly, COPD does not predict clinically relevant postoperative outcomes.

Predictors and outcomes of stroke after transcatheter aortic valve replacement.

OBJECTIVES: Stroke is a devastating complication of transcatheter aortic valve replacement (TAVR). Many studies have investigated risk factors for postoperative stroke, but reliable predictors are not yet well-established. The objective of this study was to further characterize the predictors and outcomes of stroke after TAVR. METHODS: This is a retrospective cohort study of 1022 patients who underwent TAVR at a single institution between 2012 and 2018. Multivariable logistic regression analysis was used to identify independent predictors of postoperative stroke and Kaplan-Meier method to compare 1-year survival in patients with and without postoperative stroke. RESULTS: Postoperatively, 36 patients experienced a stroke (3.5%) with most developing multiple (63.9%, N = 23), and often bilateral infarcts (50.0%, N = 18). Stroke patients more commonly had peripheral arterial disease (P = .032) and carotid stenosis (P = .013) and were less likely to receive predeployment balloon aortic valvuloplasty (P = .005). Alternative access approach (odds ratio [OR], 2.322; 95% confidence interval [CI]: 1.067-5.054) and history of transient ischemic attack (OR, 2.373; 95% CI: 1.026-5.489) were identified as independent predictors of postoperative stroke. Stroke patients more frequently developed postoperative complications, including prolonged ventilation (P < .001), major vascular complications (P < .001), and new-onset dialysis (P < .001). Operative mortality was greater in stroke patients (19.4% vs 3.7%; P < .001), and 1-year Kaplan-Meier estimates revealed worsened survival (log-rank P = .002). CONCLUSIONS: Alternative access approach and a history of transient ischemic attack emerged as independent predictors of postoperative stroke. Patients with stroke suffered more complications and had worse survival, underscoring the importance of characterizing the stroke risk in these patients.

Retrograde transmitral paravalvular leak closure through an antegrade transseptal approach: A novel technique.

Mitral paravalvular leak (PVL) remains a well-known complication after mitral valve replacement. Since the first report over 25 years ago, several catheter-based PVL closure techniques have been described. Most of these comprise of either an antegrade transseptal approach, or a retrograde transaortic or transapical approach. We herein report a novel percutaneous mitral PVL closure technique that was safely and successfully performed after failed attempt using a conventional antegrade approach.

Simultaneous kissing stent in a patient with severe bifurcation pulmonary vein stenosis.

Pulmonary vein stenosis (PVS) is a late and rare complication of pulmonary vein isolation for the treatment of atrial fibrillation. The ideal approach to the management of PVS has not yet been established, however, corrective procedures may include both surgical and percutaneous techniques. We describe the case of a complex bifurcation lesion involving the left superior pulmonary vein. The condition required percutaneous intervention using a modified kissing stent technique with bare metal stents that resulted in an excellent post-operative course, sustained symptomatic relief, and uncomplicated 1-year follow-up. © 2014 Wiley Periodicals, Inc.

Left ventricular end-diastolic pressure as an independent predictor of outcome during balloon aortic valvuloplasty.

OBJECTIVES: In this study, we examined the predictive value of the left ventricular end-diastolic pressure (LVEDP) in patients undergoing balloon aortic valvuloplasty (BAV). BACKGROUND: The LVEDP is a useful indicator of hemodynamic status in patients with severe aortic stenosis. In BAV, decompensated heart failure is associated with worse outcomes. METHODS: We identified all consecutive patients with severe symptomatic aortic stenosis who underwent retrograde BAV at the Massachusetts General Hospital from 2004 to 2008. Patients were stratified and compared according to their baseline LVEDP into ≤15 mm Hg, 16-20 mm Hg, 21-25 mm Hg, and ≥26 mm Hg. Procedural and in-hospital outcomes and adverse events were compared. Multivariate logistic regression was used for the adjusted analysis. RESULTS: A total of 111 patients with a mean age of 83±11 years underwent BAV. Of these, the LVEDP was ≤15 mm Hg in 29 (26%), 16-20 mm Hg in 41 (37%), 21-25 mm Hg in 16 (14%), and ≥26 mm Hg in 25 (23%) patients. Baseline characteristics were similar among the four groups. Noticeably, patients with high LVEDP levels had significantly higher rates of the combined endpoint of in-hospital death, myocardial infarction (MI), cardiopulmonary arrest, and tamponade was P = 0.02. Periprocedural MI was more common among those with higher LVEDP (16% vs. 2.3%; P = 0.04). Multivariate analysis revealed LVEDP (OR 1.08, for each mm Hg increase in pressure, 95 % CI 1.02-1.14), small LV chamber size, and New York Heart Association class as independent predictors of adverse outcomes. CONCLUSIONS: The LVEDP is an important independent predictor of poor in-hospital outcome during BAV. In these patients, the immediate hemodynamic status may be more important than the baseline left ventricular systolic function. Hemodynamic optimization before or during BAV should be considered and may be beneficial.

The off-label use of the Amplatzer muscular VSD occluder for large patent ductus arteriosus: a case report and review.

A percutaneous approach to the closure of patent ductus arteriosus (PDA) is the preferred procedure in the majority of cases. However, there is little experience with percutaneous closure of unusually large PDA. We report the case of a 28-year-old female with moderate left ventricular dilation and pulmonary hypertension resulting from a large 16 mm PDA. Percutaneous closure was successfully performed using an off-label Amplatzer muscular ventricular septal defect occluder after intravascular ultrasound assessment. Technical challenges, including accurate assessment of defect size and device selection are exemplified along with a comprehensive overview of the available literature.

Long-term experience and outcomes with transcatheter closure of patent foramen ovale.

OBJECTIVES: This study sought to examine the frequency of indications for and the immediate and long-term clinical outcomes of transcatheter closure of patent foramen ovale (PFO). BACKGROUND: Transcatheter PFO closure is commonly performed for several indications, including cryptogenic stroke, despite conflicting data regarding the efficacy of this intervention. METHODS: We report the outcomes of 800 consecutive patients (52% male, 50 ± 14 years of age) who underwent PFO closure at our institution after multidisciplinary evaluation over a 16-year period. RESULTS: Indications for closure included cryptogenic cerebrovascular event (94%), hypoxemia (2%), peripheral embolism (3%), and migraine headaches (2%). Procedural success was 99% with effective closure obtained in 93% of patients. At a mean follow-up of 42.7 ± 33.4 months, 21 patients suffered a recurrent ischemic neurologic event (12 strokes, and 9 transient ischemic attacks) for an incidence rate of 0.79 events per 100 person-years and freedom from recurrent events of 91.6% at 10 years. There was no device-based difference in the rate of recurrent ischemic neurologic events (p = 0.82). Only Eustachian valve prominence (hazard ratio: 9.04; 95% confidence interval: 2.07 to 39.44; p = 0.0034) was associated with recurrent neurologic events. CONCLUSIONS: Transcatheter PFO closure is safe and feasible in patients with several clinical indications. The long-term efficacy of this intervention in patients with paradoxical embolism appears superb in this observational study. Carefully selected patients with features suggestive of paradoxical embolism are the most likely to benefit from PFO closure and should be the focus of future investigation.

Effect of elevated pulmonary vascular resistance on outcomes after percutaneous mitral valvuloplasty.

Patients with mitral stenosis with severe pulmonary hypertension constitute a high-risk subset for surgical commissurotomy or valve replacement. The aim of the present study was to examine the effect of elevated pulmonary vascular resistance (PVR) on percutaneous mitral valvuloplasty (PMV) procedural success, short- and long-term clinical outcomes (i.e., mortality, mitral valve surgery, and redo PMV) in 926 patients. Of the 926 patients, 263 (28.4%) had PVR ≥4 Woods units (WU) and 663 (71.6%) had PVR <4 WU. Patients with PVR ≥4 WU were older and more symptomatic and had worse valve morphology for PMV. The patients with PVR ≥4 WU also had lower PMV procedural success than those with PVR <4 WU (78.2% vs 85.6%, p = 0.006). However, after multivariate adjustment, PVR was no longer an independent predictor of PMV success nor an independent predictor of the combined end point at a median follow-up of 3.2 years. In conclusion, elevated PVR at PMV is not an independent predictor of procedural success or long-term outcomes. Therefore, appropriately selected patients with rheumatic mitral stenosis might benefit from PMV, even in the presence of elevated preprocedural PVR.

Outcome of patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention during on- versus off-hours (a Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] trial substudy).

Patients with ST-segment elevation myocardial infarction (STEMI) admitted during nonregular working hours (off-hours) have been reported to have greater mortality than those admitted during regular working hours (on-hours), perhaps because of the lower availability of catheterization laboratory services and longer door-to-balloon times. This might not be the case, however, for hospital centers in which primary percutaneous coronary intervention (PCI) is invariably performed. We conducted a substudy using the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction study data to determine whether the STEMI arrival time was associated with differing clinical outcomes. We identified all patients with STEMI admitted to a PCI-capable hospital who underwent primary PCI. Patients presenting during on-hours were compared to those presenting during off-hours. The primary outcome of death, major adverse cardiovascular events, and net adverse clinical events was examined. We identified 2,440 patients (1,205 [49%] on-hours and 1,235 [51%] off-hours). Similar baseline characteristics were observed. The off-hour patients had a significantly longer door-to-balloon time (92 vs 75 minutes; p <0.0001) and total ischemic time (209 vs 194 minutes; p <0.0001). Despite these differences, the risk-adjusted all-cause mortality, major adverse cardiovascular events, and net adverse clinical events rates were similar for both groups during the in-hospital, 1-year, and 3-year follow-up. In conclusion, patients with STEMI presenting to primary PCI hospitals during off-hours might have slightly longer delays to revascularization; however, they experienced similar short- and long-term survival and clinical outcomes as those arriving during on-hours.

Impact of the prehospital activation strategy in patients with ST-elevation myocardial infarction undergoing primary percutaneous revascularization: a single center community hospital experience.

The strategy of prehospital activation by the emergency medical system (EMS) in patients with ST-elevation myocardial infarction (STEMI) has been poorly adopted among the US hospitals that currently offer 24/7 primary percutaneous coronary intervention. In this study, we report a single center experience after the implementation of this strategy. From 2008 to 2011, we identified a total 188 STEMI patients (age 65 ± 15 years) presenting via EMS for primary percutaneous coronary intervention. Of these, 112 (59.6%) underwent prehospital activation (EMS group), whereas the remaining 76 (40.4%) underwent emergency department activation [emergency department (ED) group]. Baseline demographic characteristics were similar between both groups. The overall median door-to-balloon (DTB) time was 49 ± 14 minutes. Patients undergoing prehospital activation had on average significantly lower overall DTB times (EMS 44 ± 11 minutes vs. ED 57 ± 15 minutes; P < 0.001). Concordantly, DTB times <60 minutes were much more commonly achieved with this strategy (EMS 95.5% vs. ED 64.5%; P < 0.001). Fallouts beyond the recommended 90-minute DTB time were seen among ED patients only. No difference in in-hospital death (EMS 5.4% vs. ED 6.6%; P = 0.75) or cumulative 30-day mortality (EMS 6.3% vs. ED 7.9%; P = 0.68) was observed between both groups. However, on average, EMS patients had higher postinfarct left ventricular ejection fraction (EMS 48 ± 9.5% vs. ED 39 ± 14.6%; P = 0.004). Differences in DTB time and left ventricular ejection fraction remained significant after adjusting for differences in baseline characteristics. In conclusion, the prehospital activation strategy is largely effective and should be systematically adopted in the treatment scheme of STEMI patients to lower mechanical reperfusion times and reduce the potential for untoward clinical outcomes.

Patients with small left ventricular size undergoing balloon aortic valvuloplasty have worse intraprocedural outcomes.

OBJECTIVES: To evaluate the impact of left ventricular (LV) chamber size on procedural and hospital outcomes of patients undergoing aortic valvuloplasty. BACKGROUND: Balloon aortic valvuloplasty (BAV) is used as an integral step during transcatheter aortic valve implantation. Patients with small, thickened ventricles are thought to have more complications during and following BAV. METHODS: Retrospective study of consecutive patients with severe, symptomatic calcific aortic stenosis who underwent retrograde BAV at Massachusetts General Hospital. We compared patients with left ventricular end-diastolic diameters (LVEDD) <4.0 cm (n = 31) to those with LVEDD ≥4.0 cm (n = 78). Baseline and procedural characteristics as well as clinical outcomes were compared. Multivariate logistic regression was used for the adjusted analysis. RESULTS: Patients with smaller LV chamber size were mostly women (80.7% vs. 19.4%, P < 0.01) and had a smaller body surface area (BSA), (1.61 ± 0.20 m(2) vs. 1.79 ± 0.25 m(2) , P < 0.01). Patients with smaller LV chamber size had higher ejection fractions and thicker ventricles. Otherwise, baseline characteristics were similar. The intraprocedural composite of death, cardiopulmonary arrest, intubation, hemodynamic collapse, and tamponade was higher for patients with LVEDD < 4.0 cm (32.3% v. 11.5%, P = 0.01). Adjusting for age, gender, BSA, LV pressure, and New York Heart Association class, LVEDD < 4.0 cm remained an independent predictor of procedural (OR 5.1, 95% CI 1.4-18.2) and in-hospital complications (OR 3.8, 95% CI 1.2-11.6). CONCLUSIONS: Compared to patients undergoing BAV with LVEDD ≥4.0 cm, those with smaller LV chambers had worse procedural and in-hospital outcomes.

Use of the Impella 2.5 system alone, after and in combination with an intra-aortic balloon pump in patients with cardiogenic shock: case description and review of the literature.

Cardiogenic shock remains a serious complication of acute myocardial infarction as it is associated with very poor prognosis. Despite the historical clinical benefits of the intra-aortic balloon pump (IABP), in some patients additional mechanical cardiac support is necessary. The recent introduction of the percutaneous Impella® 2.5 mechanical circulatory support system (Abiomed Inc., Danvers, MA, USA) represents a major advancement and has been used in these circumstances. Nevertheless, the data supporting the use of this technology alone, after, or in combination with the IABP in patients with cardiogenic shock is limited and the clinical benefits remain unproven. We herein provide an updated comprehensive overview of the literature supporting the use of the Impella 2.5 system compared to the use of IABP in patients with cardiogenic shock. We also discuss the potential role for combination therapy for a patient with refractory shock. We describe a case in which an IABP was used as a bail-out strategy to provide additional haemodynamic support in a patient with refractory cardiogenic shock after the Impella 2.5 system was in place. In selected cases of refractory cardiogenic shock, the use of combined therapy with both the the Impella 2.5 and IABP can provide enhanced circulatory support and could be considered an option to maintain haemodynamic support in these patients.

Percutaneous Techniques for the Treatment of Patients with Functional Mitral Valve Regurgitation.

Percutaneous approaches to mitral regurgitation remain largely investigational. In the last decade, novel percutaneous strategies have opened new options in the treatment of valvular heart disease. Several studies are currently underway to determine the benefits of transcatheter mitral valve repair therapy. Transcatheter chordal procedures are being developed, including chordal cutting and chordal implantation. Transcatheter valve implantation in the mitral position might offer a desirable alternative in selected patients and has been accomplished in a compassionate fashion on rare occasions in patients who are not candidates for surgical valve repair or replacement.

Bailout perventricular pulmonary valve implantation following failed percutaneous attempt using the Edwards Sapien transcatheter heart valve.

Percutaneous pulmonary valve implantation has emerged as an attractive and less invasive alternative to open-heart surgery. Nevertheless, major technical challenges and procedural complications may still occur. We report a 44-year-old woman with severe dextroscoliosis, and history of Tetralogy of Fallot repair, who underwent an attempt at percutaneous implantation of a 23-mm Edwards SAPIEN transcatheter heart valve (THV) for recurrent stenosis of the right ventricle to pulmonary artery conduit. The procedure was complicated by valve migration into the right ventricle requiring emergent surgical removal using inflow-occlusion technique to avoid cardiopulmonary bypass. A hybrid off-pump perventricular approach was then used in the operating room to successfully implant a 26-mm Edwards Sapien THV under fluoroscopic guidance. © 2010 Wiley-Liss, Inc.