Computed tomography (CT) assessment of the membranous septal anatomy prior to transcatheter aortic valve replacement (TAVR) with the balloon-expandable SAPIEN 3 valve.

OBJECTIVES: The lower limit of the membranous septum (MS) is considered an anatomic landmark for the emergence of the Bundle of His into the left ventricle. Computed tomography (CT) assessment of MS anatomy may provide useful information about the risk of conduction abnormalities following transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: The study included 102 consecutive patients undergoing TAVR with the Edwards Sapien 3 (S3) valve. Using pre-TAVR CT and post-procedure angiography we evaluated for the presence of calcium in the left ventricular outflow tract (LVOT), calcium depth (CD), implantation depth (ID) and MS length. The MS length minus the prosthesis ID was calculated (Delta MSID). Outcomes included new left bundle branch block (LBBB) or permanent pacemaker (PPM) within 30days. Seventeen patients (17%) received a PPM and 28 (27%) developed new LBBB following TAVR. Mean (±SD) MS length and delta MSID were 7.5mm (2) and 0.9mm (4.5), respectively. Twenty-one patients (20%) had calcium in the device landing zone and the mean (SD) CD was 6.8mm (±4). Calcium in the device landing zone (37% versus 16%, p=0.02) and implantation depth (6mm (4-8) versus 4mm (4-5), p=0.02) predicted new conduction abnormalities after TAVR. CONCLUSIONS: The presence of calcium in the device landing zone is associated with increased risk of conduction abnormalities after TAVR with S3. In such cases, a more aortic deployment of the prosthesis may be warranted.

Role of epinephrine and extracorporeal membrane oxygenation in the management of ischemic refractory ventricular fibrillation: a randomized trial in pigs.

xtracorporeal membrane oxygenation (ECMO) is used in cardiopulmonary resuscitation (CPR) of refractory cardiac arrest. We used a 2×2 study design to compare ECMO versus CPR and epinephrine versus placebo in a porcine model of ischemic refractory ventricular fibrillation (VF). Pigs underwent 5 minutes of untreated VF, 10 minutes of CPR, and were randomized to receive epinephrine versus placebo for another 35 minutes. Animals were further randomized to LAD reperfusion at minute 45 with ongoing CPR versus veno-arterial ECMO cannulation at minute 45 of CPR and subsequent LAD reperfusion. Four-hour survival was improved with ECMO while epinephrine showed no effect.

Coronary artery embolism from infectious endocarditis treated with catheter thrombectomy using a GuideLiner catheter.

A 27-year-old male with history of IV drug use and recurrent endocarditis necessitating bioprosthetic mitral and tricuspid valve replacements presented with 2 weeks of fevers and chest pain. ECG revealed inferior ST-elevation myocardial infarction and he was taken urgently to the cardiac catheterization laboratory. Coronary angiography revealed thrombotic occlusion of the distal right coronary artery (RCA) with no angiographic evidence of atherosclerotic disease. Aspiration thrombectomy was performed followed by rheolytic thrombectomy. Despite multiple attempts at thrombectomy, significant residual organized thrombus persisted in the distal RCA. Therefore, further thrombectomy was performed by placing a GuideLiner catheter (Vascular Solutions, Minneapolis, MN) deep within the right coronary artery near the bifurcation into the posterior descending and posterior left ventricular arteries. After repeat aspiration, there was significant improvement with thrombolysis in myocardial infarction 3 flow. Intravascular ultrasound of the RCA revealed a normal-appearing vessel without evidence of atherosclerotic disease and mild residual thrombus. The decision was made to not pursue stent placement, given the concern for a likely embolic source. Following the procedure, the patient's chest pain resolved and his ST-segments normalized.

Use of Transesophageal Echocardiography to Improve the Safety of Transvenous Lead Extraction.

OBJECTIVES: The aim of this study was to evaluate the utility of transesophageal echocardiography (TEE) during transvenous lead extraction (TLE) involving both conventional and laser lead removal. BACKGROUND: TLE carries a small but measurable risk of serious adverse events. Few studies have examined the potential benefit of continuous monitoring with TEE during this procedure. METHODS: Continuous TEE monitoring was performed in 100 consecutive patients (67% male; average age, 57 ± 17 years) who underwent TLE in the past 5 years. Lead extraction was attempted for 193 leads. The average time since lead implant was 78 ± 55 months (range, 1.4 to 274.4 months). Indications for extraction were device endocarditis (n = 28), lead fracture (n = 28), recalled lead (n = 21), pocket infection (n = 17), and other (n = 6). RESULTS: Complete success occurred in 181 leads (94%), partial success in 4 leads (2%), and failure in 8 leads (4%). Eighty patients required laser lead extraction (80%). Major complications included 1 right ventricular and 2 right atrial/superior vena cava lacerations, which were detected and localized within 1 to 2 min with the use of TEE and resulted in prompt surgical repair. There was 1 upper gastrointestinal bleed caused by the TEE probe. TEE prevented premature termination and unnecessary surgery in 4 patients with hypotension but no intracardiac abnormalities seen on TEE. In-hospital mortality rate was 0%. In total, TEE provided immediately useful clinical information in 7 patients (7%). CONCLUSIONS: Continuous monitoring with TEE facilitates prompt diagnosis and treatment of intracardiac damage and prevents premature termination of cases with hypotension but no abnormalities on TEE.