Mitral Valve Transcatheter Edge-to-Edge Repair Volumes and Trends.

Background: Despite an association between operator volumes and procedural success, there remains an incomplete understanding of the contemporary utilization and procedural volumes for mitral valve transcatheter edge-to-edge repair (MTEER). We aimed to identify annual operator procedural volumes, temporal trends, and geographic variability for MTEER among Medicare patients in the United States (US). Methods: We queried the National Medicare Provider Utilization and Payment Database for a CPT code (33418) specific for MitraClip device from 2015 through 2019. We analyzed annual operator procedural volumes and incidence and identified longitudinal and geographic trends in MTEER utilization. Results: From 2015 through 2019, a total of 27,034 MTEER procedures were performed among Medicare patients in the US. The nationwide incidence increased from 6.2 per 100,000 patients in 2015 to 23.8 per 100,000 patients in 2019, a 283% increase over the study period (Ptrend < 0.001). The incidence of MTEER by state varied by nearly 900% (range 5.5 to 54.9 per 100,000 person-years). In 2019, the mean annual MTEER operator annual volume was 9.1 MTEER procedures and had grown from 6.2 per year in 2015. Conclusions: In this nationwide study of Medicare beneficiaries in the United States, we identified a significant and sustained increase in the utilization of MTEER devices and operators and growth in annual procedural volumes from 2015 through 2019 with considerable variability in utilization by state. Further studies are needed to understand the clinical impact of variability in utilization and the optimal procedural volumes to ensure high efficacy outcomes and maintain critical access to MTEER therapies.

Intravascularly infused extracellular matrix as a biomaterial for targeting and treating inflamed tissues.

Decellularized extracellular matrix in the form of patches and locally injected hydrogels has long been used as therapies in animal models of disease. Here we report the safety and feasibility of an intravascularly infused extracellular matrix as a biomaterial for the repair of tissue in animal models of acute myocardial infarction, traumatic brain injury and pulmonary arterial hypertension. The biomaterial consists of decellularized, enzymatically digested and fractionated ventricular myocardium, localizes to injured tissues by binding to leaky microvasculature, and is largely degraded in about 3 d. In rats and pigs with induced acute myocardial infarction followed by intracoronary infusion of the biomaterial, we observed substantially reduced left ventricular volumes and improved wall-motion scores, as well as differential expression of genes associated with tissue repair and inflammation. Delivering pro-healing extracellular matrix by intravascular infusion post injury may provide translational advantages for the healing of inflamed tissues 'from the inside out'.

Right Ventricular and Pulmonary Computed Tomography Assessments in Paradoxical Low-Flow Low-Gradient Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement.

Background: Patients with paradoxical low-flow low-gradient aortic stenosis (pLFLG-AS) have high mortality and high degree of TAVR futility. Computed tomography (CT) enables accurate simultaneous right ventricular (RV) and parenchymal lung disease evaluation which may provide useful objective markers of AS severity, concomitant pulmonary comorbidities, and transcatheter aortic valve replacement (TAVR) improvement. However, the prevalence of RV dysfunction and its association with pulmonary disease in pLFLG-AS is unknown. The study objective was to test the hypothesis that pLFLG-AS patients undergoing TAVR have decreased RV function without significant parenchymal lung disease. Methods: Between August 2016 and March 2020, 194 consecutive AS patients completed high-resolution computed tomography (CT) imaging for TAVR evaluation. Subjects were stratified based on echocardiographic criteria as the study group, pLFLG (n=27), and two consecutive control groups: classic severe, normal-flow, high-gradient (n=27) and normal-flow, low-gradient (NFLG) (n=27) AS. Blinded biventricular function and lung parenchymal disease assessments were obtained by high-resolution CT imaging. Results: Patient demographics were similar between groups. pLFLG-AS had lower RV ejection fraction (49±10%) compared to both classic severe (58±7%, p<0.001) and NFLG AS (55±65%, p=0.02). There were no significant differences on lung emphysema (p=0.19), air fraction (p=0.58), and pulmonary disease presence (p=0.94) and severity (p=0.67) between groups. Conclusion: pLFLG-AS patients have lower RV ejection fraction, than classic severe and normal-flow low-gradient AS patients in the absence of significant parenchymal lung disease on CT imaging. These findings support the direct importance of RV function in the pathophysiology of aortic valve disease.

Association of advanced age with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: insights from the National Inpatient Sample of 36,065 procedures.

BACKGROUND: Age-stratified analyses of atrial fibrillation (AF) patients undergoing percutaneous left atrial appendage occlusion (LAAO) are limited. The purpose of current study was to compare in-hospital outcomes in elderly AF patients (age > 80 years) to a relatively younger cohort (age £ 80 years) after LAAO. METHODS: Data were extracted from National Inpatient Sample for calendar years 2015-2018. LAAO device implantations were identified on the basis of International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes of 37.90 and 02L73DK. The outcomes assessed in our study included complications, inpatient mortality, and resource utilization with LAAO. RESULTS: A total of 36,065 LAAO recipients were included in the final analysis, of which 34.6% (n=12,475) were performed on elderly AF patients. Elderly AF patients had a higher prevalence of major complications (6.7% vs. 5.7%, p < 0.01) and mortality (0.4% vs. 0.1%, p < 0.01) after LAAO device implantation in the crude analysis. After multivariate adjustment of potential confounders, age > 80 years was associated with increased risk of inpatient mortality (adjusted odds ratio [aOR] 4.439, 95% confidence interval [CI] 2.391-8.239) but not major complications (aOR 1.084, 95% CI 0.971-1.211), prolonged length of stay (aOR 0.943, 95% CI 0.88-1.101), or increased hospitalization costs (aOR 0.909, 95% CI 0.865-0.955). CONCLUSION: Over 1 in 3 LAAO device implantations occurred in elderly AF patients. After adjusting for potential confounding variables, advanced age was associated with inpatient mortality, but not with other LAAO procedural-related outcomes including major complications, prolonged length of stay, or increased hospitalization costs.

Association of heart failure with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: insights from the national inpatient sample of 62 980 procedures.

AIMS: To determine outcomes in atrial fibrillation (AF) patients undergoing percutaneous left atrial appendage occlusion (LAAO) with concomitant heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: Data were extracted from National Inpatient Sample for calendar years 2015-2019. LAAO device implantations were identified on the basis of ICD-10-CM code of 02L73DK. The outcomes assessed in our study included complications, in-patient mortality, and resource utilization. A total of 62 980 LAAO device implantations were studied. HFpEF (14.4%, n = 9040) and HFrEF (11.2%, n = 7100) were associated with a higher prevalence of major complications and in-patient mortality in crude analysis. In the multivariate model adjusted for potential confounders, HFpEF and HFrEF were not associated with major complications [adjusted odds ratio (aOR) 1.04, 95% confidence interval (CI) 0.93-1.16 and aOR 1.07, 95% CI 0.95-1.21] or in-patient mortality (aOR 1.48, 95% CI 0.85-2.55 and aOR 1.26, 95% CI 0.67-2.38). HFpEF and HFrEF were associated with prolonged length of stay (LOS) > 1 day (aOR 1.41, 95% CI 1.31-1.53 and aOR 1.66, 95% CI 1.53-1.80) and increased hospitalization costs > median cost 24 752$ (aOR 1.26, 95% CI 1.19-1.34 and aOR 1.21, 95% CI 1.13-1.29). CONCLUSION: The prevalence of HF in AF patients undergoing percutaneous LAAO was approximately 26%. HF was not independently associated with major complications and in-patient mortality but was associated with prolonged LOS and higher hospitalization costs.

Trends in testing and prevalence of elevated Lp(a) among patients with aortic valve stenosis.

BACKGROUND AND AIMS: Lipoprotein(a) [Lp(a)] is causally associated with aortic valve stenosis (AS) but Lp(a) testing among AS patients is not broadly incorporated into clinical practice. We evaluated trends in Lp(a) testing in an academic medical center. METHODS: Educational efforts and adding Lp(a) to the lipid panel on the electronic medical record (EMR) and pre-procedure order sets were used to increase awareness of Lp(a) as a risk factor in AS. Medical records at University of California San Diego Health (UCSDH) were analyzed from 2010 to 2020 to define the yearly frequency of first time Lp(a) testing in patients with diagnosis codes for AS or undergoing transcatheter aortic valve replacement (TAVR). RESULTS: Lp(a) testing for any indication increased over 5-fold from 2010 to 2020. A total of 3808 patients had a diagnosis of AS and 417 patients had TAVR. Lp(a) levels >30 mg/dL were present in 37% of AS and 35% of TAVR patients. The rates of Lp(a) testing in AS and TAVR were 14.0% and 65.7%, respectively. In AS, Lp(a) testing increased over time from 8.5% in 2010, peaking at 24.2% in 2017, and declining to 13.9% in 2020 (p < 0.001 for trend). Following implementation of EMR order-sets in 2016, Lp(a) testing in TAVR cases increased to a peak of 88.5% in 2018. CONCLUSIONS: Elevated Lp(a) is prevalent in AS and TAVR patients. Implementation of educational efforts and practice pathways resulted in increased Lp(a) testing in patients with AS. This study represents a paradigm that may allow increased global awareness of Lp(a) as a risk factor for AS.

Selective Valve Removal for Melody Valve Endocarditis: Practice Variations in a Multicenter Experience.

Guidelines for management of Melody transcatheter pulmonary valve (TPV) infective endocarditis (IE) are lacking. We aimed to identify factors associated with surgical valve removal versus antimicrobial therapy in Melody TPV IE. Multicenter retrospective analysis of all patients receiving Melody TPV from 10/2010 to 3/2019 was performed to identify cases of IE. Surgical explants versus non-surgical cases were compared. Of the 663 Melody TPV implants, there were 66 cases of IE in 59 patients (59/663, 8.8%). 39/66 (59%) were treated with IV antimicrobials and 27/66(41%) underwent valve explantation. 26/59 patients (44%) were treated medically without explantation or recurrence with average follow-up time of 3.5 years (range:1-9). 32% of Streptococcus cases, 53% of MSSA, and all MRSA cases were explanted. 2 of the 4 deaths had MSSA. CART analysis demonstrated two important parameters associated with explantation: a peak echo gradient ≥ 47 mmHg at IE diagnosis(OR 10.6, p < 0.001) and a peak echo gradient increase of > 24 mmHg compared to baseline (OR 6.7, p = 0.01). Rates of explantation varied by institution (27 to 64%). In our multicenter experience, 44% of patients with Melody IE were successfully medically treated without valve explantation or recurrence. The degree of valve stenosis at time of IE diagnosis was strongly associated with explantation. Rates of explantation varied significantly among the institutions.

Association of chronic kidney disease and end-stage renal disease with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: Insights from the national inpatient sample of 36,065 procedures.

BACKGROUND: Left atrial appendage occlusion (LAAO) has emerged as an alternative strategy to oral anticoagulation for mitigating ischemic stroke risk in selected patients with atrial fibrillation (AF), but safety data in patients with significant kidney disease are limited. OBJECTIVE: To determine the association of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with procedural complications and in-hospital outcomes after LAAO in AF patients. METHODS: Data were extracted from National Inpatient Sample for calendar years 2015-2018. Watchman implantations were identified on the basis of International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes of 37.90 and 02L73DK. The outcomes assessed in our study included complications, inpatient mortality, and resource utilization with LAAO. RESULTS: A total of 36,065 Watchman recipients were included in the final analysis. CKD (9.8%, n = 3545) and ESRD (3%, n = 1155) were associated with a higher prevalence of major complications and mortality in crude analysis compared to no CKD. After multivariate adjustment for potential confounders, CKD was associated with length of stay (LOS) >1 day (adjusted odds ratio [aOR] 1.355; 95% confidence interval [CI] 1.234-1.488), median cost >$24,663 (aOR 1.267; 95% CI 1.176-1.365), and acute kidney injury (aOR 4.134; 95% CI 3.536-4.833), while ESRD was associated with in-patient mortality (aOR 7.156; 95% CI 3.294-15.544). CONCLUSION: The prevalence of CKD and ESRD was approximately 13% in AF patients undergoing Watchman LAAO implantations. CKD was independently associated with prolonged LOS, higher hospitalization costs, and acute kidney injury, while ESRD was independently associated with in-patient mortality.

Sex Differences in Procedural Outcomes Among Patients Undergoing Left Atrial Appendage Occlusion: Insights From the NCDR LAAO Registry.

Importance: Left atrial appendage occlusion (LAAO) has emerged as an alternative to anticoagulation for select patients with atrial fibrillation; however, women have been underrepresented in clinical trials of LAAO, and sex-specific subanalyses are limited. Objective: To evaluate the sex differences in the baseline characteristics of patients undergoing LAAO implant and in the in-hospital outcomes after LAAO implant. Design, Setting, and Participants: A total of 49 357 patients in the National Cardiovascular Data Registry LAAO Registry undergoing LAAO with the Watchman device between January 1, 2016, and June 30, 2019, were included in this study. Exposure: Female or male sex. Main Outcomes and Measures: The primary outcomes were aborted or canceled procedure, major adverse event, any adverse event, prolonged hospital stay longer than 1 day, and death. Unadjusted and multivariable adjusted logistic regression analyses were performed to assess sex differences in in-hospital adverse events. Results: In this cohort study of 49 357 patients (mean [SD] age, 76.1 [8.0] years), 20 388 women (41.3%) and 28 969 (58.7%) men underwent LAAO. Compared with men, women were older and had a higher prevalence of paroxysmal atrial fibrillation, prior stroke, and uncontrolled hypertension but a lower prevalence of congestive heart failure, diabetes, and coronary artery disease. After multivariable adjustment, there were no differences in aborted or canceled procedures between women and men (613 [3.0%] vs 851 [2.9%]; odds ratio [OR] 1.01, 95% CI, 0.90-1.13). Women were more likely than men to experience any adverse event (1284 [6.3%] vs 1144 [3.9%]; P < .001; OR, 1.63; 95% CI, 1.49-1.77; P < .001) or major adverse event (827 [4.1%] vs 567 [2.0%]; P < .001; OR, 2.06; 95% CI, 1.82-2.34; P < .001) owing to pericardial effusion requiring drainage (241 [1.2%] vs 144 [0.5%]) or major bleeding (349 [1.7%] vs 244 [0.8%]). Women were also more likely than men to experience a hospital stay longer than 1 day (3272 [16.0%] vs 3355 [11.6%]; P < .001; adjusted OR, 1.46; 95% CI, 1.38-1.54; P < .001) or death (adjusted OR, 2.01; 95% CI, 1.31-3.09; P = .001), although death was rare and absolute differences were minimal (58 [0.3%] vs 37 [0.1%]; P < .001). Conclusions and Relevance: This study suggests that, compared with men, women have a significantly higher risk of in-hospital adverse events after LAAO. Further research aimed at risk reduction, particularly strategies to reduce the risk of pericardial effusion and major bleeding, in women undergoing LAAO is warranted.

Pericardial effusion requiring intervention in patients undergoing percutaneous left atrial appendage occlusion: Prevalence, predictors, and associated in-hospital adverse events from 17,700 procedures in the United States.

BACKGROUND: Left atrial appendage occlusion has shown promise in mitigating the risk of stroke in selected patients with atrial fibrillation. OBJECTIVE: The purpose of this study was to determine the real-world prevalence and in-hospital outcomes in left atrial appendage occlusion (Watchman) recipients complicated by pericardial effusion requiring percutaneous drainage or open cardiac surgery-based intervention. METHODS: Data were derived from the National Inpatient Sample database from January 2015 to December 2017. The primary outcomes assessed were the prevalence of pericardial effusion requiring intervention and in-hospital outcomes including mortality, other major complications, hospital stay > 1 day, and hospitalization costs. Predictors of pericardial effusion requiring intervention were also analyzed. RESULTS: Pericardial effusion requiring intervention occurred in 220 total patients (1.24%). After multivariable adjustment, pericardial effusion requiring intervention was associated with in-hospital mortality (adjusted odds ratio [aOR] 511.6; 95% confidence interval [CI] 122-2145.3), other Watchman-related major complications (aOR 1.35; 95% CI 0.83-2.19), length of stay > 1 day (aOR 17.64; 95% CI 12.56-24.77), and hospitalization cost above the median of $24,327 (aOR 3.58; 95% CI 2.61-4.91). Independent patient predictors of pericardial effusion requiring intervention from the procedure included advanced age (aOR 1.029 per 1-year increase; 95% CI 1.009-1.05 per 1-year increase), higher CHA2DS2-VASc score (aOR 1.221 per 1-point increase; 95% CI 1.083-1.377 per 1-point increase), and obesity (aOR 2.033; 95% CI 1.464-2.823). CONCLUSION: In a large, contemporary real-world cohort of Watchman recipients in US practice, the prevalence of pericardial effusion requiring intervention was 1.24%. Pericardial effusion requiring intervention was associated with several adverse events including increased in-hospital mortality, other major complications, prolonged hospital stay, and hospitalization costs.

Racial Disparities in In-Hospital Adverse Events Among Patients With Atrial Fibrillation Implanted With a Watchman Left Atrial Appendage Occlusion Device: A US National Perspective.

[Figure: see text].

Scope and mechanistic investigations of Pd-catalyzed coupling/cyclizations and cycloisomerizations of allenyl malonates.

Pd-catalyzed transformations of allenyl malonates provide convenient access to functionalized carbocycles, but the influence of the ligand, solvent, base, and reaction conditions on the mechanism, regioselectivity, and product outcome of the cyclization are not well-understood. Additionally, from the perspective of synthetic utility, access to either fully substituted or enantioenriched cyclopentane building blocks has not yet been achieved. This work describes how targeted changes to the reaction conditions enable predictable control over the mechanism of Pd-catalyzed allene cross-coupling/cyclization and cycloisomerization, irrespective of the allene substitution pattern. Both enantioenriched cyclopropanes and cyclopentenes can be obtained through axis-to-center chirality transfer from the allene precursor at room temperature, which is not possible using reported Pd-catalyzed methods that result in racemization of the allene. Finally, the ability to divert the reactivity of the allenyl malonate from cross-coupling/cyclization to cycloisomerization by a simple switch of the ligand on Pd from a bidentate phosphine to an electron-poor triphenylphosphite is demonstrated.

Left internal mammary artery side branch intervention in the management of coronary steal syndrome following coronary artery bypass grafting.

OBJECTIVE: The objective of this qualitative review is to summarize the pathophysiological and clinical data behind the clinical entity of left internal mammary artery (LIMA) side branch coronary steal as well as the potential diagnostic and therapeutic modalities available. BACKGROUND: The presence of persistent unligated LIMA side branches following coronary artery bypass grafting has previously been associated with stable angina and acute coronary syndromes. However, despite numerous attempts to objectively demonstrate a coronary steal phenomenon, the pathophysiology of LIMA side branch flow diversion remains elusive and the clinical utility of intervention is not well elucidated. METHODS: A review of literature and available data including case reports, case series, and investigational studies was performed. RESULTS: Therapeutic closure of LIMA side branches has been reported in at least 44 patients and in at least 31 publications since 1990 and is associated with an 87.5% rate of freedom from angina amongst technically successful initial interventions. In all patients with pre- and post- stress testing, intervention was associated with an improvement and/or resolution of previously observed reversible ischemia. CONCLUSIONS: LIMA side branch coronary steal should remain an ongoing consideration in symptomatic patients with large unligated side branches on angiography, particularly when there is clear evidence of reversible ischemic on perfusion imaging.

Percutaneous mitral valve repair in adults with congenital heart disease: Report of the first case-series.

BACKGROUND: Systemic atrioventricular valve regurgitation (AVVR) is frequently encountered in adults with congenital heart disease (CHD). Surgical intervention is the mainstay of therapy, but in a specific high-risk subset, percutaneous valve repair might offer a lower-risk alternative. METHODS: Three patients with complex CHD and severe symptomatic AVVR underwent percutaneous mitral valve repair at a single center. All were deemed to be high-risk for surgery by a multidisciplinary CHD team and provided informed consent for the compassionate use of the MitraClip (Abbott, Santa Clara, CA). Three-dimensional heart models were generated for the procedure, which was performed by an adult CHD cardiologist (who provided imaging support) and an interventional cardiologist with expertise in CHD and percutaneous mitral valve repair. RESULTS: The first case was a 39 year-old-woman with [S,L,D] dextrocardia, double outlet right ventricle, mild tricuspid hypoplasia, and a secundum atrial septal defect, who was palliated at age 35 with a right bidirectional Glenn and later developed severe, symptomatic mitral regurgitation, and underwent placement of one MitraClip XTR device. Two patients with L-loop transposition of the great arteries each successfully underwent placement of two MitraClip XTR devices; one patient had a single-leaflet detachment of one of the clips with no change in regurgitation or clip position on follow-up. All patients had significant reduction of AVVR and improvement in NYHA functional class. CONCLUSIONS: Percutaneous atrioventricular valve repair in adults with CHD is feasible with the MitraClip but requires significant preprocedural planning and a multidisciplinary team that combines CHD and interventional therapeutic expertise.

Resuscitation Patterns and Massive Transfusion for the Critical Bleeding Dog-A Multicentric Retrospective Study of 69 Cases (2007-2013).

Objective: To describe resuscitation patterns of critically bleeding dogs, including those receiving massive transfusion (MT). Design: Retrospective study from three universities (2007-2013). Animals: Critically bleeding dogs, defined as dogs who received ≥ 25 ml/kg of blood products for treatment of hemorrhagic shock caused by blood loss. Measurements and Main Results: Sixty-nine dogs were included. Sources of critical bleeding were trauma (26.1%), intra/perioperative surgical period (26.1%), miscellaneous (24.6%), and spontaneous hemoabdomen (23.1%). Median (range) age was 7 years (0.5-18). Median body weight was 20 kg (2.6-57). Median pre-transfusion hematocrit, total protein, systolic blood pressure, and lactate were 25% (10-63), 4.1 g/dl (2-7.1), 80 mm Hg (20-181), and 6.4 mmol/L (1.1-18.2), respectively. Median blood product volume administered was 44 ml/kg (25-137.4). Median plasma to red blood cell ratio was 0.8 (0-4), and median non-blood product resuscitation fluid to blood product ratio was 0.5 (0-3.6). MT was given to 47.8% of dogs. Survival rate was 40.6%. The estimated odds of survival were higher by a factor of 1.8 (95% CI: 1.174, 3.094) for a dog with 1 g/dl higher total protein above reference interval and were lower by a factor of 0.6 (95% CI: 0.340, 0.915) per 100% prolongation of partial thromboplastin time above the reference interval. No predictors of MT were identified. Conclusions: Critical bleeding in dogs was associated with a wide range of resuscitation patterns and carries a guarded to poor prognosis.

Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States.

OBJECTIVE: To determine trends in real-world utilization and in-hospital adverse events from Watchman implantation since its approval by the Food and Drug Administration in 2015. BACKGROUND: The risk of embolic stroke caused by atrial fibrillation is reduced by oral anticoagulants, but not all patients can tolerate long-term anticoagulation. Left atrial appendage occlusion with the Watchman device has emerged as an alternative therapy. METHODS: This was a retrospective cohort study utilizing data from National Inpatient Sample for calendar years 2015-2017. The outcomes assessed in this study were associated complications, in-hospital mortality, and resource utilization trends after Watchman implantation. Trends analysis were performed using analysis of variance. Multivariable adjusted logistic regression analysis was performed to determine predictors of mortality. RESULTS: A total of 17 700 patients underwent Watchman implantation during the study period. There was a significantly increased trend in the number of Watchman procedures performed over the study years (from 1195 in 2015 to 11 165 devices in 2017, p < .01). A significant decline in the rate of complications (from 26.4% in 2015% to 7.9% in 2017, p < .01) and inpatient mortality (from 1.3% in 2015% to 0.1% in 2017, p < .01) were noted. Predictors of in-hospital mortality included a higher CHA2 DS2 -VASc score (odds ratio [OR]: 2.61 per 1-point increase, 95% confidence interval [CI]: 1.91-3.57), chronic blood loss anemia (OR: 3.63, 95% CI: 1.37-9.61) and coagulopathy (OR: 4.90, 95% CI: 2.32-10.35). CONCLUSION: In contemporary United States clinical practice, Watchman utilization has increased significantly since approval in 2015, while complications and in-patient mortality have declined.

Planned Robotic Chronic Total Occlusion Percutaneous Coronary Intervention: Feasibility Report.

BACKGROUND: Complex robotic percutaneous coronary intervention (R-PCI) is technically possible and leads to clinically comparable outcomes compared with the manual approach. However, there are limited data on the feasibility of chronic total occlusion (CTO) revascularization via the R-PCI approach. METHODS: Ten consecutive patients undergoing R-PCI for a coronary CTO at a single tertiary academic center were analyzed. The PRECISION, PRECISION GRX, and PROGRESS CTO registries were utilized for data collection with regard to procedural/clinical details and results. RESULTS: Technical success, defined as successful CTO revascularization with full or partial robotic support, occurred in 7 of 10 patients. There were no periprocedural major adverse cardiac events. Average J-CTO score was 2; all procedures were performed from an antegrade approach. The time from robotic wire manipulation to completion of procedure regardless of method averaged 55.1 minutes; average fluoroscopy time was 29.9 minutes. CONCLUSIONS: CTO revascularization via a robotic approach is feasible. Technical success may be best predicted by those patients with low J-CTO scores and lesions amenable to antegrade wire escalation technique. Given the potential benefits to both operators and patients, further research is warranted.