Techniques to overcome difficult delivery of the Impella CP device through a previously placed transcatheter aortic valve.

The utilization of mechanical circulatory support (MCS) for complex percutaneous coronary intervention (PCI) in patient with previous bioprosthetic aortic valve replacement continues to increase. This is due to an aging population and increased utilization of transcatheter aortic valve replacement (TAVR) to treat symptomatic severe aortic stenosis (AS). These patients often have concurrent high complexity coronary artery disease (CAD). Various strategies are available for the management of significant CAD in patients undergoing TAVR, including PCI before or after TAVR. However, placement of the Impella (Abiomed Danvers, MA) device in the left ventricle post TAVR can be challenging based on the device interaction with the TAVR cage or angulations of the ascending aorta. We describe a case of unsuccessful delivery of the Impella device through a previously placed 26 mm Sapien 3 TAVR (Edwards Irvine, CA) valve and the techniques that lead to successful placement of the device and review the tips and techniques that operators can employ to optimize success.

Treatment of cardiac device-related infective endocarditis utilizing the new T20 curve catheter and flow saver with the Inari mechanical aspiration system.

Emerging innovations have led to the development of tools and techniques to perform mechanical aspiration of right-sided endocarditis vegetations. However, blood loss during aspiration, the need for veno-veno bypass, and nonsteerable catheters have limited expansion of these treatment options to more patients. We present a case of pacemaker lead endocarditis treated with the Inari mechanical aspiration system utilizing the new T20 curved catheter (Inari Medical).

Single-access during Impella hemodynamic support utilizing the Railway system.

A single-access technique during mechanical circulatory support (MCS) and percutaneous coronary intervention (PCI) has been described for those patients where an additional arterial access site is not available or desired. This technique utilizes the Impella (Abiomed, Danvers, MA) 14 French (F) sheath as a single-access point, with a 7 F sheath through the 14 F sheath hemostatic valve next to the Impella catheter (Abiomed). However, this technique is limited to a 7 F sheath or smaller and can be difficult requiring multiple attempts and limit guide catheter manipulation. We describe a single-access technique utilizing the Impella (Abiomed) 14 F sheath and a standard 7 F guide catheter placed sheathless through the 14 F sheath hemostatic valve utilizing the Railway Sheathless Access System (Cortis, Santa Clara, CA).

Treatment of focal distal abdominal aortic stenosis with the GORE VIABAHN VBX balloon expandable covered stent.

The incidence of focal infrarenal stenosis of the aorta is rare. Endovascular therapy has evolved as a first-line treatment of aortoiliac occlusive disease and has been shown to substantially improve health-related quality of life. The 8 French sheath compatible, GORE VIABAHN VBX (GORE Flagstaff, AZ) balloon expandable covered stent offers the traditional benefits of a balloon expandable covered stent with a design that improves on flexibility. We report three cases with the use of this system for treatment of infrarenal stenosis of the aorta.

Acute outcomes after coronary orbital atherectomy at a single center without on-site surgical backup: An experience in diabetics versus non-diabetics.

BACKGROUND: Percutaneous coronary intervention (PCI) of severely calcified lesions is associated with a high risk of angiographic complication, incomplete stent expansion, and restenosis. The prevalence of calcification is increased in diabetics (DM) and the PCI outcome in this population is often suboptimal. Treatment with orbital atherectomy (OA) in severely calcified lesions has been shown to result in favorable procedural outcomes and low reintervention rates; in DM and non-DM. We sought to determine the acute safety of OA in a center without on-site surgical backup in DM and non-DM. METHODS: All comers treated with OA at Sanford Bemidji Heart and Vascular Center (Bemidji, MN) from 8/30/16 to 4/14/17 were included in this retrospective analysis. Baseline, procedure, and acute outcome data were compared in DM and non-DM patients. RESULTS: Of the 70 patients treated with OA, 40% were DM. History of hypertension and chronic renal disease were more prevalent in the DM group. Successful stent delivery occurred in 96.4% of DM and 100% in non-DM, respectively. None of the patients treated with OA died or experienced abrupt closure, severe dissection, embolization, or no reflow. The overall perforation and slow flow rates were 1.4%. One non-DM patient had a non-target vessel MI due to side branch closure. CONCLUSIONS: Our study demonstrates the safety of OA in a center without on-site surgical backup. In this study, OA treatment resulted in a high rate of successful stent delivery and low rates of angiographic complications and acute MACE, in DM and non-DM patients. SUMMARY: In this retrospective study we sought to determine the acute safety of coronary orbital atherectomy treatment in a center without on-site surgical backup in diabetic and non-diabetic patients. None of the patients treated with orbital atherectomy died or experienced abrupt closure, severe dissection, embolization, or no reflow; the overall perforation and slow flow rates were 1.4% and one non-diabetic patient had a non-target vessel myocardial infarction due to side branch closure. Our study demonstrates the safety of orbital atherectomy in a center without on-site surgical backup; orbital atherectomy treatment resulted in a high rate of successful stent delivery and low rates of angiographic complications and acute major adverse cardiac events in diabetic and non-diabetic patients.

QRS duration predicts death and hospitalization among patients with atrial fibrillation irrespective of heart failure: evidence from the AFFIRM study.

AIMS: The association of QRS duration (QRSd) with morbidity and mortality is understudied in patients with atrial fibrillation (AF). We sought to assess any association of prolonged QRS with increased risk of death or hospitalization among patients with AF. METHODS AND RESULTS: QRS duration was retrieved from the baseline electrocardiograms of patients enroled in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study and divided into three categories: <90, 90-119, ≥120 ms. Cox models were applied relating the hazards of mortality and hospitalizations to QRSd. Among 3804 patients with AF, 593 died and 2305 were hospitalized. Compared with those with QRS < 90 ms, patients with QRS ≥ 120 ms, had an increased mortality [hazard ratio (HR) 1.61, 95% confidence interval (CI): 1.29-2.03, P < 0.001] and hospitalizations (HR 1.14, 95% CI: 1.07-1.34, P = 0.043) over an average follow-up of 3.5 years. Importantly, for patients with QRS 90-119 ms, mortality and hospitalization were also increased (HR 1.31, P = 0.005 and 1.11, P = 0.026, respectively). In subgroup analysis based on heart failure (HF) status (previously documented or ejection fraction <40%), mortality was increased for QRS ≥ 120 ms patients with (HR 1.87, P < 0.001) and without HF (HR 1.63, P = 0.02). In the QRS 90-119 ms group, mortality was increased (HR 1.38, P = 0.03) for those with HF, but not significantly among those without HF (HR 1.23, P = 0.14). CONCLUSION: Among patients with AF, QRSd ≥ 120 ms was associated with a substantially increased risk for mortality (all-cause, cardiovascular, and arrhythmic) and hospitalization. Interestingly, an increased mortality was also observed among those with QRS 90-119 ms and concomitant HF.

Second generation drug-eluting stents: a review of the everolimus-eluting platform.

Everolimus-eluting stents (EES) represent the next generation of drug-eluting stents (DES). Important design modifications include thin strut stent backbones, less inflammatory and more biocompatible polymers, and lower drug dosing. The cobalt chromium EES fluoropolymer XIENCE V stent has been the most extensively studied of such stents. In animal models, this stent demonstrated minimal vessel inflammation, a biologically active endothelium with strut coverage similar to a bare metal stent, and inhibition of intimal hyperplasia comparable to that seen with sirolimus-eluting stents. The SPIRIT family of clinical trials demonstrated low rates of late loss, and clinical restenosis, as well as low rates of very late stent thrombosis. These excellent clinical outcomes addressed limitations of the 1st generation DES, and substantiated widespread clinical use of the EES platform.

Adenosine testing in atrial flutter ablation: unmasking of dormant conduction across the cavotricuspid isthmus and risk of recurrence.

BACKGROUND: Adenosine-induced hyperpolarization may identify pulmonary veins at risk of reconnection following electrical isolation for atrial fibrillation. The potential role of adenosine testing in other arrhythmic substrates, such as cavotricuspid isthmus (CTI)-dependent atrial flutter, remains unclear. We assessed whether dormant conduction across the CTI may be revealed by adenosine after ablation-induced bidirectional block, and its association with recurrent flutter. METHODS AND RESULTS: Patients undergoing catheter ablation for CTI-dependent flutter were prospectively studied. After confirming bidirectional block across the CTI by standard pacing maneuvers, adenosine (≥ 12 mg IV) was administered to assess resumption of conduction, followed by isoproterenol (ISP) bolus. Further CTI ablation was performed for persistent (but not transient) resumption of conduction. Bidirectional block across the CTI was achieved in all 81 patients (63 males), age 61.2 ± 11.0 years. The trans-CTI time increased from 71.9 ± 18.1 milliseconds preablation to 166.2 ± 26.4 milliseconds postablation. Adenosine elicited resumption of conduction across the CTI in 7 patients (8.6%), 2 of whom had transient recovery. No additional patient with dormant conduction was identified by ISP. Over a follow-up of 11.8 ± 8.0 months, atrial flutter recurred in 4 (4.9%) patients, 3/7(42.9%) with a positive adenosine challenge versus 1/74 (1.3%) with a negative response, P = 0.0016 (relative risk 31.7). CONCLUSION: Adenosine challenge following atrial flutter ablation provoked transient or persistent resumption of conduction across the CTI in almost 9% of patients and identified a subgroup at higher risk of flutter recurrence. It remains to be determined whether additional ablation guided by adenosine testing during the index procedure may further improve procedural outcomes.

Increased mortality among patients taking digoxin--analysis from the AFFIRM study.

AIMS: Digoxin is frequently used for rate control of atrial fibrillation (AF). It has, however, been associated with increased mortality. It remains unclear whether digoxin itself is responsible for the increased mortality (toxic drug effect) or whether it is prescribed to sicker patients with inherently higher mortality due to comorbidities. The goal of our study was to determine the relationship between digoxin and mortality in patients with AF. METHODS AND RESULTS: The association between digoxin and mortality was assessed in patients enrolled in the AF Follow-Up Investigation of Rhythm Management (AFFIRM) trial using multivariate Cox proportional hazards models. Analyses were conducted in all patients and in subsets according to the presence or absence of heart failure (HF), as defined by a history of HF and/or an ejection fraction <40%. Digoxin was associated with an increase in all-cause mortality [estimated hazard ratio (EHR) 1.41, 95% confidence interval (CI) 1.19-1.67, P < 0.001], cardiovascular mortality (EHR 1.35, 95% CI 1.06-1.71, P = 0.016), and arrhythmic mortality (EHR 1.61, 95% CI 1.12-2.30, P = 0.009). The all-cause mortality was increased with digoxin in patients without or with HF (EHR 1.37, 95% CI 1.05-1.79, P = 0.019 and EHR 1.41, 95% CI 1.09-1.84, P = 0.010, respectively). There was no significant digoxin-gender interaction for all-cause (P = 0.70) or cardiovascular (P = 0.95) mortality. CONCLUSION: Digoxin was associated with a significant increase in all-cause mortality in patients with AF after correcting for clinical characteristics and comorbidities, regardless of gender or of the presence or absence of HF. These findings call into question the widespread use of digoxin in patients with AF.

Balloon-facilitated delivery of a left ventricular pacing lead.

While modern implant tools have contributed greatly to the success of cardiac resynchronization therapy, technical challenges remain. A common problem is the inability to advance left ventricular pacing leads into branch veins that are tortuous or arise at steep angles. In these cases, advancement of the lead causes it to buckle and prolapse into the coronary sinus or great cardiac vein. Lead prolapsed can be avoided by employing a balloon to temporarily obstruct the coronary sinus or great cardiac vein just upstream from the branch vein. The balloon redirects the force of advancement laterally into the branch vein, facilitating delivery.

Is there an association between external cardioversions and long-term mortality and morbidity? Insights from the Atrial Fibrillation Follow-up Investigation of Rhythm Management study.

BACKGROUND: Cardiac electric therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardioverter-defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regard to cardiovascular mortality and morbidity. METHODS AND RESULTS: We analyzed the data of the 4060 patients from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality, and hospitalizations after ECVe were studied. Over an average follow-up of 3.5 years, 660 (16.3%) patients died, 331 (8.2%) from cardiovascular causes. A total of 207 (5.1%) and 1697 (41.8%) patients had low ejection fraction and nonparoxysmal atrial fibrillation, respectively; 2460 patients received no ECVe, whereas 1600 experienced ≥ 1 ECVe. Death occurred in 412 (16.7%), 196 (16.5%), 39 (13.5%), and 13 (10.4%) of patients with 0, 1, 2, and ≥ 3 ECVe, respectively. There was no significant association between ECVe and mortality within any of the 4 subgroups defined by ejection fraction and atrial fibrillation type, although myocardial infarction, coronary artery bypass graft, and digoxin were significantly associated with death (estimated hazard ratios, 1.65, 1.59, and 1.62, respectively; P < 0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% versus 5.8%; estimated odds ratio, 1.39; P < 0.0001). CONCLUSIONS: In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, myocardial infarction, and coronary artery bypass graft were significantly associated with mortality.

Double atrial septal defect: diagnosis and closure guidance with 3D transesophageal echocardiography.

Atrial septal defect (ASD) is a common form of congenital heart disease that often persists well into adulthood before discovery or intervention. The authors report the case of a patient referred for routine percutaneous ASD closure that was found on three-dimensional (3D) transesophageal echocardiography to have two large separate ostium secundum defects which were subsequently closed under 3D echocardiographic guidance.