Valve-in-Valve Transcatheter Mitral Valve Replacement in a Very High-Risk Octagenerian Patient: A Case Report.

Degeneration of the surgical bioprosthetic valves remains one of the most common complications of surgical valve replacement. Redo surgery is the gold standard, but unfortunately, most of these patients are deemed inoperable because of the high perioperative mortality. Transcatheter implantation of a new valve inside the degenerated bioprosthesis (valve-in-valve (ViV)) has emerged as an alternative solution. A 79-year-old patient with a medical history of surgical replacement of the mitral valve with a bioprosthetic valve, coronary artery bypass graft surgery (CABG) with implantation of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD), paroxysmal atrial fibrillation, and chronic kidney disease was referred to our hospital for ViV transcatheter mitral valve replacement (TMVR). He had recent hospitalizations with pulmonary edema caused by severe stenosis of the bioprosthetic valve and his perioperative mortality for a redo surgery was very high (EuroSCORE II: 13.72%). The ViV TMVR was performed with a transseptal approach and after the implantation of the new valve, the mean pressure gradient was dropped from 19.39 to 2.33 mmHg. The procedure was technically successful and the patient was discharged asymptomatic.

Echocardiographic-Fluoroscopic Fusion Imaging Improves Interventionalists' Learning Curve for Percutaneous Left Atrial Appendage Closure-Initial, Single-Center, Retrospective Observations.

Due to the complex and variable anatomy of the left atrial appendage, percutaneous left atrial appendage closure (LAAC) can be challenging. In this study, we investigated the impact of fusion imaging (FI) on the LAAC learning curve of two interventionalists. The first interventionalist (IC 1) was initially trained without FI and continued his training with FI. The second interventionalist (IC 2) performed all procedures with FI. We compared the first 36 procedures without FI of IC 1 (group 1) with his next 36 interventions with FI (group 2). Furthermore, group 1 was compared to 36 procedures of IC 2 who directly started his training with FI (group 3). Group 1 demonstrated that the learning curve without FI has a flat course with weak correlations for fluoroscopy time, contrast volume, and procedure time, but not for dose area product. Group 2 with FI showed improvement with a steep course and strong correlations for all four parameters. In group 3, we also saw a steep progression with strong correlations. Furthermore, the mean measurements of the parameters in the groups with FI decreased significantly as an indicator of procedural efficacy. We demonstrated that FI may improve the learning curve of experienced and non-experienced ICs.

Revolutionizing cardiovascular care: the power of histotripsy.

Histotripsy, an innovative ultrasonic technique, is poised to transform the landscape of cardiovascular disease management. This review explores the multifaceted applications of histotripsy across various domains of cardiovascular medicine. In thrombolysis, histotripsy presents a non-invasive, drug-free, and precise method for recanalizing blood vessels obstructed by clots, minimizing the risk of vessel damage and embolism. Additionally, histotripsy showcases its potential in congenital heart defect management, offering a promising alternative to invasive procedures by creating intracardiac communications noninvasively. For patients with calcified aortic stenosis, histotripsy demonstrates its effectiveness in softening calcified bioprosthetic valves, potentially revolutionizing valve interventions. In the realm of arrhythmias, histotripsy could play an important role in scar-based ventricular tachycardia ablation, eliminating channel-like isthmuses of slowly conducting myocardium. Histotripsy`s potential applications also extend to structural heart interventions, enabling the safe sectioning of basal chordae and potentially addressing mitral regurgitation. Furthermore, it showcases its versatility by safely generating ventricular septal defects, providing a non-invasive means of creating intracardiac communications in neonates with congenital heart disease. Yet, most supporting studies are in-vitro or animal studies and there are possible challenges in translating experimental data on cardiac histotripsy to the clinical level. As histotripsy continues to evolve and mature, its remarkable potential in cardiovascular disease management holds promise for improving patient outcomes and reducing the burden of invasive procedures in the field of cardiology.

Advances in TEE-Centric Intraprocedural Multimodal Image Guidance for Congenital and Structural Heart Disease.

Percutaneous interventions are gaining rapid acceptance in cardiology and revolutionizing the treatment of structural heart disease (SHD). As new percutaneous procedures of SHD are being developed, their associated complexity and anatomical variability demand a high-resolution special understanding for intraprocedural image guidance. During the last decade, three-dimensional (3D) transesophageal echocardiography (TEE) has become one of the most accessed imaging methods for structural interventions. Although 3D-TEE can assess cardiac structures and functions in real-time, its limitations (e.g., limited field of view, image quality at a large depth, etc.) must be addressed for its universal adaptation, as well as to improve the quality of its imaging and interventions. This review aims to present the role of TEE in the intraprocedural guidance of percutaneous structural interventions. We also focus on the current and future developments required in a multimodal image integration process when using TEE to enhance the management of congenital and SHD treatments.

VATS cardiac sympathetic denervation for ventricular arrhythmias: initial experience in a tertiary care centre.

Cardiac sympathetic denervation (CSD) is a useful therapeutic option for patients with ventricular arrhythmias (VAs) refractory to anti-arrhythmic agents and/or catheter ablation. However, the experience is mostly limited to non-structural heart disease in paediatric patients. The advent of video-assisted thoracoscopic surgery (VATS) with its reduced morbidity has encouraged the use of VATS CSD in patients with structural heart disease. In this series, we report the surgical and cardiac outcomes of VATS-guided CSD in four patients who presented with electrical storm in the setting of different structural cardiomyopathies. Four patients underwent VATS-guided CSD at our centre during the period 2019-2021 after failure of conventional medical and/or ablative treatment for the management of refractory VAs. All four patients presented with electrical storm with different cardiomyopathies including ischaemic (post-acute myocardial infarction) and non-ischaemic aetiologies (sarcoidosis, non-specific right ventricular cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy). A combined total of 349 implantable cardioverter defibrillator (ICD) shocks were registered in the 4 weeks preceding the procedure with mean shocks of 87 per patient. All four patients successfully underwent CSD through the VATS approach with no operative mortality or any major surgical morbidity. All patients had resolution of electrical storms with 75% of patients remaining free of ICD shocks at a mean follow-up of 14.87 months. One patient who remained free of ICD shocks and recurrent VAs died at 23 months after the procedure due to progressive heart failure and complications. VATS CSD is a safe and effective complementary therapeutic modality in patients with life-threatening refractory VAs and electrical storms irrespective of the underlying substrate. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-022-01361-y.

Quality of life after percutaneous paravalvular leak closure - a prospective registry.

Introduction: Presence of paravalvular leaks (PVLs) can lead to heart failure, which decreases quality of life (QoL). Percutaneous closure is becoming the first-line treatment of PVLs, but whether such a procedure could improve QoL in these patients has never been examined. Aim: To examine changes in scores of the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Kansas City Cardiomyopathy Questionnaire (KCCQ) after percutaneous PVL closure. Material and methods: Forty subjects with heart failure symptoms and at least moderate PVL were included in this prospective registry. QoL was assessed at baseline and during a 12-month follow-up after percutaneous PVL closure by MLHFQ and KCCQ questionnaires. Changes in NT-proBNP and lactate dehydrogenase (LDH) levels were also analyzed. Results: Technical success (TS) was achieved in 97.5% of cases and procedural success (PS) in 85% of cases. In the group with PS a significant decrease in MLHFQ score as well as an increase in scores of all KCCQ domains was observed. No statistically significant changes were observed in the group without PS, mainly due to the small sample size. Conclusions: Percutaneous PVL closure is associated with better QoL during a 12-month follow-up provided PS was achieved. Due to the low number of subjects in whom PS was not achieved, it is not possible to determine the influence of a failed procedure in this group of patients.

The safety of catheter ablation for premature ventricular contractions in patients without structural heart disease.

BACKGROUND: Patients with frequent premature ventricular contractions (PVCs) are often symptomatic. Catheter ablation was usually indicated to eliminate symptoms in patients with PVCs-induced cardiomyopathy. Currently, PVCs-ablation is also applied for patients with PVCs and no structural heart diseases (SHD); however, the safety and efficacy of ablation in these patients remains unclear. METHODS: In this retrospective study, data from patients who underwent ablation for PVCs from January 2010 to December 2016 at our hospital was retrieved. Predictors of complications and acute procedural success were evaluated. RESULTS: A total of 1231 patients (mean age 47.8 ± 16.8 years, 59% female) were included. The overall complication rate was 2.7%, and the most common complication was hydropericardium. Two ablation-related mortalities occurred. One patient died of coronary artery injury during the procedure and the other died from infectious endocarditis. Location (left ventricle and epicardium) was the main predictor of complications, with right ventricular outflow tract (RVOT) predicting fewer complications. The acute procedural success rate was 94.1% in all patients. The main predictor of acute procedural success was RVOT origin, while an epicardial origin was a predictor of procedural failure. CONCLUSION: Locations of left ventricle and epicardium were predictors of procedural complications for patients with PVCs. Therefore, ablation is not recommended in these patients. For other origins of PVCs, particularly RVOT origin, ablation is a safety and effective treatment.

Usefulness of echocardiographic-fluoroscopic fusion imaging in adult structural heart disease.

Percutaneous approaches to treat structural heart diseases are growing in number and complexity. Multimodality imaging is essential for planning and monitoring such interventions. The combination of three-dimensional transoesophageal echocardiography with fluoroscopy is the cornerstone of interventional imaging. However, these two modalities are displayed on separate screens, and are handled by different physicians, which requires a complex mental reconstruction for the interventional team. To overcome this issue, echocardiographic-fluoroscopic fusion imaging has been introduced recently in clinical practice. This system combines, in a single view, the precise visualization of catheter and devices provided by fluoroscopy with the continuous soft tissue information provided by echocardiography. In addition, the procedure may be guided using a marker-tracking mode. However, there are few data on how this new technology can have an impact on our routine clinical practice and patient outcomes. In this review, we provide a user manual for the system, discuss its potential clinical applications in adult structural heart diseases and consider future perspectives.

Ventricular arrhythmias originating from the cardiac crux and the basal inferior segment of the interventricular septum in the patients with structural heart diseases: characteristics, mapping, and electrophysiological properties.

PURPOSE: There are few reports describing ventricular arrhythmias (VAs) from the crux and the corresponding endocardial site, i.e., the basal inferior segment of the interventricular septum (IVS). We aimed to investigate a distinct clinical group of VAs arising from the endocardium at this area in patients with structural heart diseases (SHD). METHODS: We included 17 patients with SHD and clinically documented VAs. Thirteen patients underwent endocardial mapping only. Three patients underwent both epicardial and endocardial approaches and one had only epicardial mapping. Eighteen VAs were identified, 14 focal and 4 reentrant VAs, confirmed by entrainment. RESULTS: There were 2 VAs from the crux, 5 VAs from the corresponding endocardial site in the right ventricle (RV), and 11 from the site in the left ventricle (LV). Compared with the VAs from RV endocardium, VAs from LV endocardium had a higher R wave in V3 than V2 (V2R/V3R ratio, 1.83 ± 0.84 vs. 0.86 ± 0.38, P = 0.008) and a higher V3 transition ratio percentage (2.16 ± 2.07 vs. 0.58 ± 0.62, P = 0.008). Combining all 16 patients with endocardial mapping, there were also lower bipolar voltages (1.21 ± 1.05 vs. 3.10 ± 2.65 mv, P < 0.0001), lower unipolar voltages (4.05 ± 1.92 vs. 5.75 ± 2.90 mv, P < 0.0001), and longer local electrocardiogram (EGM) lateness (157.6 ± 47.9 vs.140.3 ± 52.5 ms, P = 0.0001) in the dominant chambers. CONCLUSIONS: In VAs from the crux and the corresponding endocardial site, the complete ECG V2R/V3R ratio and V3 transition ratio percentage could differentiate the VAs from the RV or LV endocardium. The lower unipolar, bipolar voltage mapping, and longer EGM lateness are helpful to identify the abnormal substrate in the endocardium in these patients.

Fusión de ecocardiografía 2D/3D-fluoroscopia: nueva herramienta en el intervencionismo cardiaco / Fusion of 2 D and 3 D echocardiography with fluoroscopy: a new tool in cardiac interventionism

Resumen La evolución en el intervencionismo estructural percutáneo ha generado un desarrollo paralelo en las técnicas de imagen avanzada. Teniendo en cuenta que este tipo de procedimientos requiere un entendimiento total de la anatomía cardiaca y con el fin de garantizar los mejores resultados y seguridad para el paciente durante procedimientos complejos, se desarrolló un software capaz de fusionar la fluoroscopia y la ecocardiografía 3 D en una sola imagen. La tecnología del Echonavigator® integra dos técnicas de imágenes dinámicas de un corazón en movimiento; el adecuado co-registro y visualización de fluoroscopia y ecocardiografía transesofágica 2D/3D es la clave en la obtención de resultados óptimos. La fusión de dos imágenes dinámicas en tiempo real es una herramienta factible y segura en los procedimientos de intervencionismo estructural del corazón; los estudios iniciales han logrado disminuir el tiempo de realización de los procedimientos y las dosis de radiación al paciente. El futuro es prometedor y su progresiva expansión de uso teniendo en cuenta su reciente aparición, aportará más datos en el crecimiento de esta tecnología.

Abstract The evolution of percutaneous structural interventionism has led to the simultaneous development of advanced imaging techniques. Taking into account that these types of procedures require a full understanding of cardiac anatomy, and with the aim of ensuring the best results and patient safety during complex procedures, a software program was developed that was capable of fusing and 3D-echocardiography into a single image. The Echonavigator® technology combines two dynamic imaging techniques of a heart in movement. The appropriate co-recording and visualising of fluoroscopy and 2D/3D transoesophageal echocardiography is essential for obtaining optimal results. The fusion of two images in real-time is a feasible and safe tool in structural heart interventionist procedures. Initial studies have managed to decrease the time of performing the procedures, as well as the dose of radiation to the patient. The future is promising, and its gradual expansion of use, taking into account its recent appearance, will provide more data on the growth of this technology.

A Randomized Trial of Pocket-Echocardiography Integrated Mobile Health Device Assessments in Modern Structural Heart Disease Clinics.

OBJECTIVES: This study sought to determine whether mobile health (mHealth) device assessments used as clinical decision support tools at the point-of-care can reduce the time to treatment and improve long-term outcomes among patients with rheumatic and structural heart diseases (SHD). BACKGROUND: Newly developed smartphone-connected mHealth devices represent promising methods to diagnose common diseases in resource-limited areas; however, the impact of technology-based care on long-term outcomes has not been rigorously evaluated. METHODS: A total of 253 patients with SHD were randomized to an initial diagnostic assessment with wireless devices in mHealth clinics (n = 139) or to standard-care (n = 114) in India. mHealth clinics were equipped with point-of-care devices including pocket-echocardiography, smartphone-connected-electrocardiogram blood pressure and oxygen measurements, activity monitoring, and portable brain natriuretic peptide laboratory testing. All individuals underwent comprehensive transthoracic echocardiography to assess the severity of SHD. The primary endpoint was the time to referral for therapy with percutaneous valvuloplasty or surgical valve replacement. Secondary endpoints included the probability of a cardiovascular hospitalization and/or death over 1 year. RESULTS: An initial mHealth assessment was associated with a shorter time to referral for valvuloplasty and/or valve replacement (83 ± 79 days vs. 180 ± 101 days; p <0.001) and was associated with an increased probability for valvuloplasty/valve replacement compared to standard-care (34% vs. 32%; adjusted hazard ratio: 1.54; 95% CI: 0.96 to 2.47; p = 0.07). Patients randomized to mHealth were associated with a lower risk of a hospitalization and/or death on follow-up (15% vs. 28%, adjusted hazard ratio: 0.41; 95% CI: 0.21 to 0.83; p = 0.013). CONCLUSIONS: An initial mHealth diagnostic strategy was associated with a shorter time to definitive therapy among patients with SHD in a resource-limited area and was associated with improved outcomes. (A Randomized Trial of Pocket-Echocardiography Integrated Mobile Health Device Assessments in Modern Structural Heart Disease Clinics; NCT02881398).

[Catheter ablation of ventricular tachycardia : What have we achieved?] / Katheterablation ventrikulärer Tachyarrhythmien : Was haben wir erreicht?

The role of catheter ablation in patients with ventricular tachycardia (VT) has evolved over the last two decades into an established treatment option. In patients with idiopathic VT catheter ablation is the gold standard treatment option with high effectiveness and low risk of complications. Due to the high risk of side effects the use of antiarrhythmic drugs is only indicated in exceptional cases. In patients with structural heart diseases, such as ischemic and dilated cardiomyopathy, VT is the most frequent cause of death. Furthermore, recurrent shocks from implantable cardioverter defibrillators (ICD) are one of the main reasons for the high morbidity and mortality; however, in these patients a complex myocardial substrate is present and consequently there is a relevant risk of recurrence after VT ablation. A periprocedural mortality of approximately 3% must be considered in these often severely ill patients. Nevertheless, there is no reasonable alternative to catheter ablation, particularly in patients who continue to have VT episodes even under therapy with amiodarone. Questions with respect to the optimal procedural technique for VT ablation, the endpoint and optimal timing of ablation need to be clarified in clinical trials.