The use of MitraClip to prevent posttranscatheter aortic valve replacement left ventricular "suicide".

Patients with concomitant severe aortic stenosis (AS) and left ventricular outflow tract (LVOT) obstruction undergoing transcatheter aortic valve replacement (TAVR) are at risk for hemodynamic collapse due to a sudden decrease in afterload causing worsening LVOT obstruction. We present a case of an 88-year-old female with symptomatic, severe AS, and LVOT obstruction with systolic anterior motion (SAM) of the mitral leaflet in whom alcohol septal ablation was contraindicated secondary to a chronic total occlusion of the right coronary artery that filled retrograde via septal collaterals. MitraClip at the time of TAVR was successfully performed to treat SAM with subsequent stabilization of LVOT gradients despite treatment of the patient's AS. This novel approach may represent a feasible option to prevent hemodynamic complications after TAVR in patients with significant LVOT obstruction secondary to SAM and AS.

Prosthetic mitral valve paravalvular leak: A problem that requires dexterity.

Prosthetic valve paravalvular leak (PVL) is a known and relatively common complication of surgical valve replacement, which may lead to significant morbidity. Patients with significant mitral valve replacement (MVR) PVL typically present with symptoms of heart failure and elevated filling pressures or with hemolytic anemia. Percutaneous closure of these leaks has become the preferred therapy. Percutaneous closure of MVR PVL can be technically challenging, given the anatomy of the approach (trans-septal, trans-apical), the level of associated comorbidities and the geographic location of the paravalvular defect. Steerable catheters offer a unique ability to position themselves coaxial to the PVL. The Dexterity catheter (Spirus Medical LLC, Bridgewater, MA, USA) is a semi-rigid steerable catheter used in our lab with the ability to articulate at two separate points on the distal tip and flex greater than 360 degrees. We present cases of surgical valves that developed PVL which underwent successful repair with a Dexterity catheter.

Cost-effectiveness considerations in transcatheter management of valvular heart disease.

In 2011, health care spending in Canada accounted for 11.2% of gross domestic product. Increased life expectancy, combined with the fact that new medical technologies generally tend to improve clinical results at an increased cost, are leading developed nations to devote rising amounts of financial resources to health care. Valvular heart disease is an example of an age-related health problem with rising prevalence that has recently seen an emergence of new catheter-based technologies, which are rapidly changing the treatment landscape. This article reviews the current literature on the health economics of catheter-based valve therapies. Transcatheter aortic valve replacement (TAVR), a less invasive approach to valve replacement, is currently approved in the United States, Canada, and Europe for 2 groups of patients: those with symptomatic severe aortic stenosis who are unsuitable for surgery and those who are suitable but are at high risk for surgery. TAVR, when compared with medical therapy, results in significant improvement in survival for inoperable patients, with incremental costs that are generally considered to be acceptable in most western nations. However, in high-risk surgical candidates, TAVR has shown similar survival rates when compared with surgical aortic valve replacement, with only short-term advantages in quality of life. Cost-effectiveness ratios in this population have varied widely based on differing estimates of incremental costs. Information regarding the health economics of transcatheter mitral valve therapies is still quite preliminary and limited to the MitraClip (Abbott Laboratories, Abbott Park, IL). Ongoing trials should provide additional information about the health economics of this new technology.

Effect of reduction of the pulse rates of fluoroscopy and CINE-acquisition on x-ray dose and angiographic image quality during invasive cardiovascular procedures.

BACKGROUND: Reducing digital pulse rates (PR) are known to reduce total energy during invasive cardiovascular procedures, which likely has benefits for patients and staff. Physicians may be reluctant to reduce these parameters because they fear a decline in image quality that could affect procedural outcomes. We sought to assess the effect of default rates of fluoroscopy (Fluoro) and CINE-acquisition (CINE) on total x-ray dose and image quality during invasive cardiovascular procedures. METHODS AND RESULTS: We retrospectively reviewed procedures done with 2 default PRs: a standard dose cohort (PR, 15 for Fluoro and CINE), and a reduced dose cohort (PR, 10 for Fluoro and CINE). Total x-ray dose, Fluoro time, and contrast use were compared between groups. A blinded angiographic image quality assessment was then performed using an objective 10-point angiographic quality score. There were no significant differences between cohorts for fluoroscopy time or contrast use. The reduced dose cohort has a significant reduction in mean total x-ray dose (PR 15, 1763.1 mGy; PR 10, 1179.1 mGy; P<0.0001). When adjusted for potential confounders, a 38% reduction in total x-ray dose was identified (P<0.0001). There was no difference in adjusted angiographic quality score between the cohorts (PR 15, 7.90; PR 10, 8.00; P=0.67), indicating no decline in image quality with PR reduction. CONCLUSIONS: Reducing default PRs during invasive cardiovascular procedures yields large and significant reductions in total x-ray energy with no decline in angiographic image quality.