Increasing Venous Return Blood Flow to the Right Atrium Using the Party Balloon Inflation Maneuver.

The party balloon inflation maneuver increases intrathoracic pressure, decreases venous return, and after release enhances venous return to the right atrium more effectively than does the conventional Valsalva maneuver. Therefore, it shows potential for more effective detection of right-to-left shunts in patients with a patent foramen ovale. (Level of Difficulty: Intermediate.).

Body Surface Radiation Exposure in Interventional Echocardiographers During Structural Heart Disease Procedures.

Background: The distribution of radiation exposure on the body surface of interventional echocardiographers during structural heart disease (SHD) procedures is unclear. Objectives: This study estimated and visualized radiation exposure on the body surface of interventional echocardiographers performing transesophageal echocardiography by computer simulations and real-life measurements of radiation exposure during SHD procedures. Methods: A Monte Carlo simulation was performed to clarify the absorbed dose distribution of radiation on the body surface of interventional echocardiographers. The real-life radiation exposure was measured during 79 consecutive procedures (44 transcatheter edge-to-edge repairs of the mitral valve and 35 transcatheter aortic valve replacements [TAVRs]). Results: The simulation demonstrated high-dose exposure areas (>20 µGy/h) in the right half of the body, especially the waist and lower body, in all fluoroscopic directions caused by scattered radiation from the bottom edge of the patient bed. High-dose exposure occurred when obtaining posterior-anterior and cusp-overlap views. The real-life exposure measurements were consistent with the simulation estimates: interventional echocardiographers were more exposed to radiation at their waist in transcatheter edge-to-edge repair than in TAVR procedures (median 0.334 µSv/mGy vs 0.053 µSv/mGy; P < 0.001) and in TAVR with self-expanding valves than in those with balloon-expandable valves (median 0.067 µSv/mGy vs 0.039 µSv/mGy; P < 0.01) when the posterior-anterior or the right anterior oblique angle fluoroscopic directions were used. Conclusions: During SHD procedures, the right waist and lower body of interventional echocardiographers were exposed to high radiation doses. Exposure dose varied between different C-arm projections. Interventional echocardiographers, especially young women, should be educated regarding radiation exposure during these procedures. (The development of radiation protection shield for catheter-based treatment of structural heart disease [for echocardiologists and anesthesiologists]; UMIN000046478).

Novel and Efficient Method for Diagnosing Infective Endocarditis Using 16S Ribosomal RNA Gene Amplicon Sequence.

We present 2 cases that both developed infective endocarditis and underwent mitral valve replacement. In addition to positive blood culture and echocardiographic findings, such as vegetation or mitral valve perforation, the 16S ribosomal RNA gene amplicon sequence approach used was helpful for disease diagnosis. (Level of Difficulty: Intermediate.).

Predictors of bioprosthetic valve dysfunction after transcatheter aortic valve implantation.

Background: Recently, the Valve Academic Research Consortium (VARC)-3 criteria redefined bioprosthetic valve dysfunction (BVD) after transcatheter aortic valve implantation (TAVI). However, the rate of BVD is scarcely reported in current practice. Aims: We aimed to evaluate the rate and predictors of BVD after TAVI based on the VARC-3 criteria. Methods: We retrospectively analysed patients who had undergone TAVI using single-centre data. BVD was reported as exposure-adjusted event rates with a patient-year unit (per 100 patient-years). Predictors of BVD after TAVI were analysed using Fine-Gray competing risk regression to account for the competing risk of death. Results: Among 514 patients, the rate of BVD was 7.5 events per 100 patient-years (n=74) at a median follow-up of 1.9 years. The main cause of BVD was moderate or severe prosthesis-patient mismatch (PPM; n=59). The Fine-Gray model demonstrated that predilatation was associated with a lower rate of BVD, mainly moderate or severe PPM (adjusted subdistribution hazard ratio [sub-HR] 0.42, 95% confidence interval [CI]: 0.21-0.88). In a subgroup analysis, the patients with a small aortic annulus (area <400 mm2 or perimeter <72 mm) tended to benefit from predilatation (p for interaction=0.03). The same regression model also demonstrated that a small balloon-expandable valve (BEV; ≤23 mm) was associated with a higher rate of BVD (adjusted sub-HR 2.46, 95% CI: 1.38-4.38). Conclusions: Our study suggested that the rate of BVD in patients undergoing TAVI is relatively low at midterm follow-up. Predilatation, particularly in small annuli and small BEV might have an impact on BVD, mainly caused by moderate or severe PPM, after TAVI.

Blood Coagulation Changes With or Without Direct Oral Anticoagulant Therapy Following Transcatheter Aortic Valve Implantation.

Thromboembolic events remain clinically unresolved after transcatheter aortic valve implantation (TAVI). The use of direct oral anticoagulant (DOAC) to reduce thrombosis associated with TAVI remains controversial. This study aimed at investigating the periprocedural change in blood coagulation and thrombolysis parameters in 199 patients undergoing transfemoral TAVI. Prothrombin activation fragment 1 + 2 (F1 + 2), thrombin-antithrombin complex (TAT), soluble fibrin monomer complex (SFMC), and fibrin/fibrinogen degradation product (FDP) levels were measured before and 1 hour after TAVI and 1, 2, and 7 days postoperatively. Of the 199 patients, 49 were treated with DOAC (apixaban in 32, edoxaban in 10, and rivaroxaban in 7). The F1 + 2 and TAT levels immediately increased 1 hour after TAVI and then gradually decreased in both groups. The SFMC level also significantly increased with a peak on day 1. The FDP level gradually increased, peaking on day 2. The values of F1 + 2, TAT, SFMC, and FDP in patients who used DOAC were significantly lower than those who did not use DOAC at 1 hour after TAVI in F1 + 2 (600 [452 to 765] vs 1055 [812 to 1340] pmol/L; p < 0.001), TAT (21.4 [16.2 to 37.0] vs 38.7 [26.4 to 58.7] µg/mL; p < 0.001) and on day 1 in SFMC (18.2 [9.4 to 57.9] vs 113.4 [70.9 to 157.3] µg/mL; p < 0.001) and day 2 in FDP (6.0 [4.7 to 10.0] vs 12.6 [8.2 to 17.4] µg/mL; p < 0.001). Ischemic stroke within 30 days after TAVI occurred in 3 patients (1.5%), who were not treated with DOAC. Coagulation cascade activation was observed after TAVI. DOAC could reduce transient hypercoagulation following TAVI.

Predictor and Mid-Term Outcome of Clinically Significant Thrombocytopenia After Transcatheter Aortic Valve Selection.

BACKGROUND: The frequency and predictors of thrombocytopenia after transcatheter aortic valve implantation (TAVI) are unclear.Methods and Results:This study enrolled 342 patients undergoing TAVI (245 with a percutaneous transfemoral approach, 65 with transfemoral surgical cutdown, and 32 with a non-transfemoral approach). Balloon-expandable and self-expanding valves were implanted in 235 and 107 patients, respectively. Platelet counts started to drop immediately, reaching a nadir 2-4 days after TAVI. Clinically significant thrombocytopenia (CSTP) was defined as a platelet count ≤50×109/L at the time of the nadir or both a platelet count between 80 and 51×109/L and a decrease in platelet count ≥50%. CSTP occurred in 16.7% patients. Approach site and TAVI valve selection significantly predicted CSTP. In multivariate analysis, independent predictors of CSTP were liver cirrhosis (odds ratio [OR] 7.22; 95% confidence interval [CI] 1.05-49.82), baseline platelet count ≤120×109/L (OR 2.98; 95% CI 1.20-7.38), multiple blood transfusions (OR 4.03; 95% CI 1.72-9.41), and the use of balloon-expandable valves (OR 2.38; 95% CI 1.04-5.46). Kaplan-Meier survival analysis with a generalized Wilcoxon test revealed that mid-term (2 years) mortality was greater for patients with than without CSTP (31.4% vs. 15.5%; P=0.008). CONCLUSIONS: TAVI-related CSTP was not rare and was associated with poor mid-term outcomes. CSTP was not only caused by patients' comorbidities and TAVI complications, but also related to TAVI procedural factors.

Predictive value of the geriatric nutritional risk index in percutaneous coronary intervention with rotational atherectomy.

The prognostic value of the geriatric nutritional risk index (GNRI) in patients undergoing percutaneous coronary intervention (PCI) with rotational atherectomy (RA) remains unknown. Therefore, we aimed to clarify whether the GNRI could predict major adverse cardiac events (MACE) in patients undergoing PCI with RA. A total of 206 patients who underwent PCI with RA from January 2009 to December 2017 were retrospectively tracked. The patients were divided into 2 groups based on the GNRI value on admission. MACE comprised all-cause death, target lesion revascularization (TLR), target vessel revascularization (TVR), and myocardial infarction. One year of follow up was completed in 95.6% of patients. During this period, 50 cases of MACE were observed (all-cause death, 32 cases; TLR, 21 cases; and TVR, 2 cases). Patients with a low GNRI (< 98) had a significantly higher incidence of MACE than did patients with a high GNRI (≥ 98) (37.9% vs. 15.5%, log-rank p < 0.05). The GNRI was an independent predictor of MACE (hazard ratio, 0.94; 95% confidence interval [CI], 0.92-0.97). Furthermore, the GNRI had better predictive power than did its components alone (i.e. body mass index and serum albumin level) (net-reclassification improvement, 0.39; 95% CI, 0.07-0.71; p = 0.01; integrated discrimination improvement, 0.02; 95% CI, - 0.01-0.04; p = 0.07). The GNRI on admission is a predictor of MACE after PCI with RA. Further studies are required to determine whether intensive medical therapy could improve clinical events, particularly cardiovascular death and revascularization, in this population.

Quantified frequency-domain optical coherence tomography analysis for the thin-high signals on restenotic tissue after paclitaxel-coated balloon angioplasty.

Thin-high signals (THS), detectable by optical coherence tomography (OCT), represent the paclitaxel coverage of in-stent restenotic tissue. This study was conducted to assess the relationship between THS and angiographic outcomes by means of quantified post-procedural frequency-domain OCT (FD-OCT) analysis. From January 2014 to July 2016, 41 patients underwent FD-OCT-guided percutaneous coronary intervention using paclitaxel-coated balloon (PCB) to prevent in-stent restenosis. Of these, we retrospectively enrolled 32 patients (38 lesions) who underwent a 6- to 9-month follow-up angiogram. THS were assessed quantitatively, as THS length and lumen perimeter length were measured using semi-automated software; %THS was calculated by the following formula; total THS area/lumen perimeter area × 100. THS were detected in all 38 lesions that had undergone PCB angioplasty. THS and %THS were significantly higher in lesions without binary restenosis (3.34 ± 2.11 vs. 11.48 ± 8.53 mm2, p = 0.001 and 1.49 ± 0.73 vs. 4.42 ± 2.71%, p = 0.001, respectively). Values for THS, which indicates the paclitaxel coverage on restenotic tissue, are associated with reducing restenosis after PCB for in-stent restenosis.