Catheter-based Therapy Research Articles

Emerging trends in heart valve engineering: Part III. Novel technologies for mitral valve repair and replacement.

In this portion of an extensive review of heart valve engineering, we focus on the current and emerging technologies and techniques to repair or replace the mitral valve. We begin with a discussion of the currently available mechanical and bioprosthetic mitral valves followed by the rationale and limitations of current surgical mitral annuloplasty methods; a discussion of the technique of neo-chordae fabrication and implantation; a review the procedures and clinical results for catheter-based mitral leaflet repair; a highlight of the motivation for and limitations of catheter-based annular reduction therapies; and introduce the early generation devices for catheter-based mitral valve replacement.

Stroke : Highlights of Selected Articles

<i>Stroke</i> : Highlights of Selected Articles

E-028 Implementation of an ED-based Rapid Brain-Attack Triage Algorithm in a Regional Tele-stroke Network Positively Impacts Discharge Disposition for Stroke Patients

IntroductionImplementation of standardized algorithms and EMS transport to centers with catheter-based capabilities have impacted time-to-treatment and functional outcomes in ischemic cardiac patients. However, there are limited data on the impact...

Safety and efficacy of percutaneous transluminal pulmonary angioplasty in elderly patients

BackgroundPercutaneous transluminal pulmonary angioplasty (PTPA) is a recently developed catheter-based therapy for chronic thromboembolic pulmonary hypertension (CTEPH). The aim of the present study was to investigate the safety and efficacy of PTPA in elderly patients with CTEPH. MethodsIn all, 257 PTPA sessions in 70 patients (median age 63years) were analyzed. Patients were divided into two groups according to age: (i) a younger group (<65years; n=39); and (ii) an elderly group (≥65years; n=31). ResultsHemodynamic improvements were comparable between the younger and elderly groups (63.1% vs. 68.2% decrease in pulmonary vascular resistance, respectively; P>0.05). The median length of stay in the intensive care unit after each session (1.0 vs. 1.0days) and in hospital per session (9.2 vs. 9.4days) was similar between the two groups (P>0.05 for all). The prevalence of reperfusion pulmonary edema (23.4% vs. 26.3% across all sessions) and other complications, such as contrast dye-induced nephropathy (0% vs. 2.0%), infection (0% vs. 0%), and neurological complications (0% vs. 1.0%), was comparable in the younger vs. elderly groups (P>0.05 for all). One-year all-cause mortality was similar in the younger and elderly groups (0% vs. 3.2%, respectively; P>0.05). ConclusionsPTPA can be performed safely and effectively, even in elderly patients, and could be considered as an alternative therapeutic strategy for elderly patients who are too fragile for pulmonary endarterectomy (PEA) or who are treated in institutions without highly experienced PEA surgeons.

Catheter-based therapies for deep vein thrombosis.

The basic treatment of deep vein thrombosis (DVT) over the past several decades has consisted of anticoagulation only, with inferior vena cava filtration for those who either failed or could not tolerate anticoagulation. Until recently no randomized trials had studied the efficacy of thrombolysis in DVT despite advances in techniques and technologies for endovascular clot removal. This article is a review of the current evidence on catheter-based therapies for patients with DVT. Technical considerations to improve outcome as well as optimal patient selection are discussed.

A new era of therapeutic strategies for chronic thromboembolic pulmonary hypertension by two different interventional therapies; pulmonary endarterectomy and percutaneous transluminal pulmonary angioplasty.

BackgroundPulmonary endarterectomy (PEA) is established for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). Recently, percutaneous transluminal pulmonary angioplasty (PTPA) has been added for peripheral-type CTEPH, whose lesions exist in segmental, subsegmental, and more distal pulmonary arteries. A shift in clinical practice of interventional therapies occurred in 2009 (first mainly PEA, later PTPA). We examined the latest clinical outcomes of patients with CTEPH.Methods and ResultsThis study retrospectively included 136 patients with CTEPH. Twenty-nine were treated only with drug (Drug-group), and the other 107 underwent interventional therapies (Interventions-group) (39 underwent PEA [PEA-group] and 68 underwent PTPA [PTPA-group]). Total 213 PTPA sessions (failures, 0%; mortality rate, 1.47%) was performed in the PTPA-group (complications: reperfusion pulmonary edema, 7.0%; hemosputum or hemoptysis, 5.6%; vessel dissection, 2.3%; wiring perforation, 0.9%). Although baseline hemodynamic parameters were significantly more severe in the Interventions-group, the outcome after the diagnosis was much better in the Interventions-group than in the Drug-group (98% vs. 64% 5-year survival, p<0.0001). Hemodynamic improvement in the PEA-group was a 46% decrease in mean pulmonary arterial pressure (PAP) and a 49% decrease in total pulmonary resistance (TPR) (follow-up period; 74.7±32.3 months), while those in the PTPA-group were a 40% decrease in mean PAP and a 49% decrease in TPR (follow-up period; 17.4±9.3 months). The 2-year survival rate in the Drug-group was 82.0%, and the 2-year survival rate, occurrence of right heart failure, and re-vascularization rate in the PEA-group were 97.4%, 2.6%, and 2.8%, and those in the PTPA-group were 98.5%, 2.9%, and 2.9%, respectively.ConclusionThe patients who underwent interventional therapies had better results than those treated only with drugs. The availability of both of these operative and catheter-based interventional therapies leads us to expect the dawn of a new era of therapeutic strategies for CTEPH.

The relationship between the percentage of lung shunting on Tc-99m macroaggregated albumin (Tc-99m MAA) scan and the grade of hepatocellular carcinoma vascularity

BackgroundHepatocellular carcinoma (HCC) stands for the majority of primary liver malignancy. HCC has variable grade of vascularity according to the histological tumor grade and underlying liver damage. Yttrium-90 radioembolization is a promising catheter-based hepatic intra-arterial therapy for HCC that necessitates proper planning. Technetium-99m macroaggregated albumin (Tc-99m MAA), a simulation of the treatment, is used to identify the shunting of microspheres to the lungs or gastrointestinal tract. ObjectiveTo evaluate the relationship between the percentage of lung shunting on Tc-99m MAA scan performed in treatment planning of Yttrium-90 (Y-90) microsphere selective internal radiation therapy (SIRT) for HCC and the grade of tumor vascularity shown on digital subtraction hepatic angiography. Materials and methodsThis study was conducted on 19 patients diagnosed to have HCC, based on typical computed tomography (CT) criteria and/or elevated alpha-fetoprotein (AFP) ⩾200ng/ml, and planned for Y-90 therapy. They were injected by Tc-99m MAA into the hepatic arterial territory with prior digital subtraction angiography. Tc-99m MAA scan was reviewed for extrahepatic shunting within the abdomen. Additionally, the hepatopulmonary shunt (HPS) fraction or the lung shunting (LS) percentage was calculated and further evaluated in relation to the grade of tumor vascularity shown on digital subtraction hepatic angiography. ResultsThere was no extrahepatic accumulation of Tc-99m MAA related to umbilical, gastroduodenal or splenic shunting. The LS percentage assorted among patients and ranged between 0.8% and 42.9% with a median of 5.5%. LS more than 20% occurred in only 1 patient. Subsequent therapy plan was changed accordingly in 5% of patients. The more vascular the lesion was, the higher lung shunting percentage was detected. ConclusionTc-99m MAA scan is fundamental prior to Y-90 microsphere SIRT as it minimizes the risk of post-radioembolization complications, hence, enhancing the safety of Y-90 microsphere subsequent administration. Moreover, the percentage of lung shunting varies considerably among patients with HCC relying on the grade of tumor vascularity.

PM445 Dextrocardia in Adults with Congenital Heart Disease (CHD)

O ST E R A B ST R A C T S with typical Wolff-Parkinson-White syndrome occurring in 5 patients (9%). Eleven patients (21%) underwent catheter-based ablation therapy (with long term relief from arrhythmia in 8) and 4 patients (8%) required pacemaker implantation. Fifteen patients (28%) underwent tricuspid valve (TV) surgery (10 repair and 5 valve replacement). Seven patients had anti-arrhythmia surgery at the time of TV surgery. Four patients required redo TV surgery. Small LV, defined as end–diastolic diameter less than 40 mm in adulthood, was present in 21 cases (40%). One patient died of cardiogenic shock during follow up. Conclusion: EA in adulthood often has severe morphological abnormalities but is compatible with good medium-term survival, with a conservative approach to the indications for interventions. Disclosure of Interest: None Declared

PM444 Increased Cardiac Output During Exercise and Reduced Pulmonary Regurgitation in Adults with Repaired Tetralogy of Fallot

O ST E R A B ST R A C T S with typical Wolff-Parkinson-White syndrome occurring in 5 patients (9%). Eleven patients (21%) underwent catheter-based ablation therapy (with long term relief from arrhythmia in 8) and 4 patients (8%) required pacemaker implantation. Fifteen patients (28%) underwent tricuspid valve (TV) surgery (10 repair and 5 valve replacement). Seven patients had anti-arrhythmia surgery at the time of TV surgery. Four patients required redo TV surgery. Small LV, defined as end–diastolic diameter less than 40 mm in adulthood, was present in 21 cases (40%). One patient died of cardiogenic shock during follow up. Conclusion: EA in adulthood often has severe morphological abnormalities but is compatible with good medium-term survival, with a conservative approach to the indications for interventions. Disclosure of Interest: None Declared

Ultrasound-assisted thrombolysis for acute pulmonary embolism: a systematic review

Pulmonary embolism remains a common and potentially life-threatening disease. For patients with intermediate- and high-risk pulmonary embolism, catheter-based revascularization therapy has emerged as potential alternative to systemic thrombolysis or surgical embolectomy. Ultrasound-assisted catheter-directed thrombolysis is a contemporary catheter-based technique and is the focus of the present review. Ultrasound-assisted catheter-directed thrombolysis is more effective in reversing right ventricular dysfunction and dilatation in comparison with anticoagulation alone in patients at intermediate risk. However, a direct comparison of ultrasound-assisted thrombolysis with systemic thrombolysis or surgical thrombectomy is not available. Ultrasound-assisted thrombolysis with initial intrapulmonary thrombolytic bolus may also be effective in high-risk patients, but evidence from randomized trials is not available. This review summarizes current data on ultrasound-assisted thrombolysis for acute pulmonary embolism.

Left Atrial Fibrosis by Late Gadolinium Enhancement Cardiovascular Magnetic Resonance Predicts Recurrence of Atrial Fibrillation After Pulmonary Vein Isolation

Atrial fibrillation (AF) is the most common sustained arrhythmia with 3 to 6 million currently afflicted and the prevalence expected to double by 2050.1 AF carries an increased risk of cardiovascular morbidity and mortality driven largely by increased risk of stroke and congestive heart failure.1 Management of AF represents a significant and growing healthcare burden, with an estimated cost of $6.65 billion in 2005 and likely doubling by 2020.2 Article see p 23 Treatment of AF historically consists of anticoagulation to reduce the incidence of clinical stroke followed by either rate control or rhythm control. Both choices have been shown to produce similar outcomes (Atrial Fibrillation Follow-up Investigation of Rhythm Management [AFFIRM]),3 and thus rhythm control has been recommended for those who are symptomatic. Until recently, rhythm control had been most commonly achieved with the use of repeated cardioversions and antiarrhythmic therapy—many of which have undesirable side effects and potential toxicities.4 Surgical treatment using the Maze procedure (and its many modifications) makes physiological sense (interfering with the macroreentrant circuit in the atria) but is quite invasive. The advent of catheter-based therapies for rhythm management of AF has revolutionized the electrophysiological field and provides a less invasive approach similar to the surgical Maze procedure goals. Pulmonary vein isolation (PVI), the most commonly used catheter-based technique, aims to electrically isolate the pulmonary veins, a major source of ectopy that may trigger AF,5 using catheter-based mapping and ablation tools.6 Despite the excitement and ensuing enormous industry growth in this field, PVI has been met with mixed long-term success with concerns of both short-term safety and long-term efficacy. As a result, treatment guidelines remain controversial.6,7 Several studies have demonstrated clinical features that predict long-term PVI success, including paroxysmal over persistent or permanent AF.8 …

Latest advances in transseptal structural heart interventions-Percutaneous Mitral Valve Repair and Left Atrial Appendage Occlusion.

Recent advances in structural heart intervention have produced increasing demand for transseptal access, which was first introduced as a diagnostic tool to directly measure left atrial pressure. Transseptal access allows safe and adequate approach to the left atrium and surrounding structures. Percutaneous transcatheter mitral valve repair using the MitraClip device is a safe and less invasive treatment for selected patients with significant mitral regurgitation, who are at high risk for surgery. This is an echocardiographic- and fluoroscopic-guided procedure requiring accurate transseptal access of the left atrium and clipping of the mitral leaflets at the precise location of their malcoaptation. Percutaneous transcatheter closure of the left atrial appendage is another novel procedure that requires transseptal access of the left atrium, followed by closure or ligation of the left atrial appendage. This catheter-based therapy has been shown to be a safe and effective alternative to long-term anticoagulant therapy for the prevention of stroke in patients with atrial fibrillation. In this article, we systematically review these novel structural heart interventions.

Ventricular tachycardia in ischemic heart disease substrates

Advances in the treatment of myocardial infarction (MI) have improved survival after ischemic cardiac injury. Post-infarct structural and functional remodeling results in electrophysiologic substrates at risk for monomorphic ventricular tachycardia (MMVT). Characterization of this substrate using a variety of clinical and investigative tools has improved our understanding of MMVT circuits, and has accelerated the development of device and catheter-based therapies aimed at identification and elimination of this arrhythmia. This review will discuss the central role of the ischemic heart disease substrate in the development MMVT. Electrophysiologic characterization of the post-infarct myocardium using bipolar electrogram amplitudes to delineate scar border zones will be reviewed. Functional electrogram determinants of reentrant circuits such as isolated late potentials will be discussed. Strategies for catheter ablation of reentrant ventricular tachycardia, including structural and functional targets will also be examined, as will the role of the epicardial mapping and ablation in the management of recurrent MMVT.

Abstract 18857: Outcomes of Surgical Aortic Valve Replacement in Intermediate Risk Octogenarians: Insight From a Prospective Clinical Study

Introduction: Aortic valve replacement approaches have shifted towards catheter-based therapies in older patients. While this strategy is appropriate in extreme risk cases, concerns regarding aortic insufficiency(AI)/paravalvular leak and stroke with catheter valves may favor use of surgical aortic valve replacement in intermediate and low risk patients. We present outcomes of intermediate risk octogenarian patients undergoing surgical aortic valve replacement enrolled in a prospective trial with robust endpoint assessment and follow-up. Methods: The St. Jude Trifecta IDE trial was a prospective approval study for a new aortic valve prosthesis. The Trifecta bioprosthesis was implanted in 210 pts over 80 years of age between 2007 and 2009 at 28 centers in the US, Canada, and Europe. Mean age was 83.5 ± 2.7 years(range 80-95) of which 103[49.0%] were female. 62[29.5%] subjects had undergone previous cardiac surgery. Concomitant CABG was performed in 103 [49.0%] patients. Results: The mean STS predicted mortality score was 4.02 +/- 2.16. Follow-up was 399.4 late patient-years. Early (≤ 30 day) mortality occurred in 3 [1.4%] patients and there were 17 late (≥ 31 days) deaths yielding a survival of 91.7% at 2 years and 87.1% at 3 years. There was no paravalvular leak, valve thrombosis, early endocarditis or hemolysis. There were 7 early neurologic events including 2 [1.0%] strokes, and 5 [2.4%] reversible neurologic events. There were 9 late thromboembolic events, including 3 strokes and 6 reversible neurologic events or transient ischemic attacks (linearized rate 2.25%/year of follow-up). Freedom from valve explant was 99.4% at 3 years. Mean gradient and effective orifice area at 3 year follow-up was 10.2 mmHg +/- 5.0 and 1.43 cm2 +/- 0.26, respectively. 88.9% of patients demonstrated none or trivial AI, 2.2% and 0% demonstrated moderate and severe AI, respectively. Conclusions: In conclusion, surgical valve replacement in elderly intermediate risk patients demonstrates superb clinical outcomes and results. Extremely low rates of stroke and aortic insufficiency in combination with excellent 3-4 year survival show a favorable profile for intermediate risk patients to undergo surgical aortic valve replacement.

TCT-498 Safety and performance of the next generation EnligHTN(tm) Renal Denervation System in patients with drug-resistant, uncontrolled hypertension: a first-in-human multicentre study

Catheter-based renal artery denervation therapy has become established as a therapeutic option in patients with resistant hypertension. We have previously presented safety and efficacy using the first generation multi-electrode renal denervation system with the EnligHTN(tm) catheter (St. Jude

Acute ischemic stroke with medial cerebral artery hyperdense sign — /INS;Comparison of intravenous thrombolysis and catheter-based therapy: A pilot study

Acute ischemic stroke with medial cerebral artery hyperdense sign — /INS;Comparison of intravenous thrombolysis and catheter-based therapy: A pilot study

Feasibility of blind aortic catheter placement in the prehospital environment to guide resuscitation in cardiac arrest

Aortic catheter-based resuscitation therapies are emerging with laboratory investigations showing benefit in models of trauma-related noncompressible torso hemorrhage and nontraumatic cardiac arrest. For these investigational aortic catheter-based therapies to reach their greatest potential clinical benefit, the ability to initiate them in the prehospital setting will be important. Feasibility of prehospital aortic catheterization without imaging capability supports this potential and is described in this report. A physician prehospital response system was created in cooperation with the local emergency medical services system to provide invasive hemodynamic monitoring during cardiac arrest. Physicians were dispatched to all known or suspected prehospital cardiac arrests covered by the emergency medical services system. Physicians responded with a specialized vascular catheterization pack and a monitor with invasive pressure monitoring capability. The physicians performed blind thoracic aortic and central venous catheterizations in cardiac arrest patients in the prehospital setting to measure coronary perfusion pressure, to optimize closed-chest cardiopulmonary resuscitation technique, and to administer intra-aortic epinephrine. During a 2-year period, 22 medical cardiac arrest patients underwent prehospital invasive hemodynamic monitoring to guide resuscitation. Most patients had both aortic and central venous catheters inserted. The combination of intra-aortic epinephrine and adjustments in closed-chest cardiopulmonary resuscitation technique resulted in improved coronary perfusion pressure. Return of spontaneous circulation with survival to hospital admission was achieved in 50% (11 of 22) of these patients. This report demonstrates the feasibility of successful blind aortic and central venous catheterizations in the prehospital environment and supports the potential feasibility of other emerging aortic catheter-based resuscitation therapies.

GW24-e3091 The perioperative role of the echocardiography in left ventricular-right atrium shunt (Gerbode defect)

ObjectivesLeft ventricular-right atrium (LV-RA) shunt (Gerbode defect), is a rare type of ventricular septal defect. The purpose of this study was to discuss the role of the echocardiography in LV-RA...

Setting Priorities for Stroke Care and Research

Recent publications describing the sobering global increase in stroke mortality and global life years lost due to stroke despite improvements in developed countries have drawn focus on the severe impact of stroke in the developing world. At the same time, three recent interventional trials that failed to demonstrate an important role for catheter-based therapies in acute stroke have called into question this expensive use of technology. Coupling all of this new data leads to the natural conclusion that a focus on stroke prevention for the developing world, and for the poor in developed countries, should be where we set our priorities for the foreseeable future.

90 Y radioembolization versus chemoembolization in the treatment of hepatocellular carcinoma: an analysis of comparative effectiveness

Locoregional catheter-based therapies for unresectable hepatocellular carcinoma (HCC) include conventional transarterial chemoembolization (cTACE), drug-eluting bead chemoembolization and yttrium-90 ((90)Y) radioembolization. Although current guidelines recommend cTACE for inoperable HCC, comparative effectiveness of drug-eluting bead chemoembolization and (90)Y radioembolization in the management of HCC remains undefined due to the lack of data evaluating safety and effectiveness among these therapies. A comprehensive search of the literature was carried out for studies examining comparative effectiveness of cTACE and (90)Y based on objective tumor response and overall patient survival. Further data on efficacy, safety, toxicity and cost-effectiveness was also examined. The National Cancer Institute Levels of Evidence for Cancer Treatment Studies provided a useful framework for the critical understanding and stratification of current evidence on locoregional therapy for unresectable HCC. Based on current retrospective cohort studies, evidence for similar efficacy and safety between cTACE and (90)Y radioembolization was demonstrated. Further prospective, randomized studies are required to validate these observations and to analyze cost-effectiveness of these interventions in unresectable HCC patients for definitive recommendations to be made.