Diagnostic Catheterization Research Articles

Initial experience with a novel re-sterilisable decapolar electrophysiology catheter.

Diagnostic electrophysiology catheters are single-use and their expense can act as a barrier to their use. A decapolar catheter with a re-sterilisable handle and inner core was developed, along with a disposable outer sheath. This initial experience evaluated the performance of the Khelix partially recyclable steerable decapolar electrophysiology catheter. Sequential patients requiring a decapolar steerable catheter were included in the study. Parameters such as time to positioning from right femoral vein, fluoroscopy time and dose, pacing and sensing thresholds, and the requirement for reposition and/or support sheath were recorded. A retrospective analysis from cases using a standard disposable decapolar catheter was used to compare CS cannulation success, support sheath requirement and cost. 11 re-sterilisable catheter handles were used in 64 patients, each time with a disposable sheath, at two New Zealand centres from December 2017 to June 2018. Pre-defined safety measures were met in all patients, with no catheter-related adverse events. The catheter was successfully positioned in the coronary sinus for 59 cases (92%). Based on initial manufacturer recommendations, the inner recyclable portion of the catheter was able to be re-used successfully up to 12 times with re-sterilisation between cases. This initial study of an innovative, partially reusable, steerable decapolar electrophysiology catheter demonstrates that it may be used safely and successfully. Use of such a catheter may decrease the cost required for electrophysiology studies.

Przezskórna interwencja wieńcowa z dostępu przez tętnicę udową w obrębie nieprawidłowej prawej tętnicy wieńcowej przeprowadzona za pomocą cewnika diagnostycznego 5 F TIG

Anomalous coronary arteries, especially when they are right with a high take-off, are challenging substrates for percuta- neous coronary intervention (PCI). Here, we report the case of a 63 year-old female who had a critical lesion in proximal anomalous right coronary artery having an abnormal take-off, where the ostium failed to get cannulated using multiple guiding catheters. Successful PCI was done using a 5 F TIG diagnostic catheter (Optitorque, Terumo, Japan) through the transfemoral route. The unique shape of the TIG diagnostic catheter allowed coaxial engagement of anomalous right coronary artery, with adequate lesion assessment and stent delivery.

Catheter-Related Venous Thrombosis in Pulmonary Arterial Hypertension Patients on Intravenous Prostacyclin Therapy

Rationale: Intravenous prostacyclin (PG) therapies are used for managing severe pulmonary arterial hypertension (PAH). Most PAH patients respond to PG therapies, but some experience complications associated with presence of indwelling catheters. We observed development of venous thromboses in patients and present our experience. Methods: A retrospective chart review of PAH patients on long-term intravenous PG therapy was conducted between 2008 and 2017.Demographic, hemodynamic, six-minute walk distance (6MWD), WHO/NYHA functional class (FC) and outcome data were collected. Results: Six of 63 patients on intravenous PG therapy were identified with venous thromboses. Mean age was 44±15 years (mean ±SD, range 31 to 70 years). All patients were female. Duration of PAH diagnosis 15±7 years; duration of IV PG therapy7.4±3.8 years. One patient had antiphospholipid antibody syndrome; hypercoagulable workup was negative for other five patients. Diagnostic right heart catheterization showed mean pulmonary artery pressure of 53.6±5.4 mmHg and thermodilution cardiac output was 4.94±1.4 l/min. Echocardiogram showed RAP of 8.3±6 mmHg. Development of thrombosis occurred 4±2 years after initiation of therapy. most common site of thrombosis was subclavian vein followed by femoral vein. All patients were on anticoagulation therapy with warfarin or a novel oral anticoagulation agent prior to development of thrombosis. Because of repeated catheter infections and poor vascular access, two of three patients were successfully transitioned to oral therapies without significant change in FC. Conclusion: A small percentage of patients on intravenous PG therapy for PAH develop thrombosis in areas of venous access. There does not appear to be a difference in occurrence of thrombosis in patients who have idiopathic PAH or associated PAH. Anticoagulation did not prevent initial or subsequent thrombosis. Development of recurrent thrombosis limits vascular access available for infusion of intravenous PG, thereby necessitating transition to alternative therapy. Transitioning off intravenous PG could affect patient's symptoms and FC. Funding Statement: authors state that no funding was received for this research. Declaration of Interests: authors state: The authors have no conflicts to disclose. Ethics Approval Statement: A waiver of consent was granted by the Institutional Review Board.

X-ray fused with MRI guidance of pre-selected transcatheter congenital heart disease interventions.

To determine whether X-ray fused with MRI (XFM) is beneficial for select transcatheter congenital heart disease interventions. Complex transcatheter interventions often require three-dimensional (3D) soft tissue imaging guidance. Fusion imaging with live X-ray fluoroscopy can potentially improve and simplify procedures. Patients referred for select congenital heart disease interventions were prospectively enrolled. Cardiac MRI data was overlaid on live fluoroscopy for procedural guidance. Likert scale operator assessments of value were recorded. Fluoroscopy time, radiation exposure, contrast dose, and procedure time were compared to matched cases from our institutional experience. Forty-six patients were enrolled. Pre-catheterization, same day cardiac MRI findings indicated intervention should be deferred in nine patients. XFM-guided cardiac catheterization was performed in 37 (median age 8.7 years [0.5-63 years]; median weight 28 kg [5.6-110 kg]) with the following prespecified indications: pulmonary artery (PA) stenosis (n = 13), aortic coarctation (n = 12), conduit stenosis/insufficiency (n = 9), and ventricular septal defect (n = 3). Diagnostic catheterization showed intervention was not indicated in 12 additional cases. XFM-guided intervention was performed in the remaining 25. Fluoroscopy time was shorter for XFM-guided intervention cases compared to matched controls. There was no significant difference in radiation dose area product, contrast volume, or procedure time. Operator Likert scores indicated XFM provided useful soft tissue guidance in all cases and was never misleading. XFM provides operators with meaningful three-dimensional soft tissue data and reduces fluoroscopy time in select congenital heart disease interventions.

Prevalence and risk factors of sleep apnea in adult patients with congenital heart disease.

Although sleep apnea is an important disorder associated with cardiac events, data regarding its prevalence and risk factors in adult patients with congenital heart disease are limited. In this study, patients underwent a sleep study in the hospital. Indications for admission were classified as heart failure, diagnostic catheterisation, interventional catheterisation, or arrhythmia. The prevalence, characteristics, and risk factors of sleep apnea using a type-3 portable overnight polygraph in adult patients with congenital heart disease were evaluated. There were 104 patients [median age: 36 (interquartile range: 28-48) years] who were admitted for heart failure 34% (n = 36), diagnostic catheterisation 26% (n = 27), interventional catheterisation 18% (n = 19), or arrhythmia 22% (n = 23). The prevalence of sleep apnea, defined as a respiratory disturbance index ≥5, was 63% (n = 63), with a distribution of 37%, 16%, and 10% for mild (5≤ respiratory disturbance index <15), moderate (15≤ respiratory disturbance index <30), and severe (respiratory disturbance index ≥30) sleep apnea, respectively. A large majority of the sleep apnea cases were categorised as obstructive sleep apnea (92%, n = 58). The respiratory disturbance index ≥15 group had a significantly higher proportion of male patients and higher body mass index, noradrenaline level, and aortic blood pressure than the group without sleep apnea (respiratory disturbance index <5). Multivariable analysis showed that New York Heart Association class ≥II (OR, 4.36; 95% CI, 1.09-20.87) and body mass index ≥25 (OR, 4.29; 95% CI, 1.32-15.23) were independent risk factors for a respiratory disturbance index ≥15. Our results showed a high prevalence of sleep apnea in adult patients with congenital heart disease. Its unique haemodynamics may be associated with a high prevalence of sleep apnea. Congestive heart failure and being overweight are important risk factors for sleep apnea. Management of heart failure and general lifestyle improvements will be important for controlling sleep apnea symptoms in these patients.

Locating Atrial Fibrillation Rotor and Focal Sources Using Iterative Navigation of Multipole Diagnostic Catheters

PurposeMulti-polar diagnostic catheters are used to construct the 3D electro-anatomic mapping of the atrium during atrial fibrillation (AF) ablation procedures; however, it remains unclear how to use the electrograms recorded by these catheters to locate AF-driving sites known as focal and rotor source types. The purpose of this study is to present the first algorithm to iteratively navigate a circular multi-polar catheter to locate AF focal and rotor sources without the need to map the entire atria.MethodsStarting from an initial location, the algorithm, which was blinded to the location and type of the AF source, iteratively advanced a Lasso catheter based on its electrogram characteristics. The algorithm stopped the catheter when it located of an AF source and identified the type. The efficiency of the algorithm is validated using a set of simulated focal and rotor-driven arrhythmias in fibrotic human 2D and 3D atrial tissue.ResultsOur study shows the feasibility of locating AF sources with a success rate of greater than 95.25% within average 7.56 ± 2.28 placements independently of the initial position of the catheter and the source type.ConclusionsThe algorithm could play a critical role in clinical electrophysiology laboratories for mapping patient-specific ablation of AF sources located outside the pulmonary veins and improving the procedure success.

Radial Approach for Left Gastric Artery Angiography and Embolization for the Treatment of Obesity: Technical Considerations.

Bariatric embolization of the left gastric artery (LGA) is being investigated as a technique to induce substantial weight loss in obese patients. Radial access is associated with less vascular complications than femoral access, especially in patients with severe obesity. We sought to assess the feasibility, safety and technical challenges of LGA angiography through radial access. Patients with suspected coronary artery disease (CAD) and obesity (BMI > 30 kg/m2) referred for diagnostic catheterization and/or percutaneous coronary intervention (PCI) were eligible. After completion of diagnostic and/or PCI, selective cannulation of celiac artery was performed and images of the LGA were taken from multiple views. Detailed procedural parameters such as procedure time, contrast volume and radiation data as well as anatomical variations were assessed. Between February and December 2018, we successfully achieved 50 selective angiographies of celiac artery from 54 enrolled patients (92.6%) and LGA was optimally visualized in 47/50 (97%) of cases. Right radial access was used in 50 cases. Mean age was 63.9 ± 8.0 years and 74% were men. Median BMI was 34.4 kg/m2 [32.2-39.4]. The median procedural time was 7 [5-10] minutes, contrast volume was 41 ml [33-63], fluoroscopy time was 160 [103-248] seconds and radiation exposure was 3125 [1906-4735] Gy.cm2. No complications were noted. The mean difficulty of the procedure on a visual analogue scale was 4/10. LGA angiography via transradial approach was feasible in the large majority of CAD patients with obesity. No safety issues were encountered.

Wygięcie cewnika typu „pętli kobry” w obrębie odejścia tętnicy bezimiennej od łuku aorty w trakcie cewnikowania z dostępu przez tętnicę promieniową — fluoroskopowe wskaźniki tętnicy błądzącej

The retroesophageal right subclavian artery (ROSRA; arteria lusoria) is one of the anatomical abnormalities encountered at innominate-arch junction during transradial catheterization by right route. Here, we report a case of a 49-year old female who presented with chronic stable angina (Canadian Cardiovascular Society class-III) despite guideline directed medical treatment. Coronary arteries were cannulated with difficulty showing critical lesion of proximal left anterior descending artery (LAD). During angiography, diagnostic catheter has a peculiar cobra loop in the ascending aorta. As the left subclavian artery also has critical lesion at the proximal part, percutaneous coronary intervention of proximal LAD artery was successfully performed with 3.5×23 mm Xience Prime Everolimus eluting stent (Abott, USA) through right femoral route. Multi detector computed tomography (MDCT) contrast aortography showed the origin of the right subclavian artery in the right posterior side of the horizontal aorta with a tortuous course, proximal stenosis of left subclavian artery (LSC), and a bicarotid truncus. This abnormality can be easily detected by angiographic visualization, in the anteroposterior projection, of the angle of the catheter when it engages the ascending aorta, and by manual angiography at the ostium of the right subclavian artery. In such a case, selective catheterization of both coronary arteries may be very difficult, time consuming, and require more catheters. In such cases, one should not be hesitant to switch to transfemoral route if left radial route cannot be utilised.

Heart catheterization in adults in a sub-Saharan tertiary centre: 8 years' experience.

The goal of the investigation was to analyze the results of heart catheterization in the Cardiac centre Shisong from December 2010 till December 2017. This retrospective study done in the Cardiac centre Shisong in adult patients that underwent a procedure in the catheterization laboratory from December 2010 till December 2017. Three hundred and sixty-five adult underwent a cardiac catheterization procedure during the study period. Among the patients, 126 were female while 239 were male. The mean age at presentation was 52.6±12.9 years old. Patients were coming from neighboring countries: Nigeria n=5 (1.3%), Tchad n=3 (0.8%), Equatorial Guinea n=4 (1%), Democratic republic of Congo n=2 (0.5%). Patients were also coming from all the ten regions of Cameroon: Littoral n=122 (33.2%), Centre n=127 (34.8%), North west n=47 (12.9%), South west n=17 (4.5%), West n=26 (7.1%), North n=7 (1.8%), Adamaoua n=8 (2.1%), Far North n=5 (1.3%), South n=2 (0.5%), East n=4 (1%). Depending on the type of procedures diagnostic coronarography in case with suspicion of coronary artery disease and presurgical coronarography were the main procedures done in 171 patients (46.8%) and in 146 patients (40%) respectively. Diagnostic coronarography was positive in 31 cases (8.4%). In patients with ischemic heart disease (IHD), percutaneous intervention with dilatation of the coronary arteries and implantation of stents was done in 19 cases (5.2%). The remaining 12 cases (3.2%) were having many lesions that could be managed only by coronary artery grafting surgery, done with success in all the cases. In grown up congenital heart disease patients, diagnostic catheterization was done in 48 cases meanwhile interventional catheterization: pulmonary artery valvuloplasty, patent ductus arteriosus (PDA) closure, atrial septal defect closure and decoarctation of the aorta were done in n=11 (3.4%), n=9 (2.4%), n=12 (3.2%), n=6 (1.6%) cases respectively. Coronary heart disease was confirmed by angiography in 8.4% cases, and among grown up congenital heart disease 'patients, atrial septal defect was the pathology the most managed. Heart catheterization is done in the Cardiac centre Shisong with good results.

Olağan Dışı Yerleşimli Yalancı Anevrizmalar: Yüzeyel Palmar Ark ve Yüzeyel Temporal Arter

Peripheral pseudoaneurysms mostly occur owing to diagnostic catheterization but rarely owing to blunt or penetrating trauma, infection, or recurrent microtrauma. They appear as a soft pulsatile mass. Complications may occur owing to rupture or distal embolization. Doppler ultrasound and computed tomography are the imaging techniques used in diagnosis. Endovascular interventions and surgery are among the treatment options. In this report, we present two unusually located pseudoaneurysms, one in the superficial palmar arch following penetrating trauma and another in the superficial temporal artery following blunt trauma.

Angioplasty with Stenting in Acute Coronary Syndromes with Very Low Contrast Volume Using 6F Diagnostic Catheters and Bench Testing of Catheters.

AIM:To safely perform angioplasties in acute coronary syndromes with low contrast volume using Cordis 6F diagnostic catheters and to perform mechanical bench tests on the diagnostic and guide catheters in a radial path model.METHODS:In 191 patients (242 lesions/268 stents) with acute coronary syndromes angioplasty were performed with cordis 6F diagnostic catheters.RESULTS:The lesions were present at left anterior descending (121), Left main (5), left circumflex (51), ramus (5) and right coronary artery (60). In 72% of cases, Iodixanol was used. All contrast injections were given by hand. Regular follow-up of the patients was performed at 30 days. The procedures were performed in the femoral route only. Pre-dilatation was performed in 43 cases. Successful revascularization of the target lesion was achieved in all cases. The mean contrast volume used per patient was 28 ml (± 8 ml). Mild reversible contrast-induced nephropathy (CIN) was observed in two patients. Cardiogenic shock was seen in 7 cases, and one death was observed. Pushability and trackability tests showed good force transmission and hysteresis in diagnostic catheters compared to guide catheters.CONCLUSIONS:Angioplasty with stenting could be performed safely in patients using cordis 6F diagnostic catheters using a low volume of contrast in acute coronary syndromes. Low contrast volume usage would result in a lower incidence of contrast-induced nephropathy and cardiac failures.

The Reuse of (Single-Use) Cardiac Disposable of Coronary Angiography and Angioplasty: Safety and Economic Issues in Gaza Strip

Most countries outside the United States routinely reuse disposable medical equipment. We investigated the reuse of puncture needle, wires, sheath, manifold, inflation device, diagnostic and angioplasty catheters restored by a process strictly controlled for bioburden and sterility, in patients undergoing diagnostic coronary angiography and PCI.

Cardiac Magnetic Resonance Imaging-Based Right Ventricular Strain Analysis for Assessment of Coupling and Diastolic Function in Pulmonary Hypertension

ObjectivesThis study sought to compare cardiac magnetic resonance (CMR) imaging-derived right ventricular (RV) strain and invasively measured pressure-volume loop-derived RV contractility, stiffness, and afterload and RV-arterial coupling in pulmonary hypertension (PH). BackgroundIn chronic RV pressure overload, RV-arterial uncoupling is considered the driving cause of RV maladaptation and eventual RV failure. The pathophysiological and clinical value of CMR-derived RV strain relative to that of invasive pressure-volume loop-derived measurements in PH remains incompletely understood. MethodsIn 38 patients with PH, global RV CMR strain was measured within 24 h of diagnostic right heart catheterization and conductance (pressure-volume) catheterization. Associations were evaluated by correlation, multivariate logistic binary regression, and receiver operating characteristic analyses. ResultsLong-axis RV longitudinal and radial strain and short-axis RV radial and circumferential strain were −18.0 ± 7.0%, 28.9% [interquartile range (IQR): 17.4% to 46.6%]; 15.6 ± 6.2%; and −9.8 ± 3.5%, respectively. RV-arterial coupling (end-systolic [Eds]/arterial elastance [Ea]) was 0.76 (IQR: 0.47 to 1.07). Peak RV strain correlated with Ees/Ea, afterload (Ea), RV diastolic dysfunction (Tau), and stiffness (end-diastolic elastance [Eed]) but not with contractility (Ees). In multivariate analysis, long-axis RV radial strain was associated with RV-arterial uncoupling (Ees/Ea: <0.805; odds ratio [OR]: 5.50; 95% confidence interval [CI]: 1.50 to 20.18), whereas long-axis RV longitudinal strain was associated with increased RV diastolic stiffness (Eed: ≥0.124 mm Hg/ml; OR: 1.23; 95% CI: 1.10 to 1.51). The long-axis RV longitudinal strain-to-RV end-diastolic volume/body surface area ratio strongly predicted RV diastolic stiffness (area under receiver operating characteristic curve: 0.908). ConclusionsIn chronic RV overload, CMR-determined RV strain is associated with RV-arterial uncoupling and RV end-diastolic stiffness and represents a promising noninvasive alternative to current invasive methods for assessment of RV-arterial coupling and end-diastolic stiffness in patients with PH. (Right Ventricular Haemodynamic Evaluation and Response to Treatment [Rightheart I]; NCT03403868)

Neurointerventional Procedural Complications in a Growing Canadian Regional Stroke Center: Single Hospital Experience Analysis in the Context of Recommended Case Volumes

Evidence continues to emerge regarding the inverse relationship between high neurointerventional case volume and complication rates, leading several medical/surgical societies to recommend minimum volumes for specific procedures. Recent data suggest few centers are meeting these requirements. We report a single center's neurointerventional complication rates with associated case volumes, along with a review of the literature. A retrospective cohort review of all consecutive patients undergoing diagnostic catheter cerebral angiography and/or neurointerventional procedures between January 1, 2013, and March 1, 2018, was undertaken. No diagnostic or interventional procedures were excluded. All major and minor complications were recorded. A total of 1000 procedures (463 diagnostic cerebral angiograms and 537 neurointerventional procedures) were completed. Of the neurointerventional procedures, 216 (40%) were endovascular thrombectomy, 170 (32%) were aneurysmal embolization, and 48 (9%) were carotid stenting. The mean and median age was 60 years. There were 460 women and 540 men. The total number of major complications for diagnostic angiography, endovascular thrombectomy, ruptured aneurysm embolization, unruptured aneurysm embolization, and carotid artery stenting were 4 (0.9%), 4 (1.9%), 10 (11%), 4 (5.4%), and 3 (6.3%), respectively. We provided a single-center experience of the relationship between neurointerventional procedural case volume and complication rates in the growth phase of our center's establishment. We demonstrated that as our center was being developed, specific procedural staffing measures allowed proficiency maintenance, acquisition of new techniques, and complication avoidance, whereas specific case volumes crossed the suggested thresholds as defined in the literature.

Impact of Transradial Catheterization on Vascular Function of the Brachial Artery Assessed by Flow-Mediated Dilatation.

Few studies have evaluated long-term vascular function after radial access catheterization. Furthermore, the impact of repeated catheterization remains unknown. We investigated flow-mediated dilatation (FMD) of the brachial artery after transradial catheterization. We prospectively enrolled 50 patients with suspected coronary artery disease referred for diagnostic coronary angiography. No ad-hoc percutaneous coronary interventions (PCI) had been performed at the time of the index procedure. In 30 patients (63.8%), PCI and/or repeated follow-up diagnostic catheterization were subsequently performed via the radial artery used at the index catheterization. FMD was successfully measured before catheterization, at 24 h after catheterization, and after long-term follow-up (mean, 32 months; range, 24-43) in 47 patients. FMD at follow-up was compared between patients receiving only one procedure and those receiving multiple procedures via the same arteries. FMD was significantly decreased after catheterization and recovered well in long-term follow-up (3.7 ± 1.6%, 3.0 ± 1.7%, and 3.9 ± 1.6%). There was no significant difference in follow-up FMD between the patients undergoing single catheterization and those with multiple procedures (3.4 ± 1.3 vs. 4.3 ± 1.7, p = 0.06). When the patients were divided into two groups according to the median follow-up FMD value, no significant predictive factor was identified for worse FMD. After transradial catheterization, FMD of the brachial artery temporarily decreased but recovered in long-term follow-up. Recovery of FMD was not jeopardized by repeated catheterization, which suggests the potential of the brachial artery to recover endothelial function after repeated transradial procedures.

Distal transradial artery access in the anatomical snuffbox for coronary angiography as an alternative access site for faster hemostasis.

This study investigated the feasibility, safety, and the potential benefit of faster hemostasis with the distal transradial artery access (TRA). TRA has been shown to be associated with lower bleeding and vascular complications. Limited data are available regarding the new technique of accessing the distal radial artery in the anatomical snuffbox. We retrospectively reviewed 202 consecutive patients who underwent coronary angiography and intervention with distal TRA. Two hundred and six conventional TRA cases were collected as a comparison arm. Out of 408 patients, successful distal radial access was obtained in 99.5% (201/202) in the distal TRA cases and 99.0% (204/206) in the conventional TRA cases. The rate of access site crossover was 2.0% (4/202) for distal TRA. Right distal radial artery was accessed in 176 cases (87.6%). Mean access time from local anesthesia to radial flush was 7.3 min. Ninety cases (44.8%) were percutaneous coronary interventions (PCIs) and the mean heparin dose used was 4,448 units (6,009 units for PCI and 3,182 units for diagnostic catheterization). Mean time to remove TR band was 104.7 min (120.8 min for PCI and 91.7 min for diagnostics). Follow-up ultrasound study showed two partial occlusions (1.0%) and one arteriovenous fistula (0.5%) that resolved with prolonged TR band inflation. Despite longer time to access the distal radial artery in the anatomical snuffbox, it is a safe and feasible alternative to conventional TRA and might result in shorter time to hemostasis especially in cases of PCI.

Iterative navigation of multipole diagnostic catheters to locate repeating-pattern atrial fibrillation drivers.

IntroductionTargeting repeating‐pattern atrial fibrillation (AF) sources (reentry or focal drivers) can help in patient‐specific ablation therapy for AF; however, the development of reliable and accurate tools for locating such sources remains a major challenge. We describe iterative catheter navigation (ICAN) algorithm to locate AF drivers using a conventional circular Lasso catheter.Methods and ResultsAt each step, the algorithm analyzes 10 bipolar electrograms recoded at a given catheter location and the history of previous catheter movements to determine if the source is inside the catheter loop. If not, it calculates new coordinates and selects a new position for the catheter. The process continues until a source is located. The algorithm was evaluated in a computer model of atrial tissue with various degrees of fibrosis under a broad range of arrhythmia scenarios. The latter included slow and fast reentry, macroreentry, figure‐of‐eight reentry, and fibrillatory conduction. Depending on the initial distance of the catheter from the source and scenario, it took about 3 to 16 steps to localize an AF source. In 94% of cases, the identified location was within 4 mm from the source, independently of the initial position of the catheter. The algorithm worked equally well in the presence of patchy fibrosis, low‐voltage areas, fragmented electrograms, and dominant‐frequency gradients.ConclusionsAF repeating‐pattern sources can be localized using circular catheters without the need to map the entire tissue. The proposed algorithm has the potential to become a useful tool for patient‐specific ablation of AF sources located outside the pulmonary veins.

Pulmonary artery interventions after the arterial switch operation: Unique and significant risks.

In the modern era, results of the arterial switch operation (ASO) for transposition of the great arteries are excellent. However, because of the LeCompte maneuver, there may be a propensity for development of pulmonary artery stenosis. We encountered atypical complications of pulmonary artery stenting in patients after the ASO, including aorto-pulmonary fistula and coronary compression. We performed a 10-year retrospective review of catheterizations performed in patients after ASO in our institution with a focus on adverse events. Diagnostic and interventional catheterizations were performed in 47 patients. In 29 patients, 37 interventional procedures performed, which included pulmonary artery angioplasty and/or stenting. In this group, there were five major adverse events (14%), including three aorto-pulmonary fistulae and one coronary artery compression among patients having stent implantation or stent redilation. In addition, there were 6/37 (16%) intended stent procedures, which were aborted because there appeared to be high-risk of significant adverse events. This review suggests that percutaneous intervention on pulmonary artery stenosis after ASO has high-risk and should be undertaken advisedly. Prior thorough evaluation of coronary arteries is mandatory as coronary reimplantation sites may be adjacent to sites of pulmonary artery stenosis. Furthermore, if pulmonary artery stent implantation or stent redilation is contemplated, the risk of stent fracture and possible AP fistula should be recognized. Primary use of reinforced covered stents should be considered.

Right-heart catheterization using antecubital venous access in patients with complex congenital heart defects and Glenn anastomosis.

Right-heart catheterization using the antecubital veins has recently regained attention, and studies demonstrating the feasibility and safety of antecubital access in adults have been published. However, no changes have been observed in the preferred entrance sites in right-heart catheterizations in children with congenital heart diseases. This article is a description of the technique and features of the antecubital venous approach in pediatric patients with complex congenital heart defects and a Glenn anastomosis. The data regarding a right cardiac catheterization through the antecubital fossa veins performed in 18 patients with various clinical indications between January 2014 and August 2017 were reviewed retrospectively and the results were assessed. Ten patients (55%) were male and 8 patients were female. All of the patients but 1 had a complex congenital heart disease with a Glenn anastomosis. One patient had been operated on for a sinus venosus atrial septal defect and an abnormal pulmonary venous return and had a total occlusion of the superior vena cava. A diagnostic catheterization was performed in all cases. Additional procedures consisted of a balloon test occlusion of the pulmonary valve in 2 patients, a superior vena cava-right pulmonary artery anastomosis dilatation in 1, and abnormal veno-venous collateral occlusion with various devices in 2 patients. The antecubital venous approach technique can be performed easily and safely for diagnostic and therapeutic catheterization in patients with complex congenital heart defects. The authors advocate that the antecubital venous approach should be the first site selected for right-heart catheterization, especially in patients with a Glenn anastomosis.

IMPACT Registry and National Pediatric Cardiology Quality Improvement Collaborative: Contributions to Quality in Congenital Heart Disease.

The IMproving Pediatric and Adult Congenital Treatments (IMPACT) Registry and the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) are two efforts initiated to improve outcomes in the congenital heart disease field. The IMPACT Registry is focused on evaluating the use, risks, adverse events (AEs), and outcomes associated with diagnostic and common interventional catheterization procedures in all children and adults with congenital heart disease. Utilizing a modular approach, the common procedures include diagnostic cardiac catheterization, atrial septal defect device closure, patent ductus arteriosus device closure, pulmonary valvuloplasty, aortic valvuloplasty, balloon and stent angioplasty of coarctation of the aorta, pulmonary artery balloon stent angioplasty, transcatheter pulmonary valve replacement, and electrophysiology procedures including radiofrequency ablation. To date, important observations on the common procedures have been made and a risk stratification methodology has been created to allow comparisons between centers in AEs and quality improvement activity. The registry is open to international participation. The NPC-QIC was developed to reduce mortality and improve the quality of life of infants with Hypoplastic Left Heart Syndrome (HLHS) during the interstage period between discharge from the Norwood operation and admission for the bidirectional Glenn procedure. Mortality in the interstage has been reduced by 44%. The IMPACT Registry and the NPC-QIC have demonstrated value to the congenital heart disease community. The IMPACT Registry, however, has not yet demonstrated an impact on patient outcomes. The NPC-QIC, which combines both a registry with a learning collaborative with specific aims, key drivers, and change strategies, has made more significant gains with reductions in variation, growth failures, and mortality.