Echo Guidance Research Articles

V-A ECMO weaning with pump-controlled retrograde trial off (PCRTO) approach: an illustration of safety, benefits and feasibility

Abstract Introduction Weaning cardiogenic shock patients off V-A ECMO is a crucial but difficult step in the management of these patients. Conventional weaning strategies reduce the ECMO flow to approximately 1 L/min, yet this still entails significant unloading of the cardiopulmonary circulation. Background The PCRTO technique enables controlled retrograde flow of oxygenated blood from the patient’s arterial side into the right ventricle, resulting in an incremental increase of 0.5 L/min in right ventricular preload. This process challenges and evaluates the entire cardiopulmonary system (Figure). Methods We prospectively examined the use of the Pump-Controlled Retrograde Trial Off (PCRTO) approach (-0.5 L/min) compared to conventional ECMO weaning (+1 L/min) in a cross over study including 14 V-A ECMO patients across three quaternary high-output cardiogenic shock centers. Both the conventional and the PCRTO-technique are performed under continuous cardiac echo and PA-catheter guidance. Results After achieving adequate anticoagulation levels (Xa>0.3), no thrombotic or other complications were observed, confirming 100% safety of this technique. Table 1 provides an overview of our PCRTO-cohort and their evaluation after conventional versus PCRTO weaning. In 43% (6/14) of our cohort, conventional weaning strategies determined feasibility of ECMO-device weaning, while ultimately failing with PCRTO due to e.g. right ventricular failure or oxygenation failure. In contrast, 4/14 patients who failed the conventional weaning showed a positive weaning potential with PCRTO, potentially enabling patients to be liberated from bridging to durable ventricular assist devices or heart transplant. Conclusions In conclusion, PCRTO is a safe weaning strategy that increases the likelihood of successful weaning in critically ill V-A ECMO patients by challenging oxygenation/ventilation and cardiac circulation through increased right ventricular preload and reduced left ventricular afterload. Here, PCRTO ultimately led to a different destination scenario in 78,5% of our patient cohort compared to conventional V-A ECMO weaning alone. PCRTO may provide a standardised, reproducible approach to ECMO assessment and liberation which will be useful for future clinical trials in this population.

First-in-Man Experience of Telerobotic Transcatheter Edge-to-Edge Repair With Pure Echo Guidance.

First-in-Man Experience of Telerobotic Transcatheter Edge-to-Edge Repair With Pure Echo Guidance.

First-in-Man Experience of Robotic-Assisted Transcatheter Edge-to-Edge Repair With Pure Echo Guidance

First-in-Man Experience of Robotic-Assisted Transcatheter Edge-to-Edge Repair With Pure Echo Guidance

B-17 | Feasibility of Transfemoral Venous Liver Biopsy with Intracardiac Echo Guidance in Fontan Patients

B-17 | Feasibility of Transfemoral Venous Liver Biopsy with Intracardiac Echo Guidance in Fontan Patients

Feasibility of a Percutaneous and Non-Fluoroscopic Procedure for Transcatheter Mitral Valve Edge-to-Edge Repair.

Transcatheter edge-to-edge repair (TEER) of the mitral valve has emerged as an alternative treatment for mitral regurgitation (MR). However, the high radiation exposure during the process has been associated with multiple adverse effects for medical staff. In this study, we assessed the feasibility and safety of TEER performed solely under the echocardiographic (echo) guidance. Between April 2021 to August 2021, we retrospectively collected characteristics of 23 patients with MR who underwent TEER under echocardiographic guidance exclusively. Follow-up evaluations were performed at 1- , 3-months and 1-year post procedure. All 23 patients (mean age, 66.1 12.1 years; 65.2% males) successfully underwent echo-guided TEER, with 22 patients under transesophageal echo (TEE) guidance and 1 patient under transthoracic echo (TTE) guidance for severe esophageal stenosis. Of the patients, 60.9% received 1 implant and 39.1% received 2 implants. The median total procedural time was 130 (interquartile range, IQR: 90-150) min and the device procedure time was 73 (IQR: 58-100) min. The median length of stay was 6 (IQR: 5-9) days. At 3-months follow-up, 63.6% of patients had an MR 1+ and 90.9% had an MR 2+ (p 0.001 vs. baseline). Improvement in functional status was observed, with 40.9% of patients classified as New York Heart Association (NYHA) functional class I and 45.5% as NYHA functional class II (p 0.001 compared to baseline) at 3-months. At 1-year follow-up, 90.4% maintained MR reduction with MR 2+ (p 0.001 vs. baseline). Single leaflet device attachment (SLDA) occurred in one patient (4.3%) 1-week post procedure. This retrospective, single-center, and pilot study demonstrates the feasibility, safety, and low complication rates of TEER guided solely by echocardiography. Our findings support the systematic use of echocardiography as the sole guidance modality for TEER, highlighting its potential as an alternative to fluoroscopy-guided procedures. Further multicenter and comparative studies are warranted to confirm these results and provide a more comprehensive evaluation of this approach.

Microinvasive mitral valve repair with transapical mitral neochordae implantation.

Microinvasive cardiac surgery includes procedures performed off-pump, on the beating heart, with limited or absent skin incision, and those that rely on live imaging techniques. Transapical off-pump beating heart neochordae implantation allows the repair of severe mitral valve regurgitation due to leaflet prolapse or flail with live three-dimensional echo guidance. This procedure has shown good results for up to 5 years and can be considered as a valid alternative to conventional surgery in selected patients with high prediction of success based on clinical and anatomical considerations. The aim of this review is to describe the devices, indications, patient screening process, clinical and echocardiographic results, and future perspectives of this procedure.

Minimalist transcatheter aortic valve replacement misses paravalvular regurgitation:Incidence and echocardiographic distribution of missed paravalvular regurgitation.

Paravalvular regurgitation (PVR) may be missed intraoperatively with transthoracic echocardiography (TTE) guided minimalist TAVR. We sought to determine the incidence and echocardiographic distribution of PVR missed on intra-op TTE, but detected on predischarge TTE. From July 2015 to 2020, 475 patients with symptomatic severe native aortic stenosis underwent TTE-guided minimalist TAVR. Missed PVR was defined as predischarge PVR that was ≥1 grade higher than the corresponding intra-op PVR severity. PVR was classified as anterior or posterior on the four standard TTE views; parasternal short-axis (PSAX), parasternal long-axis (PLAX), apical 3-chamber (A3C), and 5-chamber (A5C). Location-specific risk of missed PVR was then determined. Mild or greater PVR was seen in 55 (11.5%) cases intra-op and 91 (19.1%) at predischarge, with no severe PVR. Among the 91 patients with ≥mild predischarge PVR, missed PVR was present in 42 (46.2%). Compared to the corresponding anterior jets, missed PVR rate was significantly higher for posterior jets in PLAX (62.5% vs. 25.0%, p = 0.005), A5C (56.9% vs. 25.0%, p = 0.009), PSAX (66.7% vs. 24.3%, 0.001), but not A3C (58.5% vs. 40.0%, p = 0.28). Intraoperative TTE-guided minimalist TAVR either misses nearly half of ≥mild PVR or underestimates PVR by ≥1 grade when compared to predischarge TTE. Posterior PVR jets are more likely to be missed. Transesophageal echo guidance may help minimize missing PVR. Further studies are warranted.

Successful Fenestration of an Extracardiac Conduit in a Fontan Patient With the Baylis NRG RF Transeptal Needle and Creation of Fontan Fenestration with a 20-mm 535 Formula Stent

Successful Fenestration of an Extracardiac Conduit in a Fontan Patient With the Baylis NRG RF Transeptal Needle and Creation of Fontan Fenestration with a 20-mm 535 Formula Stent

Sciatic Nerve Intrafascicular Injection Induces Neuropathy by Activating the Matrix Modulators MMP-9 and TIMP-1.

Background: Peripheral nerve block (PNB) under echo guidance may not prevent intrafascicular anesthetic injection-induced nerve injury. This study investigated whether unintended needle piercing alone, or the intrafascicular nerve injectant could induce neuropathy. Methods: 120 adult male Sprague-Dawley rats were divided into four groups: 1) group S, only the left sciatic nerve was exposed; 2) group InF-P, the left sciatic nerve was exposed and pierced with a 30 G needle; 3) group InF-S, left sciatic nerve was exposed and injected with saline (0.9% NaCl 30 µL); 4) group InF-R, left sciatic nerve was exposed and injected with 0.5% (5 mg/mL, 30 µL) ropivacaine. Behaviors of thermal and mechanical stimuli responses from hindpaws, sciatic nerve vascular permeability and tight junction protein expression, and macrophage infiltration were assessed. Pro-inflammatory cytokine expression and TIMP-1 and MMP-9 activation at the injection site and the swollen, and distal sites of the sciatic nerve were measured by cytokine array, western blotting, and immunofluorescence of POh14 and POD3. Results: Intrafascicular saline and ropivacaine into the sciatic nerve, but not needle piercing alone, significantly induced mechanical allodynia that lasted for seven days. In addition, the prior groups increased vascular permeability and macrophage infiltration, especially in the swollen site of the sciatic nerve. Thermal hypersensitivity was induced and lasted for only 3 days after intrafascicular saline injection. Obvious upregulation of TIMP-1 and MMP-9 on POh6 and POh14 occurred regardless of intrafascicular injection or needle piercing. Compared to the needle piercing group, the ratio of MMP-9/TIMP-1 was significantly higher in the intrafascicular injectant groups at the injected and swollen sites of the sciatic nerve. Although no gross changes in the expressions of tight junction proteins (TJPs) claudin-5 and ZO-1, the TJPs turned to apparent fragmentation and fenestration-like degenerative change in swollen endothelial cells and thickened microvessels. Conclusion: Intrafascicular nerve injection is a distinct mechanism that induces neuropathy. It is likely that the InF nerve injection-induced neuropathy was largely due to dramatic, but transient, increases in enzymatic activities of MMP-9 and activating TIMP-1 in the operated nerves. The changes in enzymatic activities then contributed to certain levels of extracellular matrix degradation, which leads to increases in endoneurial vascular permeability.

Hemodynamic and Echocardiographic Assessment of Left Ventricle Recovery with Left Ventricular Assist Devices: Do We Explant?

<h3>Introduction</h3> Explantation of left ventricular assist devices (LVAD) after left ventricular (LV) recovery is estimated to occur in 1-2% of cases. Herein, we present a case of hemodynamic and echocardiographic assessment of LV recovery during outflow graft balloon occlusion leading to LVAD explantation. <h3>Case Report</h3> A 56-year-old female with medical history of systolic heart failure due to non-ischemic cardiomyopathy with LVEF 25%. She underwent an urgent HeartMate 3 LVAD implant after an admission for cardiogenic shock. Post LVAD course was complicated by driveline infection. History was notable for admissions due to low-flow alarms in the setting of dehydration. On echocardiogram, progressive LVEF improvement was noted although with suboptimal images. CT angiography did not demonstrate any occlusion of the cannulas. Right heart catheterization showed stable cardiac index despite minimal flow on LVAD. Cardiopulmonary testing was favorable. After multi-disciplinary discussion, patient underwent LVAD wean study in the cath lab under hemodynamic and transesophageal echo (TEE) guidance with therapeutic anticoagulation. LVAD was turned off for 10 minutes with outflow graft occluded by Armada 14 mm x 20 cm peripheral balloon. Wiring of the outflow graft from aorta and balloon occlusion were visualized by TEE (Figure). The left and right ventricular function were similar to baseline with no change in mitral regurgitation. Cardiac index was normal (Figure). Patient subsequently underwent successful LVAD explant. She is doing well with NYHA class I symptoms and LVEF 45-50% noted upon 3-months follow-up <h3>Summary</h3> LVAD explantation is a feasible option in LV recovery after appropriate hemodynamic and echocardiographic assessment. TEE is an essential tool, especially in patients with suboptimal windows. Outflow graft balloon occlusion can be used if there is concern about falsely poor results related to backflow or ongoing LVAD support at low speed leading to falsely improved results

Invasive Aspergillosis Manifesting As An Intracardiac Mass In A Heart Transplant Patient

<h3>Introduction</h3> Invasive aspergillosis (IA) is the third most common form of invasive fungal infections in immunocompromised patients, and has the second highest mortality rate at 30-70%. Invasion of lung parenchyma is the most common presentation, but can rarely present as aspergillus endocarditis. To our knowledge, IA presenting as a mass lesion in the heart is very rare and has never been reported in an orthotopic heart transplant (OHT) patient. We present a case of invasive aspergillus manifesting as an intracardiac mass in the right atrium (RA) in a heart transplant patient who survived. <h3>Patient presentation</h3> This is a 68 year-old-male with ischemic cardiomyopathy s/p OHT in June 2019 complicated by Aspergillus fumigatus sternal osteomyelitis requiring complete sternectomy on chronic antifungal therapy who was readmitted for right shoulder pain and failure to thrive. On admission, the patient was afebrile and hemodynamically stable. Pertinent workup showed transthoracic echocardiogram (TTE) with right atrial (RA) mass confirmed to be 3.5 × 3.3 cm by transesophageal echocardiogram (TEE) attached to interatrial septum. Initial malignancy workup was negative. Further infectious work up was remarkable for Aspergillus antigens. Intra-cardiac echocardiogram (ICE) and TEE techniques were utilized to locate and culture the mass. Argon epitome was placed into the mass under fluoroscopic and intracardiac echo guidance, extracting two specimens. Gross examination suggested identical specimens without any evidence of endocardium or lipomatous tissue. Initial pathology showed findings consistent with a thrombus but no evidence of fungal organisms, inflammation or malignancy. However, cultures from the specimen revealed Aspergillus fumigatus. Unfortunately, the patient was deemed a poor surgical candidate for resection due to other comorbidities and attempts are being made for long term antifungal therapy in management. <h3>Discussion</h3> Opportunistic infections such as invasive fungal infections are the leading cause of mortality in heart transplant recipients. Approximately 65% of OHT cases will have an infection within the first year of surgery. In a single institution, both incidence and mortality of IA in heart transplant recipients declined over the years. Despite this decrease, it remains a common pathogen observed in immunocompromised populations, specifically in solid organ transplantations. Most IA present as pulmonary disease as the route of entry for aspergillus conidia particles is inhalation, but rarely has intracardiac manifestations. To our knowledge, this is the first case report of invasive aspergillosis in a heart transplant recipient who had rare systemic manifestations including intra-cardiac mass and sternal osteomyelitis.

Averted Catastrophic Transseptal Puncture: Percutaneous Transseptal Mitral Commissurotomy in a Patient With Undiagnosed Azygous Continuation of the Inferior Vena Cava

A case is presented of a patient requiring percutaneous mitral balloon commissurotomy. During positioning of the transseptal needle, an unusual needle position on the lateral projection prompted the physician to abandon the puncture and do an angiogram of the inferior vena cava. This revealed an azygous vein continuation. The valve was treated at a later date under general anesthesia with transesophageal echo guidance. This case illustrates how reliance on the posterior-anterior projection to find the optimal point for transseptal puncture can be very misleading and how crucial the lateral projection is.

Combined Echo and Fluoroscopy-Guided Pulmonary Valvuloplasty in Neonates and Infants: Efficacy and Safety

Percutaneous balloon pulmonary valvuloplasty (PBPV) is the treatment of choice for isolated pulmonary valve stenosis. While this procedure is highly efficacious and has an excellent safety profile, as currently practiced, patients are obligatorily exposed to the secondary risks of ionizing radiation and contrast media. To mitigate these risks, we developed a protocol which utilized echo guidance for portions of the procedure which typically require fluoroscopy and/or angiography. Ten cases of echo-guided pulmonary valvuloplasty (EG-PBPV) for isolated pulmonary stenosis in children less than a year of age were compared to a historical cohort of nineteen standard cases using fluoroscopy/angiography alone, which demonstrated equivalent procedural outcomes and safety, while achieving a median reduction in radiation (total dose area product) and contrast load of 80% and 84%, respectively. Our early experience demonstrates that EG-PBPV in neonates and infants has results equivalent to standard valvuloplasty but with less radiation and contrast.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

Bedside Right Atrium to Left Atrium ECMO Cannulation: A Novel Approach in Patients With Severe ARDS Due to Covid-19

Background: Extracorporeal membrane oxygenation (ECMO) can provide life-saving treatment of adult respiratory distress syndrome (ARDS) complicating COVID-19 infection. We hypothesized that a modified ECMO (right to left atrium [RA-LA] cannulation with TandemHeart cannula and an oxygenator;TandemHeart ECMO) might be superior to conventional veno-venous (VV)-ECMO. Methods: A total of 19 patients with COVID-19 underwent ECMO at Princeton Hospital. We compared in-hospital complications and short-term outcomes between patients with VV ECMO vs. RA-LA ECMO. VV-ECMO was initiated in the cath lab, while RA-LA ECMO was initiated bedside using intracardiac echo guidance. We used Fisher’s exact test for mortality and Student’s t-test for other variables. Results: Between March and September 2020, 19 patients underwent ECMO cannulation. Out of 19 patients, 5 patients had beside TandemHeart ECMO (we performed bedside ICU ECMO procedure in 5 patients, 3 males and 2 females). We placed a 21F LA cannula (TandemHeart, TandemHeart, Pittsburgh, PA) via the right common femoral vein (CFV) and a 25F RA cannula (Edwards, Irvine, CA) through the left CFV. Both the oxygenator and pump were also a TandemHeart system. The median duration of ECMO was 16 days (range 7 to 19 days) for RA-LA ECMO compared to 26 days (range 12-81 days) for conventional VV-ECMO (p<0.02). The mean number of blood transfusions was 10.4±1.6 vs. 21.8±7.1 units, p<0.0001. One patient in the TandemHeart ECMO arm required dialysis, while 8/14 patients on VV-ECMO required dialysis, p=0.1. Intensive care unit (ICU) length of stay was shorter in the RA-LA ECMO group compared to VV ECMO (25.8±7.4 vs. 3.67±14.1 days, p<0.05). A total of 6/14 (42.8%) patients in the VV-ECMO vs. 0/5 (0%) in the RA-LA ECMO died in the hospital. However, this was not statistically significant (p=0.2). No major procedural complications, including tamponade occurred in the RA-LA arm despite using bedside ICE without fluoroscopy. Conclusion: Bedside percutaneous RA-LA cannulation was feasible and safe and was associated with significantly shorter ECMO and ICU days among COVID-19 patients presenting with ARDS. This strategy has the potential benefit of providing complete cardiopulmonary support in patients with ARDS. However, larger studies are needed to confirm its role in COVID-19 infections and potentially other ARDS scenarios.

Echocardiographic versus Angiographic Measurement of the Patent Ductus Arteriosus in Extremely Low Birth Weight Infants and the Utility of Echo Guidance for Transcatheter Closure

Transthoracic echocardiography (TTE) is increasingly utilized for guiding transcatheter closure of patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants. The objectives of this study were to compare PDA size measurements by TTE with angiographic measurements and to describe TTE techniques used in guiding transcatheter PDA closure (TCPC) in ELBW infants. One hundred twenty-five consecutive ELBW infants (gestational age<27weeks, birth weight<1kg) who underwent TCPC before 8weeks of age under TTE guidance were included. Patent ductus arteriosus sizes were measured from the procedural TTE and angiograms retrospectively by blinded observers. The TTE PDA diameters at the aortic (ED1) and pulmonary end (ED2) were compared with the corresponding angiographic diameters (CD1 and CD2). The TTE PDA lengths, obtained by two techniques (EL1, a straight line between ED1 and ED2; and EL2, a curvilinear line along the PDA), were compared with the PDA length by angiography (CL). Transthoracic echocardiography was used to guide accurate device positioning within the PDA. The procedure weight was 600-1,460g. The TTE and angiographic PDA diameters were comparable (mean ED1 vs CD1=4.5±0.68 vs 4.4±0.85mm, P=.26; and mean ED2 vs CD2=3.1±0.72 vs 3.2±0.94mm, P=.14). The angiographic length was underestimated by EL1 by 2.6±1.6mm(P<.0001), while EL2 estimated it better (mean EL2 vs CL=11.0±1.83 vs 10.8±2.15mm; P=.40). Transcatheter PDA closure was successful in 100% of the cases using TTE guidance. There were no intraprocedural complications. Transthoracic echocardiography guidance during TCPC in ELBW infants eliminates the need for aortograms via femoral arterial access, preventing the complications associated with it. Transthoracic echocardiography PDA measurements are comparable to angiographic measurements, thereby assisting in appropriate device size selection.

Traitements des synéchies associées à une infertilité

Synechiae are intrauterine adhesions that affect the fertility of women. They are most often of post-traumatic origin. The management of pregnancy abortions in the first trimester and post-delivery retention are the main contributing factors. Synechiae is responsible for cycle disorders and repeated pregnancy loss. Hysteroscopy is the reference method for its diagnosis and treatment. The surgical objective is the restoration of a normal sized cavity and a functional endometrium to allow fertilization and implantation. The use of small diameter (5mm) hysteroscopes and no energy or bipolar energy instruments are recommended. Echo guidance facilitates the treatment of severe synechiae and limits the risk of intraoperative perforation. The main risk of treatment is recurrence, particularly in severe cases where multiple operating times are sometimes necessary. An office hysteroscopy at 6 weeks is recommended to identify and treat these recurrences. Different physical, molecular or cellular methods are studied as primary and secondary prevention of postoperative synechiae. The objective of this review is to provide an update on the treatment of synechiae in the context of infertility.

A Novel Protocol for the Evaluation and Management of Patients for Successful HeartMate III Explantation

<h3>Introduction</h3> Left ventricular assist devices (LVADs) are used in cases of heart failure refractory to medical therapy. In certain cases, myocardial function recovers and LVADs can be explanted. Weaning protocols and post explantation management are lacking. We describe the case of successful Heartmate III (HM III) LVAD insertion, followed by myocardial recovery and successful explanation. <h3>Case Report</h3> 35-year-old male with a history of chronic systolic heart failure due to poly-substance abuse with a left ventricular ejection fraction (EF) of 15% presented in acute cardiogenic shock, INTEMACS 2. A HM III was implanted and he remained stable. Over a period of 14 months, he was able to tolerate up titration of his goal directed medical therapy that included valsartan 160 mg twice daily, spironolactone 50 mg daily, digoxin 125 mcg daily, isosorbide mononitrate 60 mg daily, hydralazine 100 mg three times a day, and carvedilol 25 mg twice a day. On repeat imaging, he demonstrated a decrease in left ventricular (LV) size and an increase in intrinsic function (EF50%), represented by an aortic valve that opens with every beat and low flow alarms necessitating lower speeds. The decision was made to wean him from the LVAD. He was given 5000 units of IV heparin and under echo guidance his LVAD speed was decreased from 5000 to 4500 rpm. He walked 537 m on a 6-minute walk test. He was admitted for further reduction in HM III dependence. He received additional heparin and his LVAD speed was dropped to 4,000rpm for a cardiopulmonary exercise test, which was notable for peak VO₂ of 13 with an RER of 1.4 and a VE/VCO2 slope of 39. His RHC demonstrated acceptable intra-cardiac pressures with a normal cardiac index. HM III was explanted and he was discharged. <h3>Summary</h3> To date no weaning protocols for HM III have been accepted or standardized. We describe the case of a patient who required LVAD insertion, followed by myocardial recovery and explanation. We suggest the above protocol for the evaluation of patients deemed appropriate for LVAD explant.

The Impella 5.5 as a Short Term Mechanical Circulatory Support Device in High Risk Cardiac Surgery

Purpose Post-cardiotomy cardiogenic shock (PCCS) is a life-threatening condition characterized by severe myocardial contractile impairment and reduced end organ perfusion. PCCS has been reported to occur in up to 9% of all cardiac surgery cases with a mortality approaching 40%. The Impella 5.5 micro-axial, full support, surgical pump has emerged as a useful support device in the setting of weaning from cardiopulmonary bypass (CPB) and for the mitigation of a low cardiac output syndrome. Methods From July 2020 to September 2020, 7 consecutive patients underwent urgent cardiac surgery supported by the Impella 5.5 device. In all cases, the Impella 5.5 was implanted during the index cardiac surgery via the ascending aorta using a 10mm woven Dacron graft and positioned using transesophageal echo guidance. In this retrospective study, we evaluated short-term outcomes of hospital mortality, acute kidney injury, cerebrovascular events, and device-related adverse events. Results The mean age was 61 years (range 46-71). Mean preoperative LVEF was 31% (range 25-50). Six patients underwent coronary artery bypass grafting and one patient underwent redo sternotomy and mitral valve replacement. The Impella 5.5 was implanted prior to weaning from cardiopulmonary bypass in six patients and for the onset of post-cardiotomy shock in one patient. In all patients, hemodynamics improved and stabilized immediately after the initiation of Impella support. The mean duration of Impella support was 3.8 days (1.9-6.6 days). There were no in-hospital deaths, no reoperation for bleeding, and no patients suffered a neurologic complication or renal failure requiring dialysis. There was no incidence of hemolysis requiring device explantation. All patients experienced native heart recovery. Four patients (57%) were discharged home, and three patients were discharged to a skilled nursing facility or rehabilitation center. Conclusion The peri-operative use of the Impella 5.5 heart pump facilitates surgery on high‐risk patients with depressed left ventricular ejection fraction and helps to prevent post-cardiotomy shock. Prospective studies looking at the preemptive use of the Impella 5.5 in these patients are needed.

Experience of transcatheter device closure of atrial septal defect in a tertiary care institute.

To share institutional experience of transcatheter device closure of secundum atrial septal defect in children and adults. The descriptive cross-sectional study was conducted at the Department of Paediatric Cardiology, Institute of Cardiology, Multan, Pakistan, from February 2011 to September 2019, and comprised patients with moderate to large secundum atrial septal defect without severe pulmonary hypertension. All procedures were performed under general anaesthesia and trans-oesophageal echo guidance. Success and safety of procedure were evaluated. Data was analysed using SPSS 16. Of the 75 patients, 26(34.6%) were males and 49(65.3%) were females. The overall mean age was 25±1.53 years (range: 4 -54 years). Mean defect was 20.38±0.58mm (range: 9-32mm). Large defects >25mm were 17(22.7%). Significant pulmonary stenosis was observed in 3(4%) patients and valvuloplasty was performed. Device size was selected on the basis of trans-oesophageal echo measurement +4-5mm. Balloon sizing was performed in only 3(4%) patients. Amplatzer septal occluder was used in 60(80%) patients. Balloon-assisted technique was used in 9(12%) patients. All the procedures were successful except 2(2.7%) where device was embolised and retrieved by surgery. Transient arrhythmias were observed in 6(8%) patients and small pericardial effusion in 1(1.3%) patient who was managed conservatively. There was no procedure-related mortality. Transcatheter closure of moderate to large secundum atrial septal defect in children and adults was found to be a safe procedure.