Transthoracic Echocardiographic Guidance Research Articles

Development of an atrial transseptal puncture procedure in horses to access the left heart: An ultrasound‐guided jugular vein and transhepatic approach

AbstractBackgroundRadiofrequency ablation has been successfully applied to treat right atrial arrhythmias in horses. Ablation of left‐sided arrhythmias requires a retrograde transarterial approach which is complicated. In human medicine, the left atrium is accessed through transseptal puncture (TSP) of the fossa ovalis (FO) using a caudal approach via the femoral vein.ObjectivesTo develop a zero fluoroscopy TSP technique for horses using a jugular vein (cranial) and transhepatic (caudal) approach.Study designIn vivo experimental study.MethodsTransseptal puncture was performed in 18 horses admitted for euthanasia and donated for scientific research under general anaesthesia: using a jugular vein approach (10 horses), a transhepatic approach (2 horses) or both (6 horses). Radiofrequency energy was applied on a guidewire to perforate the FO and allow sheath advancement under intracardiac and transthoracic echocardiographic guidance. Puncture lesions were inspected post‐mortem.ResultsTransseptal puncture was successful in 17/18 horses, of which 15/16 jugular vein approaches and 5/8 transhepatic approaches. Failure was due to technical malfunction, inability to advance the guidewire toward the heart and inability to advance the sheath through the FO. Intracardiac echocardiography was essential to safely guide the puncture process. Atrial arrhythmias caused by the TSP occurred in 13/18 horses. Puncture lesions were found in the right atrium in the FO region, and left atrium ventral to pulmonary vein ostium III.Main limitationsBecause in several horses two approaches were tested consecutively, it cannot be excluded that the second TSP was performed at the previous puncture site. Due to the developmental nature of the study the approaches were not randomised and did not allow comparison.ConclusionTransseptal puncture is feasible in horses using ultrasound guidance and allows for electrophysiological exploration of the left heart. Further studies are needed to evaluate post‐operative follow‐up.

Feasibility of transcatheter device closure of secundum atrial septal defect under transthoracic echocardiography guidance.

Objective: To determine the usefulness and safety of transthoracic echocardiography (TTE) imaging for real time guidance in transcatheter device closure of atrial septal defect (ASD) secundum. Study Design: Cross-sectional study. Setting: Department of Paediatric Cardiology, CPEIC, Multan, Pakistan. Period: January 2022 to December 2023. Material & Methods: Patients of both genders aged above 3 years with clinical and echocardiographic evidence of ASD secundum with significant left to right shunt were analysed. All cases had morphologically suitable margins of defect confirmed on TTE. Usefulness and safety of intra-procedure and immediate post-procedure transcatheter device closure of secundum ASD were noted. Results: In a total of 34 patients, 20 (58.8%) were female and 14 (41.2%) male. The mean age was 21.32±17.21 years. The TTE findings revealed that the mean ASD side was 17.47±4.32 mm. Aortic margins were deficient among 28 (82.4%) cases. The mean fluoroscopy and procedure time were 9.29±6.98 minutes and 49.91±39.76. Residual leak was noted in one (2.9%) cases while none of the cases were observed to have superior vena cava, inferior vena cava or pulmonary vein obstructions. Post-procedure, transient supraventricular tachycardia (SVT) arrhythmia was the most common type of complication reported among 2 (5.9%) cases. None of the cases needed any kind of emergency surgical exploration. No cases of pericardial effusion were found. No mortality was reported. Conclusion: Transcatheter device closure of secundum atrial septal defect was found to be effective and safe using TTE.

Percutaneous closure of infantile postoperative left ventricular pseudoaneurysm exclusively under transthoracic echocardiography guidance.

Percutaneous closure of infantile postoperative left ventricular pseudoaneurysm exclusively under transthoracic echocardiography guidance.

Transthoracic echocardiography guidance of transcatheter tricuspid valve repair

Abstract Funding Acknowledgements Type of funding sources: None. Background Transcatheter edge-to-edge tricuspid valve repair (TTVR) for tricuspid regurgitation (TR) is an emerging treatment option in inoperable patients. TTVR is always guided by transesophageal echocardiography (TOE) and performed under general anesthesia. In patients with excellent acoustic window, transthoracic echocardiography (TTE) can also provide a comprehensive morphological understanding. Moreover, in TTVR there is no need for transseptal puncture. Purpose We investigated if TTVR can be successfully conducted by a novel TTE guiding approach, in conjunction with fluoroscopy, based on the concept of the 4 right-sided chamber views. Methods Thirty TTVR patients were assigned to a TTE (n=10) and a TOE group (n=20), depending on acoustic window and corresponding guidance. Multimodality imaging was paramount for procedural planning and included TTE, TOE and cardiac CT, from which the corresponding fluoroscopic angulations of the 4 right-sided chamber views were derived. Thus, interventionalists and cardiac imaging specialists were assessing the same chamber views from their respective imaging modality. TR severity and quality of life parameters were assessed at baseline and up to 12 months. Results Except for lower BMI (TTE 22.3±0.8 vs TOE 29.8±4.3, p<0.001), baseline characteristics were similar between groups e.g., age (81.7±3.9 vs 82.8±4.1, p = 0.483) or EuroSCORE II (11.9±10.3 vs 10.4±8, p = 0.692). Device success was achieved in all patients, with a total of 15 implanted clips in the TTE (clips / patient 1.5±0.7) vs 31 clips in the TOE group (1.5±0.6), and device times of 75±37.1 vs 65.7±31.3 minutes (p = 0.506). TR reduction was successful in all but one patient, in each group (90% vs 95%, p = 1.000). TR improvement was equal between-groups, with 2- or more grade reduction in 60% of cases, at 30 days. No device associated complications occurred. Nine patients in the TTE group and 17 in the TOE group completed one-year follow-up. Quality of life and functional capacity similarly improved in both groups, with NYHA class reduction in all survivals [100% (9/9) vs 95% (17/17), p = 1.000], and significant improvement in KCCQ score and 6-minute walk distance in each respective group (∆24.8±21.4 vs 20.1±13.6 points, p = 0.227; ∆93.5±100.4 vs 80.8±64 meters, p = 0.121). TR reduction impacted major organs e.g., liver and kidney. Thus, glomerular filtration rate (GFR) increased [TTE group 56.8±18.7 vs 64.6±14.9 ml/m2/1,73m2, p = 0.050; TOE group 50.7±19.9 vs 53.8±20.9, p = 0.347], while liver congestion parameters decreased e.g, aspartate aminotransferase (AST) [TTE group 28.6±7.5 vs 26.2±8.6 U/L, p = 0.274; TOE group 33.1±5.8 vs 23.6±9, p = 0.388]. Conclusions TTE guidance of TTVR is feasible in selected patients with excellent acoustic window and represents an alternative to TOE or, in combination, may facilitate transition to conscious sedation. Successful TTVR leads to improvement in quality of life, symptom control, and multiorgan function.

Delayed tracheoesophageal fistula and refractory respiratory failure caused by inhalation burns and emergency venovenous ECMO to facilitate its management: a case report.

Acquired tracheoesophageal fistulae are uncommon in burn patients but can occur as a complication of inhalation injury. We report a case of a 30-year-old male patient presenting after suffering from inhalation and 25% total body surface area burns. On post burns day 14 he developed a massive tracheoesophageal fistula causing refractory acute respiratory failure. Veno-venous extracorporeal membrane (VV ECMO) oxygenation was initiated without systemic anticoagulation via bi-femoral cannulation under transthoracic echocardiography guidance. He underwent successful 5-hour apnoeic ventilation-assisted surgical repair of the fistula via a right posterolateral thoracotomy. ECMO was discontinued after 36 hours, and he was discharged to the ward after 33 days in the intensive care unit. Inhalation burn injury can cause a delayed life-threatening tracheoesophageal fistula. Surgical repair can be successfully performed for this condition. VV- ECMO can be used to facilitate prolonged apnoeic surgery and to manage refractory respiratory failure due to this condition.

A Case Report of Acute Cardiac Tamponade Creation in a Macaque: Echo-Guided Catheter Manipulation to Perforate Coronary Artery.

Although acute cardiac tamponade is one of the major problems in clinical practice, a suitable animal model is still lacking. We tried to create acute cardiac tamponade in macaques by echo-guided catheter manipulation. A 13-year-old male macaque was anesthetized, and a long sheath was inserted into the left ventricle via the left carotid artery under the guidance of transthoracic echocardiography. The sheath was then inserted into the orifice of the left coronary artery to perforate the proximal site of the left anterior descending branch. A cardiac tamponade was successfully created. Injection of diluted contrast agent into the pericardial space via a catheter made it possible to clearly distinguish between the hemopericardium and the surrounding tissues on postmortem computed tomography. This procedure did not need an X-ray imaging system during catheterization. Our present model would help us examine the intrathoracic organs in the presence of acute cardiac tamponade.

Transthoracic echocardiography guidance of transcatheter edge-to-edge percutaneous tricuspid valve repair: the TTE-TTVR pilot study and methodology proposal

Abstract Background Transcatheter tricuspid valve repair (TTVR) is an emerging option for treating high-grade tricuspid regurgitation (TR) [1], mostly performed by edge-to-edge repair, and always guided by transesophageal echocardiography (TOE). In patients with excellent acoustic window, transthoracic echocardiography (TTE) can also provide a comprehensive understanding of tricuspid valve (TV) morphology [2]. Also, in TTVR there is no need for transseptal puncture. Purpose We sought to determine if TTVR can be successfully conducted by a novel TTE guiding approach, in conjunction with fluoroscopy [3]. Methods 30 consecutive patients, scheduled for TTVR, were assigned to a TTE group (n=10), in the presence of excellent acoustic window, and a TOE group (n=20). On top of fluoroscopy, TTVR was guided exclusively by TTE in the first group, with TOE result confirmation solely upon clip release, due to safety reasons. The second group underwent classical TOE guidance. Understanding the 4 right heart chamber views (Fig. 1) and their respective fluoroscopic angulations was paramount. TR severity, parameters of quality of life and functional capacity were assessed and compared between-groups, at baseline and 30 days. Results Except for lower BMI (TTE 22.3±0.8 vs TOE 29.8±4.3, p<0.001), other baseline characteristics were very similar between groups, e.g., age (81.7±3.9 vs 82.8±4.1, p=0.483) or EuroSCORE II (11.9±10.3 vs 10.4±8, p=0.692).Device success was achieved in all patients, with a total of 15 implanted clips in the TTE group (mean no. of clips / patient 1.5±0.7) and 31 clips in the TOE group (1.5±0.6). Device time (75±37.1 vs 65.7±31.3 minutes, p=0.506) and fluoroscopy duration (16.3±10.5 vs 14.4±7.2 minutes, p=0.564) were also close. TR reduction was successful in all but one patient, in each group (90% vs 95%, p=1.000). TR improvement was equal between-groups, with 2 or more grade reduction in 60% of each group, at 30 days. Thus, grade IV/V and V/V TR, present in 60% of all patients at baseline, dropped to 10% (9/10 vs 18/20, p=1.000) by procedure end and follow-up (Fig. 2). No device associated complications occurred. By 30 days, there was one non-cardiac death and one major bleeding. At follow-up, all but one patient had at least one grade reduction in NYHA class (10/10 vs 19/20, p=1.000). Kansas City Cardiomyopathy Questionnaire score and 6-minute walk distance similarly improved (Δ20.7±14.9 vs 15.5±7.9 points, p=0.227; Δ80.5±60.1 vs 46.6±30.6 meters, p=0.121). A statistical in-group difference was also noticed in renal function improvement by follow-up [glomerular filtration rate (GFR) TTE group 56.8±18.7 vs 64.8±12.5 ml/m2/1.73 m2, p=0.028; TOE group 50.7±19.9 vs 62.2±25.9, p=0.001]. Conclusion TTE guidance of TTVR is feasible in selected patients with excellent acoustic window and could offer an alternative in case of high anesthetic risk. Similar procedural success and clinical outcomes, as with TOE guidance, can be achieved. Funding Acknowledgement Type of funding sources: None.

Transcatheter closure of persistent ductus arteriosus in 2 to 6 kg infants: Preliminary results from an international, retrospective study

Transcatheter patent ductus arteriosus (PDA) closure has proved to be safe in < 2 kg preterm infants, but major safety concerns remain when applied to the 2 to 6 kg body weight range. The aim of the present work is to assess efficacy and safety of transcatheter PDA occlusion in low-body-weight infants. Patients weighing 2 to 6 kg who underwent attempted transcatheter closure of an isolated PDA in 10 tertiary pediatric cardiology units (5 countries, 2000 to 2022) were retrospectively analyzed to review the outcome. A total of 339 infants (m/f sex ratio: 0.53; 56% ex-preterm, median age: 5.3 months [9 days–41 months], median weight: 4.7 kg [2 kg–6 kg]) were analyzed. Patients were all symptomatic (respiratory support: 33.2%, hospitalization for heart failure: 49.6%, nutrition care: 45.7%) with a hemodynamically significant PDA. Ductus was large (minimal ductal diameter: 4.2 ± 1.6 mm) and mainly conical (Krichenko type A: 57%) or tubular (Krichenko type C: 23%). Procedure was performed under both fluoroscopy (fluoro time: 10.7 ± 7.3 min) and transthoracic echocardiography guidance in all patients, with both arterial and venous femoral access (90%). Successful device implantation and complete PDA occlusion was achieved in 320 (94.4%) patients using devices in 91% (mainly ADO-I: 43.1%, ADO-IIAS: 20.0%, AVP-II: 8.0%, ODO: 5.3%, ADO-II: 3.5%, MFO: 2.1%, AVP-IV: 0.9%) vs. coils in 9%. Moderate to major complications occurred in 27 (8.0%) patients, including one death (0.3%) after delayed device embolization to descending aorta, device embolization (5.3%) and device-related obstruction of the left pulmonary artery (1.5%) or of the aorta (0.3%). These are preliminary data from a wider international study. We plan to collect both surgical and transcatheter cases in a wider series (40 tertiary centers, 20 countries), i.e. the largest cohort to date. This will allow better delineation of risk stratification, to keep refining indications for device closure in low-body-weight infants and achieve ever-safer results.

Transcatheter closure of secundum atrial septal defect using Cocoon septal occluder: immediate and long-term results

BackgroundAtrial septal defect (ASD) is one of the common congenital heart defects. Its management has transformed dramatically in the last 4 decades with the transition from surgical to percutaneous transcatheter closure for most secundum-type ASDs. Various devices are available for transcatheter closure of ASD with Amplatzer atrial septal occluder being most commonly used worldwide. Cocoon septal occlude has a nanocoating of platinum using nano-fusion technology over nitinol framework that imparts better radiopacity and excellent biocompatibility and prevents leaching of nickel into circulation, and by smoothening nitinol wire makes this device very soft and smooth. The aim of this study was to evaluate feasibility, effectiveness, safety, and long-term outcome of transcatheter closure of ASD using Cocoon septal occluder (Vascular Innovation, Thailand).ResultsAll patients undergoing transcatheter closure of hemodynamically significant ASD between September 2012 and July 2019 in our institute were included into this single-center, prospective study. Exclusion criteria were defect > 40 mm, unsuitable anatomy, Eisenmenger syndrome, and anomalous pulmonary venous return. Three hundred and twenty patients underwent device closure, of which 238 (74%) were female. The mean age was 14.6 years (range 6–29), and the median weight was 30.2 kg (range 10–53 kg). Procedure was performed under fluoroscopy using transthoracic and transesophageal echocardiography in 298 (93.1%) and 22(6.9%) patients, respectively. Balloon-assisted technique was used, when septal defect was ≥ 34 mm, in 9 (2.8%) patients. The mean diameter of defect and device was 21.4 mm (range 12–36 mm) and 26.9 mm (range 14–40 mm), respectively. Aortic rim was absent in 11 (3.4%) patients. Primary success was achieved in 312 (97.5%) patients. Early embolization to right ventricle was noted in 2 (0.6%) patients. In both cases, 40-mm device was attempted for defect of 36 mm with inadequate aortic rim using balloon-assisted technique. One (0.3%) patient developed perforation of right atrium. All were surgically repaired. Three (0.9%) patients developed complete heart block following device deployment requiring device retrieval. Two patients had had moderate residual shunt at 6 months of follow-up. After mean follow-up of 50.92 months (range 12.5–89 months), no erosion, allergic reactions to nickel, or other major complications were reported.ConclusionsPercutaneous transcatheter closure of ASD by Cocoon septal occluder (up to 36 mm) is safe and feasible with high success rate and without any significant device-related major complications over long-term follow-up. With unique device design and excellent long-term safety, it could be preferred dual-disk occluder for transcatheter closure of atrial septal defect. In most of the patients, ASD device can be safely deployed under transthoracic echocardiographic guidance.

Transcatheter Closure of a Paravalvular Leak Guided by Transesophageal Echocardiography and Three-Dimensional Printing

BackgroundClosure of a percutaneous paravalvular leak (PVL) is a technically challenging procedure because of the specific anatomy postoperatively and the complex catheter techniques required. Transesophageal echocardiography (TEE) and three-dimensional (3D) printing might be helpful in identifying complex anatomical structures and the procedural design.ObjectivesThe purpose of this study was to review our experiences with transcatheter closure of PVL guided by TEE and 3D (TEE&3D) printing.MethodsA total of 166 patients with PVL after surgical valve replacement underwent transcatheter closure, from January 2015 through December 2020. Among these patients, 68 had preoperative guidance from TEE&3D printing. We reviewed the catheter techniques, perioperative characteristics, and prognosis. The median follow-up period was 36 (3–70) months.ResultsAcute procedural success was achieved in 154/166 (92.8%) patients; of these, 64/68 (94.1%) had TEE&3D guidance and 90/98 (91.8%) had transthoracic echocardiography (TTE) guidance. No hospital deaths occurred. All patients having percutaneous procedures were given local anesthesia, while 13 patients having transapical procedures were given general anesthesia. Multiple approaches were used, including transfemoral, transapical, and transseptal via the arteriovenous loop. We also deployed multiple devices, including the Amplatzer Vascular Plug II (AVP II), the Amplatzer duct occluder II, the patent ductus arteriosus (PDA) occluder, and the Amplatzer muscular ventricular septal defect occluder. Those cases guided by TEE&3D printing had shorter procedural times compared with those guided by TTE [(61.2 ± 23.4) vs. (105.7 ± 53.9) min, p < 0.05]. The fluoroscopic time was also shorter for operations guided by TEE&3D printing compared with those guided by TTE alone [(18.5 ± 11.4) vs. (27.3 ± 5.6) min, p < 0.05]. The complications included recurrent hemolysis, residual regurgitation, acute renal insufficiency, and anemia. There was no significant difference in the incidence of complications between the 2 groups.ConclusionTransesophageal echocardiography and 3D printing show advantages compared with standalone TTE in guiding the transcatheter closure of PVL with shorter procedural and fluoroscopic times. This minimally invasive treatment could provide reliable outcomes in selected patients.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [NCT02917980].

Comparison of the efficacy and safety of sedation protocols with the use of dexmedetomidine\u2013remifentanil and propofol\u2013remifentanil during percutaneous closure of atrial septal defects: a randomized clinical trial

BackgroundThe study was aimed to compare the efficacy and safety of different sedation protocols of dexmedetomidine–remifentanil and propofol–remifentanil for percutaneous closure of atrial septal defects (ASD) under transthoracic echocardiography (TTE) guidance.Material and methodsFrom March 2020 to January 2021, of 114 patients screened, 59 ASD patients scheduled for percutaneous closure under TTE guidance were randomly allocated into the dexmedetomidine–remifentanil (D–R) group (n = 29) and the propofol–remifentanil (P–R) group (n = 30). The incidence of hemodynamic and respiratory adverse events, arterial blood gas analysis, induction and recovery time, pain score, infusion rate of remifentanil, satisfaction of the surgeon and patient, additional sedatives were collected for analysis and comparison.ResultsThe induction time was longer in the D–R group than that in the P–R group (17.66 ± 2.65 min vs 11.43 ± 1.48 min; difference, 6.22 min; 95% CI 5.10 to 7.35; P < 0.001). No differences were observed in the 2 groups in terms of the additional sedatives, infusion rate of remifentanil, pain score, recovery time (P > 0.05). There was no difference between the two groups regarding the incidence of cardiovascular adverse events (6 [20.7%] vs 4 [13.3%]; difference, 7.4%; 95% CI − 11.7 to 26.5%; P = 0.506). Respiratory adverse events occurred in 1 patient (3.4%) in the D–R group, and 8 patients (26.7%) in the P–R group (difference, 23.3%; 95% CI 6.2 to 40.5%; P = 0.026). The incidence of hypercapnia was significantly lower in the D–R group (4 [13.8%]) than in the P–R group (13 [43.3%]; difference, 29.5%; 95% CI 7.8 to 51.2%; P = 0.012).ConclusionsExcept for more rapid the induction time and higher the surgeon satisfaction score in the propofol–remifentanil protocol, the efficacy was similar between two sedation protocols. The hemodynamic stability was comparable, the dexmedetomidine–remifentanil protocol had superior airway security due to fewer hypercapnia and respiratory adverse events.

Performance of artificial intelligence system for prescriptive acquisition guidance of transthoracic echocardiography by novice users combined with automated quantification of ejection fraction

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Caption Health Background Artificial intelligence (AI) has the potential to expedite the acquisition of transthoracic echocardiograms (TTE) and provide automated quantitative data including left ventricular ejection fraction (LVEF). Specifically, AI-based imaging systems may permit less experienced individuals to obtain quantitative measurements of LVEF, with important implications for clinical workflow. Purpose We sought to evaluate the accuracy of an AI-based imaging system for the evaluation of LVEF in a spectrum of novice TTE imagers in a real-world clinical setting, and hypothesized that after appropriate training, it can perform as well as experienced sonographers. Methods Consecutive exams (N = 102; BMI 29 ± 7; most common indications for TTE: heart failure, arrhythmia, valve assessment) were performed by a cohort of physician trainees (MD) and nurses (RN) with no prior TTE experience, using an AI-guided imaging system equipped with real-time prescriptive guidance software that automatically measures LVEF. Guided imaging included 3 views: parasternal long-axis (PLAX), apical 4-and apical 2-chamber (AP4, AP2), with the software recognizing when a satisfactory imaging window is obtained and then auto-capturing and automatically generating an AI based LVEF. AI-EF measurements were compared against the reference standard EF (Ref EF) measured by 2 expert sonographers according to ASE chamber quantification guidelines. Bland-Altman analysis was performed to determine inter-technique agreement. Results Feasibility was 80%. AI-EF and Ref EF demonstrated strong correlation when all 3 views were obtained, with a small bias (Table). In cases when &amp;lt;3 views were available, the combination of PLAX and AP4 views achieved comparable results, with a slight increase in bias and limits of agreement. When results were stratified by cohort (MD vs RN), MD AI-EF attempts showed greater feasibility (100%, n = 51) with stronger correlation (r = 0.93) and smaller bias (-1.9%) compared to RN (feasibility of 61%; n = 31 and r= 0.85, bias -2.1%). Conclusions Use of an AI-assisted imaging system for limited TTE imaging by novices is feasible in a real-world setting, with the AI based EF in good agreement with reference standard. Acquisition of all 3 views provided optimal results, but the combination of AP4/PLAX views performed reasonably well, without the AP2 view that is more difficult to acquire for less skilled users. Untrained MD were more successful when compared to RN, suggesting additional training may be needed for specific user groups. Abstract Figure.

Routine use of fluoroscopic and real-time transthoracic echocardiographic guidance to ensure safety of right ventricular endomyocardial biopsy in a low-volume center.

To determine whether the routine use of real-time transthoracic echocardiographic (TTE) guidance in addition to fluoroscopy would ensure the safety of right ventricular endomyocardial biopsy(RV EMB) in a low-volume center.RV EMBis a valuable tool and plays an important role in the diagnosis and management of patients with myocardial diseases. However, it has yet to gain widespread acceptance due to its perceived low diagnostic yield and concerns regarding its invasive nature and potential complications. Although the safety of EMB when performed by experienced operators in high-volume centers is well established, the complication rate in low-volume centers is less well defined but appears to be higher.This is a retrospective single-center cross-sectional study. Consecutive adult patients who underwent RV EMB procedures at Tygerberg Hospital (Cape Town, South Africa) between August 2017 and December 2020 were included.RV EMB was successfully performed in 85 patients. No major complications were reported. Five (5.88%) patients experienced minor complications: three transient right bundle branch blocks and two hemodynamically stable ventricular tachycardia. A definitive biopsy diagnosis was made in 37 (43.54%) patients. The average procedural time was 27.06 min, which equated to 4.09 min per specimen taken.The routine use of real-time TTE guidance in addition to fluoroscopy ensured the safety of RV EMB in a low-volume center without unnecessarily prolonging procedural time.

C67. Patent Ductus Arteriosus Closure with Transthoracic Echocardiography Guidance, Small Changes with a Big Impact: a case report

Abstract Background Patent Ductus Arteriosus (PDA) is one of the most common congenital heart diseases with a left to right shunt. PDA occurs in 5-10% of all congenital heart disease, excluding premature infants. It is more frequently occurs in women compared to men. Patients could be asymptomatic depending on the size of the PDA, systemic and pulmonary vascular resistance, and the size of the left-to-right shunt. Case Description We report a case of an 18-year-old girl presenting with PDA and left-to-right shunt. The patient underwent a PDA closure with a transthoracic echocardiography (TTE) guidance and used an occluder device. The procedure was performed without any complication, the patient was stable, and from the TTE control, we found no residual shunt and device in situ. Discussion Several adverse effects of PDA closure using fluoroscopy guidance had been highlighted due to its radiation exposure. The necessity of using a contrast agent is also confirmed to increase the patient risk. To this end, the closure of PDA using TTE guidance was developed to prevent the side effect of fluoroscopy for both doctors and patients. This method required a well-developed collaboration between the pediatric interventional cardiologist and echo-cardiologist. In conclusion, PDA Closure using a device and TTE guidance is as effective as fluoroscopy guidance. Closure of the PDA using TTE guidance may prevent patients and doctors from the adverse effects of radiation and minimize the risk of contrast agents.

C67. Patent Ductus Arteriosus Closure with Transthoracic Echocardiography Guidance, Small Changes with a Big Impact: a case report

Abstract Background Patent Ductus Arteriosus (PDA) is one of the most common congenital heart diseases with a left to right shunt. PDA occurs in 5-10% of all congenital heart disease, excluding premature infants. It is more frequently occurs in women compared to men. Patients could be asymptomatic depending on the size of the PDA, systemic and pulmonary vascular resistance, and the size of the left-to-right shunt. Case Description We report a case of an 18-year-old girl presenting with PDA and left-to-right shunt. The patient underwent a PDA closure with a transthoracic echocardiography (TTE) guidance and used an occluder device. The procedure was performed without any complication, the patient was stable, and from the TTE control, we found no residual shunt and device in situ. Discussion Several adverse effects of PDA closure using fluoroscopy guidance had been highlighted due to its radiation exposure. The necessity of using a contrast agent is also confirmed to increase the patient risk. To this end, the closure of PDA using TTE guidance was developed to prevent the side effect of fluoroscopy for both doctors and patients. This method required a well-developed collaboration between the pediatric interventional cardiologist and echo-cardiologist. In conclusion, PDA Closure using a device and TTE guidance is as effective as fluoroscopy guidance. Closure of the PDA using TTE guidance may prevent patients and doctors from the adverse effects of radiation and minimize the risk of contrast agents.

MULTIDISCIPLINARY APPROACH USING CATHETER DIRECTED MECHANICAL THROMBECTOMY IN TREATMENT OF A PULMONARY EMBOLISM WITH CLOT IN TRANSIT

TOPIC: Pulmonary Vascular Disease TYPE: Fellow Case Reports INTRODUCTION: Clot in transit (CIT) is a term associated with pulmonary embolism (PE) used to describe thrombus found in the right atrium or ventricle on echocardiography. We present a case of CIT treated in a multidisciplinary approach with catheter-directed mechanical thrombectomy. CASE PRESENTATION: A 60 year old male with a history of unprovoked PE off anticoagulation presented with dyspnea and syncope. At presentation, he was tachycardic to 130 but normotensive and not hypoxemic. Troponin-I was elevated at 0.06 ng/mL and B type-NP at 96 pg/mL. SARS-CoV-2 PCR was negative. CT angiography revealed extensive acute bilateral PE with increased RV/LV ratio of 1.9. A stat transthoracic echocardiography (TTE) found a dilated right ventricle with severely reduced systolic function, positive McConnell sign, a tricuspid annular plane systolic excursion (TAPSE) < 1cm, and a serpiginous mobile echodensity in the right atrium consistent with a CIT. A stat ultrasound of the legs also revealed extensive deep venous thrombosis in the proximal left femoral vein extending to the popliteal vein. After a multidisciplinary PE response team discussion, the patient was taken emergently to the catheterization lab. Prior to transport, VA ECMO safety lines were preemptively placed to facilitate ECMO initiation in case of decompensation. With the ECMO circuit primed and the ECMO team, cardiac anesthesiologist, and cardiothoracic surgery on standby, the patient underwent percutaneous mechanical thrombectomy utilizing the Inari Flowtriever® system. With adjunctive TTE guidance, the right atrial clot was first extracted in its entirety with no hemodynamic deterioration. This was followed by aspiration of clot from the right and left pulmonary arteries. Pulmonary artery pressures and cardiac index improved, and the procedure ended with placement of an IVC filter. The patient was transferred to the ICU and was started on enoxaparin at 1mg/kg twice a day. He was discharged on day 4 with rivaroxaban. DISCUSSION: CIT is a rare phenomenon with a prevalence rate of around 4% and is considered a medical emergency given its high mortality rate of 25-40%. While treatment guidelines are limited, anticoagulation alone has shown to be insufficient to treat CIT effectively. While there is data supporting the use of catheter directed therapies for PE, data on its use for CIT is scarce but growing. Furthermore, the preparation of advanced support prior in conjunction with the use of catheter directed therapy may be beneficial in case of life-threatening decompensation. CONCLUSIONS: Catheter-directed mechanical thrombectomy may be effective and safe as shown in this case, but requires a team capable of advanced therapies like ECMO and urgent surgical intervention if needed. REFERENCE #1: Otoupalova E, Dalal B, Renard B. Right heart thrombus in transit: a series of two cases. Crit Ultrasound J. 2017;9(1):14. doi:10.1186/s13089-017-0069-9. REFERENCE #2: Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020 Mar;187:139-147. doi: 10.1016/j.thromres.2020.01.006. Epub 2020 Jan 10. PMID: 31991381. REFERENCE #3: Dhulipala V R, Fayoda B O, Kyaw H, et al. (August 04, 2020) Thrombus in Transit: Extract or Dissolve?. Cureus 12(8): e9550. doi:10.7759/cureus.9550. DISCLOSURES: No relevant relationships by Mara Caroline, source=Web Response No relevant relationships by Eliot Friedman, source=Web Response No relevant relationships by Eric Gnall, source=Web Responseresearch relationship with Inari Please note: April,2021 to presen Added 04/29/2021 by Lee Greenspon, source=Web Response, value=Grant/Research Support No relevant relationships by Patrick Ho, source=Web Response

Day-Case Patent Foramen Ovale Closure Under Transthoracic Echocardiography and Fluoroscopic Guidance: A Safe and Cost-Effective Approach as Compared to Conventional Hospitalization

Background: Transcatheter Patent Foramen Ovale (PFO) is recommended as a therapy in secondary prevention of cryptogenic stroke. The aim of this study was to report one-year French single-center experience in PFO closure under sole Transthoracic Echocardiography (TTE) and fluoroscopy guidance performed as a day-case procedure versus a 3-day hospitalization. Methods: In 2018, all consecutive patients undergoing PFO closure for stroke were retrospectively included: 108 patients as a day-case procedure (group 1) versus 20 patients performed under a 3-day hospitalization (group 2). A comparison was performed between Occlutech and Amplatzer PFO devices and the impact on hospitalization costs was studied. Results: Occluders included Occlutech (n=81), Amplatzer (n=43), Lifetech (n=2) and PFM (n=2) PFO devices. Implantation succeeded in all. In-group 1, hospital discharge was delayed in only 3 cases. At one-month, 5 patients had Atrial Fibrillation (AF) and 91 patients (84%) had no residual shunt. In-group 2, hospital discharge was delayed in 4 patients. At one month, 1 patient had AF and no shunt was observed in 80%. In the comparative study, no significant statistical difference could be observed between Amplatzer and Occlutech devices. The one-day strategy leaded to a positive balance of 1825 euros per procedure in 2018, with a difference of 3785 euros with group 2. Conclusion: Our experience suggests that day-case PFO closure under fluoroscopy and TTE guidance is safe and effective in the majority of patients leading to a cost reduction and no increased risk of embolization.

Feasibility study for echocardiography-guided lead insertion for permanent cardiac implantable electronic devices.

BackgroundPermanent cardiac implantable electronic devices (CIEDs) are traditionally implanted with the assistance of fluoroscopy. While clinically effective, this technique exposes both patients and providers to radiation which is associated with adverse health effects and represents an occupational hazard. In this study, we investigate the safety and feasibility of permanent CIED placement under the guidance of transthoracic echocardiography (TTE). There is also increasing interest in use of non‐fluoroscopic options for noninvasive cardiac electrophysiologic procedures.MethodsFifteen patients consecutively consented for initial implant of CIEDs, specifically dual chamber pacemakers (DCPM) and dual chamber implantable cardioverter defibrillators (DCICDs). Patients were excluded if they had previous implants, abandoned leads, or anatomic anomalies including congenital and known persistent left superior vena cava (PLSVC). We used TTE to guide and implant atrial and ventricular leads.ResultsEleven patients received DCPMs and four patients received DCICDs. The procedure duration was 49.3 min for DCICD and 52.3 min for DCPM, p = .807. The average number of right atrial lead attempts was 1.6 for DCPMs and 1.8 for DCICD, p = .860. The average number of right ventricular lead attempts for DCPMs was 2.2 and 1.0 attempt for DCICDs, p = .044. There were no complications at 90‐day follow‐up.ConclusionWe demonstrate the feasibility of TTE‐guided DCPM/DCICD implantation without use of fluoroscopy. We present this method as a safe alternative for permanent CIED placement that may reduce risk of radiation exposure and cost while maintaining safety and efficacy. No operators wore lead aprons during the procedure.

Animal model of coronary microembolization under transthoracic echocardiographic guidance in rats

The aim of the study was to develop a model of coronary microembolization (CME) in rats at a lower cost. We developed a novel rat model without thoracotomy and ventilation under the guidance of echocardiography. Rats were sacrificed at 3 h, 24 h and 1 month postoperatively in both the Echo-CME and Open-chest CME groups for the comparison of the modeling accuracy, mortality, cardiopulmonary circulation, pleural adhesion and ventilation-induced lung injury (VILI). Results showed that the coronary microthrombus formed at 3 h and reached its peak at 24 h postoperatively, which included platelet aggregation and fibrin web. The Echo-group increases success rates, decreased mortality, postoperative complications including pleural adhesion, cardiopulmonary dysfunction and VILI postoperatively than the Open-chest group at 1month postoperatively. The ejection fraction of the CME group decreased to 50% and obvious cardiac fibrosis formed at 3 months postoperatively. Our unique surgical method provided a platform to study molecular mechanisms and potential new pathways for CME treatment.

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.