Heart Interventions Research Articles

Transseptal puncture for structural heart intervention: an old technique with new indications

### Learning objectives To learn how to: Transseptal catheterisation was introduced in the late 50s1 and gained popularity with the introduction of the electrophysiological and structural heart interventions.2–10 Here, we...

Intracardiac Echocardiography for Structural Heart and Electrophysiological Interventions.

With an increasing number of interventional procedures performed for structural heart disease and cardiac arrhythmias each year, echocardiographic guidance is necessary for safe and efficient results. The purpose of this review article is to overview the principles of intracardiac echocardiography (ICE) and describes the peri-interventional role of ICE in a variety of structural heart disease and electrophysiological interventions. Both transthoracic (TTE) and transesophageal echocardiography have limitations. ICE provides the advantage of imaging from within the heart, providing shorter image distances and higher resolution. ICE may be performed without sedation and avoids esophageal intubation as with transesophageal echocardiography (TEE). Limitations of ICE include the need for additional venous access with possibility of vascular complications, potentially higher costs, and a learning curve for new operators. Data supports the use of ICE in guiding device closure of interatrial shunts, transseptal puncture, and electrophysiologic procedures. This paper reviews the more recent reports that ICE may be used for primary guidance or as a supplement to TEE in patients undergoing left atrial appendage (LAA) closure, interatrial shunt closure, transaortic valve implantation (TAVI), percutaneous mitral valve repair (PMVR), paravalvular leak (PVL) closure, aortic interventions, transcatheter pulmonary valve replacement (tPVR), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) closure. ICE imaging technology will continue to expand and help improve structural heart and electrophysiology interventions.

The last frontier: transcatheter devices for percutaneous or minimally invasive treatment of chronic heart failure.

Heart failure has a high prevalence in the general population. Morbidity and mortality of heart failure patients remain high, despite improvements in drug therapy, implantable cardioverter-defibrillators and cardiac resynchronisation therapy. New transcatheter implantable devices have been developed to improve the treatment of heart failure. There has been a rapid development of minimally invasive or transcatheter devices used in the treatment of heart failure associated with aortic and mitral valve disease and these devices are being incorporated into routine clinical practice at a fast rate. Several other new transcatheter structural heart interventions for chronic heart failure aimed at a variety of pathophysiologic approaches are currently being developed. In this review, we focus on devices used in the treatment of chronic heart failure by means of left ventricular remodelling, left atrial pressure reduction, tricuspid regurgitation reduction and neuromodulation. The clinical evaluations of these devices are early-stage evaluations of initial feasibility and safety studies and additional clinical evidence needs to be gathered in appropriately designed clinical trials.

Transatlantic medical consultation and second opinion in pediatric cardiology has benefit past patient care: A case study in videoconferencing.

Telemedicine is a rapidly evolving form of modern information and communication technology used to deliver clinical services and educational activities. The aim of this article is to report and analyze our experience with transatlantic consultation via videoconferencing in pediatric cardiology. In February, 2013, videoconferencing project was launched between a medium-volume pediatric cardiac center in Bratislava, Slovakia and subspecialty experts from a high-volume pediatric cardiac program at The Children's Hospital of Philadelphia (CHOP), USA. During 1.5-2 hours videoconferences, 2-3 patients with similar complex clinical scenarios were presented to CHOP experts. The main goal of the project was consultation on individual patients to validate, alter or radically change clinical management plans. From February, 2013 to January, 2017, 25 videoconferences occurred and 73 cases were discussed. The median patient age was 52 months (range; 1 day-30 years). Forty-six discussed cases were outpatients, 21 patients were in the intensive care unit and 6 patients were discussed post mortem. Thirty-one CHOP experts from different subspecialties participated actively in patient consultations. The most frequent recommendations were related to single ventricle, pulmonary hypertension or heart failure patients and intervention in complex and/or rare cardiac diseases. Specialists from CHOP agreed completely with the original care plan in 16% of cases. In 52% cases, adjustments to original plan were suggested. Radical changes were recommended in 30% of cases. Receiving institution adopted recommendations to the patient care fully in 79% and partially in 13% of patients. Based on our 4-year experience we consider videoconferencing between medium-size pediatric cardiac center and subspecialty experts from a high-volume pediatric cardiac program a suitable form of medical consultations. Videoconferencing assists in clinical decision making for complex patient cases and serves as an effective educational tool to gain knowledge and experience "without borders."

Kazakhstan: coronary and structural heart interventions from 2010 to 2015.

This paper presents data on the nascence and development of the interventional cardiology service in Kazakhstan. It provides details of the structure of the Kazakhstan interventional cardiology service, staff training, the number of coronary and structural heart interventions for the period of 2010-2015, as well as the peculiarities of the capitation payment method. The number of coronary interventions is increasing year by year, though the number of intracoronary imaging techniques and intracoronary flow/pressure techniques remains inadequate. Structural heart interventions are mostly performed at tertiary hospital level, with an ever increasing number of transcatheter aortic valve implantation (TAVI) procedures.

Switzerland: coronary and structural heart interventions from 2010 to 2015.

In 2015, Switzerland had a population of 8.3 million inhabitants. Since the first coronary angioplasty performed by Andreas Grüntzig in Zurich in 1977, the number of percutaneous procedures has steadily increased. The aim of this report is to summarise the current state of catheter-based cardiac interventions in adults in the country and to detail trends between 2010 and 2015. Since 1987, the Working Group for Interventional Cardiology of the Swiss Society of Cardiology has collected annually aggregate data from all facilities with cardiac catheterisation laboratories in the country. In 2015, a total of 37 institutions covered 17 of the 26 Swiss cantons. Over the six-year period, there was a continuous increase in the number of coronary angiography and percutaneous coronary interventions (PCI) (median increase rate of 3.2%/year for coronary angiography and of 2.6%/year for PCI). Notable was the adoption of the transradial approach for PCI, going from a median rate of 17% in 2012 to 51.9% in 2015. With respect to structural heart interventions, the number of patent foramen ovale as well as atrial septal defect closures has remained stable, while the number of transcatheter aortic valve implantations and transcatheter mitral valve repairs has shown a fourfold increase.

Turkey: coronary and structural heart interventions from 2010 to 2015.

Growing populations and ageing demographics lead to an increased burden of ischaemic heart disease and related cardiovascular interventions, resulting in pressure on healthcare systems. Although the healthcare system in Turkey has undergone comprehensive remodelling over the last decade, there are many challenges to overcome, including better reimbursement for cardiovascular interventions, standardisation of interventional cardiology services and research-related activities. In this manuscript, we present an overview of coronary and structural heart interventions in Turkey, as well as providing information on current reimbursement policies and the healthcare system.

Egypt: coronary and structural heart interventions from 2010 to 2015.

Interventional cardiology procedures are constantly increasing in numbers and in quality, especially in developing countries such as Egypt. The numbers and types of procedure now available have driven development in the field and in its accompanying services. The aim of this short report is to present a review of the development of interventional cardiology in Egypt during the period 2010-2015 and the demographic, economic and educational factors that have affected this process. We collected and analysed data provided by different centres and from the distributors of intervention tools for the years 2010 to 2015. Analysis of these data showed a steady growth of primary PCI, amounting to a threefold increase over the six-year period. There are increasing numbers of PCI-capable centres, especially in Cairo. Almost 55,000 PCIs are performed yearly in Egypt utilising around 100,000 stents; the percentage of drug-eluting stents (DES) used has increased to 65-70% (90% in private and insured patients). Structural intervention is growing fast for congenital heart disease, and balloon mitral valvuloplasty has become the default strategy. The numbers of TAVI and EVAR are also increasing, although cost remains the greatest challenge. These changes can be attributed to the increasing numbers of ischaemic heart disease patients over the last 25 years, involving improved education and awareness, patients presenting at a younger age, and improved practice in intervention. In Egypt, there has been a steady growth in PCI and intervention tools which has been faster in coronary and congenital heart disease than in structural heart disease during the period from 2010 to 2015.

Macedonia: coronary and structural heart interventions from 2010 to 2015.

The aim of this report is to describe invasive cardiology procedural practice in Macedonia during the period from 2010 to 2015. Details of all consecutive 39,899 patients who underwent cardiovascular, peripheral or structural heart procedures during the period from 2010 until 2015 were examined. Clinical and procedure characteristics, access site, procedural success and complications were analysed. The number of coronary angiographies increased from 5,540 in 2010 to 8,550 in 2015. Transfemoral access (TFA) was present in 4% of coronary angiographies in 2010 and had decreased to 1% in 2015. The number of primary percutaneous coronary interventions (PCI) for acute ST-segment elevation myocardial infarction increased from 763 to 1,175 and both chronic total occlusion and left main coronary artery interventions also increased over time. In 2015, the drug-eluting stent penetration rate was 65%. Structural heart interventions, including transcatheter aortic valve implantations (TAVI) were introduced in 2014 and 23 TAVI cases have since been performed. Transradial access was performed in 38,455 (96%) of all patients. Wrist access adoption in the majority of cardiovascular interventions is possible in all PCI centres in Europe if an appropriate national strategy is developed.

Israel: coronary and structural heart interventions from 2010 to 2015.

The Israel Heart Society is a member of the European Society of Cardiology, and the Israeli Working Group of Interventional Cardiology is an active participant in EAPCI. The aim of this manuscript is to provide a snapshot of cardiac interventions performed in the State of Israel during the period 2010-2015. Data for this manuscript were collected via collaboration with the National Diseases Registries Unit of the Israel Center for Disease Control. During the survey period, the Israeli population increased by 7% but only one additional hospital with an active cardiac catheterisation laboratory was opened. The vast majority of the percutaneous procedures are performed in public hospital settings. Total coronary angiography procedures remained stable throughout the survey period, and the percentage of PCI out of total coronary angiography procedures remained approximately 50% throughout the survey period. More than 90% of the PCI procedures were performed using stent deployment, and the use of drug-eluting stents increased significantly during the survey period from 46% in 2010 to 92% in 2015. The number of TAVI procedures increased dramatically, by more than sixfold, from 130 procedures in 2010 to 851 procedures in 2015 (with 130 implants/million population at Q4 of 2015). The vast majority of interventional cardiology procedures are funded by the governmental healthcare providers, and all the citizens of the country have access to the most advanced cardiac interventions. If corrected for the increase in the population, the volumes of coronary interventions are decreasing throughout the country. However, structural heart disease interventions, and specifically valvular interventions, are growing rapidly and this trend is expected to continue in the near future.

Portugal: coronary and structural heart interventions from 2010 to 2015.

The aim of the present paper is to report trends in Portuguese interventional cardiology from 2010 to 2015. We studied data from the prospective multicentre Portuguese National Registry of Interventional Cardiology (RNCI) to analyse percutaneous coronary intervention (PCI) procedures and structural heart interventions from 2010 to 2015. A total of 73,977 PCIs and 780 transcatheter aortic valve implants were performed during the study period. Since 2010 there has been a 60% increase in PCI procedures and a twofold increase in primary angioplasty rates reaching 316 per million population. Significant PCI trends were observed, notably the increase of radial access, a reduction in restenosis indications, as well as an increase in stent use, including DES, in imaging and in functional techniques. Importantly, there was a fourfold increase in the TAVI rates reaching 29 per million population.

Denmark: coronary and structural heart interventions from 2010 to 2015.

Interventional cardiology in Denmark has been carried out since the mid 1980s. Interventional cardiology is only performed at a few high-volume centres. Healthcare coverage is universal and is essentially free of charge. Hospitals are mostly publicly owned and financed by fixed budgets and, in part, an activity-based funding system. Approximately 30,000 coronary angiographies (CAG), 10,000 percutaneous coronary interventions (PCIs) of which approximately 25% are primary PCIs, and 500 transcatheter aortic valve implantations (TAVIs) are carried out each year. The numbers of CAG and PCI have reached a plateau in recent years, whereas structural heart interventions, in particular TAVI, are increasing. Around 90% of all patients treated with PCI have a stent implanted, with more than 95% of these being drug-eluting stents. There is a low but increasing use of bioabsorbable scaffolds and drug-eluting balloons.

Italy: coronary and structural heart interventions from 2010 to 2015.

The aim of this report is to analyse trends in Italian cathlab activity between 2010 and 2015. Data were obtained from the national database of the Italian Society of Interventional Cardiology (GISE), which includes 97% of Italian cardiac catheterisation laboratories. The number of percutaneous coronary interventions (PCI) has remained relatively stable in the past five years. We have observed a significant increase in the number of primary PCI (pPCI) from 471.5 to 557.5 per million inhabitants with a consequent reduction of rescue primary PCI/fibrinolysis. One of the possible explanations for this might be the extensive networking for primary PCI and the adoption of Stent for Life initiatives in five regions. There has been a notably increased use of drug-eluting stents and, despite the fact that the introduction of bioabsorbable vascular scaffolds is recent, there is a slight, progressively positive trend. Invasive physiologic evaluation of coronary stenosis has markedly increased. Radial artery access has become the default option for PCI and for pPCI. In the last five years, TAVI procedures have doubled in number, while MitraClip and mitral repair procedures have shown a fivefold increase. Left atrial appendage (LAA) occlusion procedures have more than doubled in four years.

Belgium: coronary and structural heart interventions from 2010 to 2015.

In a ranking of the gross domestic product per capita in 2015, Belgium ranked 19th in the world according to the International Monetary Fun1d and the World Bank. It has a Human Development Index of 0.890, in which it is preceded by only 20 other countries in the world. This is, at least in part, due to a well-developed social security system on which all citizens can rely. Over the last 5-10 years, however, this system has come under increasing pressure. This has resulted in insufficient, incomplete and late reimbursement of all technologies that were introduced over the last ten years in the cathlab: intracoronary imaging techniques are not reimbursed at all, and FFR only to a vastly insufficient degree. For several structural heart interventions, a system of limited and incomplete reimbursement has recently been set up, with a requirement to organise these procedures within the frames of hospital networks. Numbers of PCIs have risen by 15% over the last four years, coinciding with an increase in the number of cathlabs by 50%, aiming at better access to primary PCI for STEMI patients. This has also resulted in a decrease in the average procedure volume per centre. Two thirds of PCIs are performed via the radial access. DES penetration has increased to 74%, approaching 100% in some centres, while the uptake of BRS has been very limited so far.

Poland: coronary and structural heart interventions from 2010 to 2015.

For the last five years, invasive cardiology in Poland has developed extensively. Currently, 98% of the 161 Polish cathlabs operate in 24/7 mode, 37 of them supported by cardiac surgery departments on-site. A certification curriculum for interventional cardiology operators is supported by dedicated workshops and scientific meetings during national conferences. The rise in the number of coronary angiographies and PCIs was paralleled by an increased use of drug-eluting stents, bioresorbable vascular scaffolds and physiologic assessment of coronary arteries. Radial artery access has become the default option for PCI. A rapid adoption of the EAPCI Stent for Life Initiative resulted in a significant increase in primary PCIs. Unlike coronary interventions, structural heart interventions have evolved unevenly, despite the solid network of Heart Teams set up in the 21 most experienced centres. Left atrial appendage closure is offered in an increasing number of cathlabs. MitraClip therapy remains largely underused (1 procedure/million population/year). Despite the slow growth of TAVI since 2008, the current annual number of 17.1 TAVI procedures per million population is incomparable with countries in Western Europe. A recently introduced EAPCI Valve for Life campaign was followed by a 42.6% annual increase in TAVI procedures and an improvement in patients' access to therapy in life-saving indications.

Sweden: coronary and structural heart interventions from 2010 to 2015.

Sparsely populated and with wide non-urbanised areas, Sweden faces specific challenges in providing publicly financed, high-quality and equal healthcare to all parts of the country. As a result, a decentralised organisation for acute coronary care has been developed with coronary care units and catheterisation laboratories in several small- and medium-sized city areas. In contrast, highly specialised non-emergent interventional procedures are centralised to a few high-volume centres, mainly located at university hospitals in large city areas. Nationwide quality registries with nearly complete coverage facilitate healthcare quality improvement and form a basis for clinical research. In this report, we present an overview of demographics, healthcare organisation, quality registries and procedural data for coronary and structural heart interventions in Sweden over the past six years.

United Kingdom: coronary and structural heart interventions from 2010 to 2015.

In the United Kingdom, a clinical data set is completed for every patient undergoing coronary intervention and certain structural interventions, and sent to central servers in the National Institute for Cardiovascular Outcomes Research (NICOR) on behalf of the British Cardiovascular Intervention Society (BCIS). These data are linked to the national mortality register. In addition, data are obtained about the structure of healthcare provision using an annual survey. Analyses of these data are provided for different audiences in several formats. Public reports of individual consultant operator activity and risk-adjusted outcomes from percutaneous coronary intervention (PCI) have also been produced annually since 2012. Transcatheter aortic valve implantation (TAVI) has been performed since 2007. Over 2,000 cases were performed in 2015, giving a rate of 30 per million population. Complications to discharge have fallen as case mix has changed and technologies improved. While the mean age has remained about 81 years, the logistic EuroSCORE of patients treated by TAVI has fallen from about 22 in 2010 to 18 in 2015. Tracked 30-day mortality was 3.7% in 2014. Left atrial appendage occlusion and patent foramen ovale (PFO) closure for stroke, and the use of the MitraClip® system (Abbott Vascular, Santa Clara, CA, USA) for mitral regurgitation have been funded through a process called "commissioning through evaluation".

Serbia: coronary and structural heart interventions from 2010 to 2015.

Serbia's interventional community has been facing the multifaceted challenge of an ageing population with cardiovascular diseases as the primary cause of death nationwide, coronary artery disease (CAD) being the most prevalent subset. The following two fields of activity have marked the trajectory of progress in the field of interventional cardiology in Serbia: first, the expansion of the infrastructure, mainly through the opening of new catheterisation laboratories across all of the country's administrative regions, which has resulted in better accessibility to coronary interventions for the general population; second, the creation of national platforms for continuous education, training and the promotion of clinical research in interventional cardiology, with close programmatic links to European Association of Percutaneous Cardiovascular Interventions (EAPCI)-based educational initiatives, including the curriculum for interventional cardiology. As growth seems to be inherent to the concept of progress, we report here on the expanding numbers of coronary interventions in the period between January 2010 and December 2015, and the early experiences with structural heart interventions in Serbia.

France: coronary and structural heart interventions from 2010 to 2015.

France, with its 66 million inhabitants, has a long tradition in interventional cardiology, with numerous innovations and contributions to the dynamism of European activity. The development of interventional cardiology requires supervised training, organisation and participation in studies. This also translates into an ever-expanding clinical activity since 2010, such as the coronary and structural interventions that are detailed in the present review.

Spain: coronary and structural heart interventions from 2010 to 2015.

Since 1990 The Spanish Society of Cardiology Working Group on Cardiac Catheterization and Interventional Cardiology has presented a yearly report on the data collected in the National Registry, with online support since 2010. The Steering Committee has analysed all data provided voluntarily by institutions, which consisted of a total of anywhere between 105 and 113 hospitals. Medical care was provided to a population of 46.8 million inhabitants in 2015. During this period, diagnostic procedures increased progressively from 2010, reaching a maximum of 145,836 in 2015, 86% (125,484) corresponding to coronary angiograms. This means a ratio of 3,127 diagnostic studies per million inhabitants and 2,746 coronary angiograms per million inhabitants. Total percutaneous coronary interventions have increased to 67,671 procedures, with a ratio of 1,466 per million inhabitants where 18,418 were carried out during the acute phase of myocardial infarction (21.7%). Radial access has been successfully implemented in up to 73.8% of diagnostic procedures and 76.1% of percutaneous interventions. Concerning structural interventions such as septal defects, valve interventions and closure of left atrial appendage, these have had a marked evolution over time, with a total of 1,586 TAVI and 334 LAA closure procedures performed in 2015.