High Procedural Success Rate Research Articles

Abstract 15185: Outcomes of Radiofrequency Catheter Ablation of Atrial Arrhythmias in Lung Transplant Recipients

Introduction: Atrial arrhythmias (AA) are common after lung transplant (LT) and may impact overall mortality. The majority of arrhythmias tend to be organized flutter, amenable to ablation; however the data is limited. Hypothesis: The purpose of this study was to investigate the outcomes of radiofrequency catheter ablation of AA in LT recipients. Methods: All LT recipients undergoing electrophysiology study at our institution between 2011-2018 were retrospectively reviewed. A total of 20 atrial ablations were identified in 16 patients. Mean follow-up was 4 ± 2.9 years. Results: Overall, mean age was 55 ± 13 years, 63% were male, 63% were status post bilateral (vs. single) LT, and mean LVEF was 57%. Transplant indications included interstitial lung disease (44%), COPD (19%), and cystic fibrosis (19%). Antiarrhythmics and beta blockers were used in 44% and 75%, respectively. Mean time from transplant to first ablation was 2.7 years. Of 20 ablations, macro-reentrant flutter (75%) and focal atrial tachycardia (15%) were common, particularly in double LT recipients (Figure). The most common ablation sites were pulmonary vein anastomosis/left atrial ridge (60%), mitral annulus (35%) and left atrial roof (30%). Restoration of sinus rhythm occurred in 19 of 20 procedures and only one complication occurred (e.g. small pericardial effusion without tamponade). Arrhythmia recurred in 10 (63%) patients, however, most were managed conservatively. Repeat ablation was needed in 4 patients, of which AAs originated from different locations. Beta blocker use was associated with a lower risk of SVT recurrence (p=0.04). Reduced LVEF and longer time to procedure post-transplant were associated with repeat ablation (p<0.05). Conclusions: The majority of AAs in LT recipients are atrial flutter originating near the pulmonary vein anastomosis sites. Despite a high immediate procedural success rate, recurrence is high and 25% of patients require multiple ablation attempts.

Very long-term outcomes after catheter ablation of atrioventricular nodal reentrant tachycardia: How does cryoenergy differ from radiofrequency?

Either cryoenergy or radiofrequency can be used during atrioventricular nodal reentrant tachycardia (AVNRT) ablation. There are still limited data comparing their respective long-term efficacy (>1 year). This study sought to compare the very long-term outcomes of AVNRT ablation using radiofrequency or cryotherapy. We retrospectively included all patients who had undergone a first AVNRT ablation in our institution between January 2010 and December 2017. The primary endpoint was recurrence of documented AVNRT. The study population consisted of 409 patients (274 females; mean age, 49.9 years). Ablation was performed using cryoenergy in 260 patients and radiofrequency in 149. High acute procedural success rate (>98%) was obtained and no permanent AV block was observed using both techniques. During a mean follow-up of 3.3 ± 2.3 years, documented AVNRT recurrence occurred in 24 (9.2%) and 4 patients (2.7%) in the cryoablation (CA) and radiofrequency (RF) group, respectively. The risk of AVNRT recurrence was significantly higher in the CA group as compared with the RF group (hazard ratio [HR] = 3.7; 95% confidence interval [CI], 1.3-5.9). Most of the recurrences after CA occurred between 1- and 6-year follow-up (14/24; 58.3%), with one-third of late recurrences after 3-year follow-up. In multivariable analysis, only Koch's triangle anatomical variant was associated with AVNRT recurrence after CA (HR = 6.7; 95% CI, 2.7-16.3). While AVNRT recurrence rates were similar at 1 year of follow-up regardless of the energy used, long-term efficacy appeared higher after radiofrequency ablation. Strikingly, recurrences occured much later after cryotherapy compared with radiofrequency ablation.

Subclavian-Axillary Access for Transcatheter Aortic Valve Implantation with SAPIEN 3: Results from the ACCESS Study

ABSTRACT Background The ACCESS Study is a prospective, multicenter registry to evaluate the efficacy and safety of trans-subclavian and axillary transcatheter aortic valve replacement (TAx-TAVR) with the latest-generation balloon-expandable transcatheter valve (THV). The secondary goal of this study was to determine whether the type of TAx access (left versus right, supraclavicular-subclavian versus infraclavicular-axillary, cutdown versus percutaneous) made a difference in procedural and 30-day outcomes. Methods 75 consecutive patients from March 2016 to June 2018 with hostile femoral anatomy and favorable subclavian or axillary anatomy underwent TAx-TAVR using the SAPIEN 3 THV (Edwards Lifesciences, Irvine, CA) at six experienced centers. Demographics, procedural characteristics, in-hospital, and 30-day outcomes were recorded. Results Successful TAx access was obtained in 73 (97.3%) patients. Left subclavian 32 (42.7%) and left axillary 26 (34.6%) were the most common access sites followed by right subclavian 9 (12.0%) and right axillary 6 (8.0%). Nineteen (25.3%) of the patients underwent TAx-TAVR using a complete percutaneous technique. Vascular access complications requiring intervention during hospitalization occurred in 5 (6.7%). The in-hospital total stroke rate was 5.3% with debilitating stroke occurring in 2.7% of patients and did not appear to differ based on the type of TAx access. Thirty-day mortality was 4.0%. Conclusions TAx-TAVR with the SAPIEN 3 THV is an effective and safe alternative showing high procedural success and low rates of vascular injury. The type of TAx access (left versus right, subclavian versus axillary, cutdown versus percutaneous) does not appear to make a significant difference in procedural and 30-day outcomes. Abbreviations TAVR: transcatheter aortic valve replacement; TAx: trans-subclavian-axillary; THV: transcatheter valve; TA: transapical; TC: transcarotid; TF: transfemoral; LIMA: left internal mammary artery; SEM: standard error of the mean; SD: standard deviation; STS: Society of Thoracic Surgeons; BMI: body mass index; CABG: Coronary artery bypass graft; ICU: Intensive care unit; LOS: length of stay; MI: myocardial infarction; PCI: percutaneous coronary intervention; ESRD: end-stage renal disease; TAo: trans-aortic; TIA: transient ischemic attack.

Prosthesis embolization during transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has been a revolution in the treatment of severe aortic stenosis evolving to a high procedural success rate and low rate of complications. Embolization of the percutaneous device is a rare but potentially life-threatening complication. The spectrum of clinical manifestations ranges between incidental finding on cardiac imaging to cardiogenic shock or cardiac arrest. Data about predictors and management of transcatheter heart valve embolization are scarce and mostly anecdotical. Management strategies are related to the type, the size, the location of the embolized device, the timing of diagnosis, and the clinical presentation of the patient. According to recent data from TRAVEL registry, device embolization and migration occur in approximately 1% of the patients and is responsible for increased morbidity and mortality. However, in a considerable proportion of cases it could have been prevented, hence structural interventionalists should plan the procedures carefully and know thoroughly the risk factors for device embolization. Increased awareness of predisposing factors, preventive measures, and appropriate bail-out options and techniques are strongly advisable. This paper is a review of the incidence, and outcomes of percutaneous prosthesis embolization during TAVI. It also suggests an integrated algorithmic approach for the management of device embolization incorporating both percutaneous and surgical techniques.

Use and outcomes of the PK Papyrus covered stent in France: SOS PK Papyrus Registry

To evaluate the rate of procedural success and long-term outcomes of the PK Papyrus (PKP) covered stent (CS). CS are essential in the treatment of coronary artery perforation (CAP). They have also been used to treat coronary artery aneurysms. Limited evidence is available on clinical outcomes with the PKP. This was a multicenter, observational, retrospective, and prospective study. Consecutive patients undergoing intentional PKP implantation in 22 centers in France were included. The primary endpoint was the rate of procedural success. Secondary endpoints included rates of death, myocardial infarction (MI), target lesion revascularization (TLR), in-stent restenosis (ISR), and stent thrombosis (ST). Data from 130 patients were analyzed (mean age 72.5± 10.5 years; 71% men). The main indication for PKP was CAP, in 84 patients (65%). Delivery success was achieved in 95% and procedural success in 91%. During the in-hospital stay, 15 patients died (12%) and 7 (5%) presented with ST. Data from 127 patients were available at 19.2± 12.8month follow-up. Thirty-three patients died (26%), 15 (12%) had an MI and 21 (17%) presented with TLR. TLR was due to ISR in 12 patients (9%), 10 had definite ST (8%) and 1 patient for stent under-expansion. The principal indication for PKP was CAP. PKP had high rates of delivery and procedural success. At long-term follow-up, there was a high rate of TLR, mainly due to ISR and ST. These results are consistent with previously reported data in these clinical settings.

Is left main percutaneous coronary intervention justified in the presence of concomitant complex coronary artery disease – immediate and remote results – single Bulgarian center experience

Revascularization in patients with severe stenosis of left coronary artery (LCAS) trunk signifi cantly improves their prognosis. Modern clinical studies, registries and meta-analyses have identifi ed percutaneous coronary intervention (PCI) of LCAS as a safe alternative to aorto-coronary bypass (ACB) in patients with low and intermediate lesion complexity. Aims: To confi rm the safety and effectiveness of PCI and implantation of second generation drug eluting stent (DES) in patients with unprotected LCAS and concomitant complex coronary pathology. Material and Methods: For the period March 2013–October 2018 we performed 225 PCIs of patients with LCAS. 170 of patients who received PCI were divided into 2 groups, according to their SS-1 (ST elevation excluded). We analyzed the major adverse cardio-vascular events (MACE – all-cause mortality, cardiac mortality, stroke and ischemia driven TLR) rate and time-to-fi rst MACE during follow up. Results: 103 patients had SS-I < 32 and 67 patients had SS-I ≥ 32 and their mean age was 67,25 ± 11,03. The median follow-up was 26,6 ± 19,1 months. MACE rate was 12,4% and there was no signifi cance between groups (p = 0,118). Conclusions: PCI of unprotected LCAS has high procedural success rate and good mid-term results, even in pts with complex anatomy. High anatomical complexity of coronary lesions defi ned by SS-I ≥ 32 is not predictive for poor clinical outcome after PCI.

Outcomes After Coronary Orbital Atherectomy at Centers Without On-Site Surgical Backup: Diabetics Versus Non-Diabetics and Impact of Access Site

Background/purposeThere is limited data available on atherectomy usage in hospitals or centers without on-site surgical backup. The purpose of this retrospective analysis was to gain further knowledge by analyzing the in-hospital and 30-day outcomes of complex PCI patients (including diabetics) treated with coronary orbital atherectomy (OA) at centers without on-site surgical back-up. Methods/materialsAll comers treated with OA at two centers without on-site surgical backup were included. Baseline, procedure, and outcome data were compared in diabetic and non-diabetic patients. The impact of transfemoral (TFA) versus transradial (TRA) vascular access was also assessed. ResultsOf the 221 patients treated with OA, 43% were diabetics. The diabetes and no-diabetes groups had similar baseline demographic and lesion characteristics, except for the higher rate of chronic kidney disease seen in the diabetics. Overall, there was a high freedom from major adverse cardiac events (MACE; in-hospital: 99.5%; 30-day: 98.6%), as well as a high success in stent delivery (99.5%) and procedural success (97.3%). The rate of angiographic complications was low in both the diabetes and no-diabetes groups (3.1% vs. 1.6%, p = 0.450). TFA and TRA were used in 36% and 64% of the patients, respectively—resulting in low angiographic complications in both groups (3.8% vs. 1.4%, p = 0.263). ConclusionsDespite the complexity of patient co-morbidities and the presence of heavily calcified lesions, the results indicate that coronary OA can be used safely and effectively without on-site surgical back-up. OA treatment resulted in a high rate of successful stent delivery and procedural success, as well as low rates of angiographic complications and MACE, in diabetic and non-diabetic patients, regardless of access site. Table of contents summaryThere is limited data available on atherectomy usage in centers without on-site surgical backup. The purpose of this retrospective analysis was to gain further knowledge by analyzing the outcomes of complex PCI patients (including diabetics) treated with coronary orbital atherectomy (OA) at centers without on-site surgical back-up. The impact of transfemoral (TFA) versus transradial (TRA) vascular access was also assessed. Despite the complexity of patient co-morbidities and the presence of heavily calcified lesions, the results indicate that coronary OA can be used safely and effectively without on-site surgical back-up. OA treatment resulted in a high rate of successful stent delivery and procedural success, as well as low rates of angiographic complications and major adverse cardiac events, in diabetic and non-diabetic patients, regardless of access site (TFA or TRA).

Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction technique in transcatheter aortic valve-in-valve procedures: a single-center initial experience.

To describe six cases using the bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction technique to prevent coronary artery obstruction during transcatheter aortic valve-in-valve procedures. All patients presented degeneration of a bovine pericardium bioprosthesis [four Trifecta (19, 21, 23, and 25 mm); two Mitroflow (25 and 27 mm)] resulting in severe aortic stenosis (n = 5) or severe aortic regurgitation (n = 1). Procedures were performed under fluoroscopic and echocardiography guidance, and the transfemoral access was used to deliver a self-expanding valve. Data are expressed as frequency or median (Q1-Q3). Age, EuroScore II, and Society of Thoracic Surgeons score were 81 years (75-83.2), 2.9% (2.6-10.7), and 2.7% (2.3-3.2), respectively. Median left and right coronary heights were 9.1 mm (6.2-10.3) and 12.4 mm (10-13.5), respectively, with a median virtual transcatheter heart valve-to-coronary distance of 2.9 mm on the left and 4.6 mm on the right side. Isolated left leaflet laceration was planned in four patients, and bileaflet in two. One unsuccessful right leaflet laceration was reported, corresponding to the first patient (success rate 87.5%). All other seven leaflets lacerations were successfully performed, with no intraprocedure complications. No coronary obstruction, in-hospital death, valve complication, cardiovascular event, or pacemaker implantation were reported. All patients are being followed in routine outpatient visits, and no adverse events were registered. The high procedural success and low complication rate reported in this initial experience, demonstrates that the bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction technique can be a viable solution to prevent coronary obstruction in selected patients undergoing valve-in-valve procedures. Operator experience, periprocedural imaging and teamwork are essential to enable an accurate and successful procedure.

Efficacy of three-dimensional road mapping by fusion of computed tomography angiography and fluoroscopy in endovascular treatment of aorto-iliac chronic total occlusion.

The efficacy of multimodality image fusion road-mapping technique for endovascular therapy has been reported recently. Our aim was to evaluate the efficacy of endovascular therapy (EVT) with three-dimensional (3D) road mapping by fusing computed tomography (CT) and angiographical volumetric data for aorto-iliac chronic total occlusion (CTO). We retrospectively analyzed 36 patients with aorto-iliac CTO from June 2017 to November 2019 and classified them into two groups: EVT using a CT fused 3D roadmap (CTf3D-RM; 3D group, n = 14) and standard EVT (standard group, n = 22). Primary endpoint was wiring time and secondary endpoints were procedural success rate, number of guidewires, procedure time, radiation dose, contrast medium dose, and complications. Wiring time was significantly shorter in the 3D group than the standard group (3D, 15.6 ± 10.23min vs. standard, 44.6 ± 35.3min; p = 0.0052). Both groups had high procedural success rates (3D, 100% vs. standard, 100%) and low complication rates (3D, 0.0% vs. standard, 9.1%; p = 0.51). There were significantly fewer guidewires in the 3D group than the standard group (3D, 2.78 ± 1.31 vs. standard, 4.36 ± 2.01; p = 0.0138). The 3D group trended towards shorter procedural time (3D, 78.8 ± 32.5min vs. standard, 107.5 ± 52.5min; p = 0.076), lower radiation dose (3D, 28.6 ± 18.9 Gycm2 vs. standard, 48.9 ± 49.2 Gycm2; p = 0.15), and lower contrast medium dose (3D, 102.2 ± 30.6 vs. standard, 127.5 ± 51.3; p = 0.11) than the standard group. Therefore, we concluded that EVT with CTf3D-RM is effective for aorto-iliac CTO. This method may improve the quality of aorto-iliac CTO interventions.

Systematic review and meta-analysis of valve-in-valve transcatheter aortic valve replacement in patients with failed bioprosthetic aortic valves.

The aim of this meta-analysis was to evaluate the evidence regarding the rates of procedural success and the incidence of adverse outcomes following valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) in patients with failed bioprosthetic aortic valves. A systematic search of major electronic databases was conducted for studies relevant to patients with failed bioprosthetic aortic valves undergoing VIV-TAVR. The primary outcome was procedural success. A total of 5,553 patients from 24 studies were included. The mean Society of Thoracic Surgeons (STS) score was 7.84±5.14. The procedural success rate was high (97%, 95% confidence interval [CI]: 94-98%). At 30 days, all-cause mortality was 5% (95% CI: 3-6%), stroke 2% (95% CI: 1-2%), myocardial infarction 1% (95% CI: 1-2%), permanent pacemaker placement 6% (95% CI: 5-8%), and aortic regurgitation 7% (95% CI: 5-10%). At one year, the incidence of all-cause mortality was 12% (95% CI: 10-14%), stroke 3% (95% CI: 2-4%), myocardial infarction 1% (95% CI: 0-2%), and permanent pacemaker placement 7% (95% CI: 5-11%). At three years, the incidence of all-cause mortality was 29% (95% CI: 25-34%) and stroke 6% (95% CI: 5-9%). VIV-TAVR appears to be associated with high procedural success rates and low adverse outcomes during the short-term and midterm follow-up period.

Comparison of bailout and planned rotational atherectomy for severe coronary calcified lesions

BackgroundTo compare outcomes of bailout and planned rotational atherectomy (RA) in the treatment of severe calcified coronary lesions.MethodsData of patients treated with RA from 2017 to 2018 at a single-center registry were retrospectively analyzed. All patients were divided into planned RA and bailout RA groups, data between two groups were compared.ResultsA total of 190 patients were included in this study, 138 patients received planned RA and 52 patients received bailout RA. Baseline clinical characteristics had no significant differences between groups. The number of implanted stents and total stents length were similar. But the number of balloon (1.6 ± 0.8 vs. 2.7 ± 1.3, P < 0.001), procedure time (83.5 ± 26.2 vs. 100.8 ± 36.4 min, P = 0.007), fluoroscopy volume (941 ± 482 vs. 1227 ± 872 mGy, P = 0.012] and contrast amount (237 ± 62 vs. 275 ± 90 ml, P = 0.003) were all lower in planned RA group. Planned RA had a higher procedural success rate (99.3% vs. 92.3%, P = 0.007) and a lower complication incidence (4.3% vs. 17.3%, P = 0.009). But the primary outcomes at 3 years (9.2 and 16.6%, log rank p = 0.24) had no difference between groups.ConclusionsFor severe coronary artery calcification, although planned RA did not improved the long term prognosis compared with bailout RA, but it can improve the immediate procedural success rate, reduce the incidence of complications, the procedure time and the volume of contrast.

The impact of chronic kidney disease on outcomes following peripheral vascular intervention.

BackgroundPatients with chronic kidney disease (CKD) have worsened clinical outcomes following percutaneous coronary intervention; however, limited evidence exists in patients undergoing peripheral vascular intervention (PVI).PurposeWe aimed to assess the effect of CKD on outcomes following PVI for symptomatic peripheral artery disease.MethodsUsing patients from the LIBERTY 360 study, we compared the rates of 30 day and 1 year major adverse vascular events (MAVE), a composite of all‐cause mortality, major amputation, and target vessel/lesion revascularization, between patients with and without CKD (estimated glomular filtration rate less than 60) following PVI. Multivariable adjustment was performed to assess for independent association between CKD and outcomes.ResultsAmong 1189 patients enrolled, 378 patients (31.8%) had CKD. At 1 year, patients with CKD had higher rates of MAVE (34.6% vs 25.6%), all‐cause mortality (11.9% vs 5.5%), and major amputation (5.9% vs 2.6%) when compared with patients without CKD (all P < .05). After adjustment, patients with CKD had higher risks of 1‐year MAVE (HR 1.30, 95% CI 1.04‐1.64; P = .023) and all‐cause mortality (HR 1.88, 95% CI 1.22‐2.91; P = .005) when compared with patients without CKD. There was no statistically significant difference in risk of major amputations (HR 1.70, 95% CI 0.91‐3.17; P = .094).ConclusionsDespite high procedural success and low amputation rates, patients with CKD remain at greater risk for MAVE and all‐cause mortality after PVI. Further research is needed to determine treatment strategies to mitigate substantial mortality risk in this vulnerable population.

Efficacy and Safety of Angiography-Guided Retrograde Posterior Popliteal Puncture Technique in the Supine Position

Various techniques are needed for successful treatment of femoropopliteal long chronic total occlusion (CTO). Previous reports have described popliteal puncture by duplex echo guidance, but the safety of angiography-guided popliteal puncture remains unclear. This study was performed to examine the efficacy and safety of angiography-guided retrograde posterior popliteal puncture in the supine position. We analyzed 44 consecutive patients treated with retrograde femoropopliteal puncture for femoropopliteal CTO from October 2013 to February 2019. We compared 24 patients who underwent angiography-guided posterior popliteal puncture (posterior group) and 20 patients who underwent frontal superficial femoral artery/popliteal artery puncture (frontal group). The primary end point was successful revascularization. The secondary end points were the puncture time, hemostasis time, and procedure-related complications. The posterior group tended to have a higher procedural success rate than the frontal group (100% vs. 90.0%, respectively; P=0.20). The hemostasis time was significantly shorter in the posterior than frontal group (527.1±146.5 vs. 710.0±337.8sec, respectively; P=0.021). There was no significant difference in the puncture time between the posterior and frontal groups (8.19±9.22 vs. 7.50±9.68min, respectively; P=0.81). Both groups had a low complication rate (posterior, 0.0% vs. frontal, 5.0%; P=0.4). Angiography-guided posterior popliteal puncture in the supine position can facilitate hemostasis and may improve the success rate of the procedure. This technique may contribute to the treatment of complex femoropopliteal CTO as one option for a retrograde approach.

Initial experience of a MitraClip valve repair program in Spain.

BackgroundThe main objective of this study was to evaluate one-year clinical outcome of patients with symptomatic mitral regurgitation (MR) treated with transcatheter mitral valve repair (TMVR) according to the etiology of MR.MethodsData from a single high-volume center of all consecutive cases with symptomatic MR undergoing TMVR where prospectively included and followed.ResultsBetween October 2015 and October 2019, 81 consecutive patients underwent TMVR and were included in the investigation. The mean age was 75.73±7.81 years, 55 (67.9%) were male. The most frequent mechanism was functional MR (FMR) (59%). The mean EuroSCORE II was 5.7±4.94 [FMR 5.38±3.9, degenerative MR (DMR) 5.72±4.7 and mixed MR (MMR) 6.6±7.5; P=0.7776] and STS score mean was 5.21±3.31 (FMR 4.6±2.3, DMR 6.43±5.2 and MMR 5.7±3.2; P=0.126). Patients with FMR had higher rates of dilated (36 patients, 75.5%) and ischemic (15 patients, 31.3%) cardiomyopathy, as well as worse left ventricular ejection fraction (LVEF). Procedural success was achieved in 72 (88.9%) patients, with a similar distribution between groups. The median of follow-up was 16.3 months. The primary combined endpoint occurred in 19 (23.5%) cases. The number of the combined event regarding the different etiologies were 15 (31.2%) in FMR, 2 (11.8%) in DMR and 5 (31.3%) in MMR (P=0.276). Sixteen patients (20.0%) died during the first year of follow-up and 19 (23.5%) had unplanned heart failure (HF) hospitalization. Previous surgical revascularization (HR =4.94, P=0.004) and a redo TMVR (HR =11.3, P=0.006) predicted the main event.ConclusionsTMVR with the Mitraclip device is safe, with a low incidence of complications and a high rate of procedural success. One-year outcomes show reduction of all cause death and HF admissions. Moreover, most of the patients have sustained MR reduction and an improvement in the functional class at the end of follow-up.

Hybrid transvenous lead extraction during cardiac surgery for valvular endocarditis.

In patients with endocarditis and cardiac implantable electronic devices (CIED), lead extraction is recommended according to current guidelines. In patients with short lead implant duration, lead extraction by manual traction might be sufficient for intraoperative lead removal. However, in patients with long implant duration, specialized extraction tools like laser or mechanical rotational sheaths are necessary. We report our experience with transvenous lead extraction during concomitant cardiac surgery for valvular endocarditis using mechanical rotational sheaths. Between December 2018 and April 2020, 12 patients were treated with transvenous lead extraction during open-heart surgery using mechanical rotational sheaths. Cardiac surgery was performed due to mitral, aortic, or tricuspid valve endocarditis. All patient-related and procedural data were collected, and in-hospital outcome was analyzed retrospectively. Mean patients' age was 65.2 ± 16.4 years, and 75.0% were male. Nine atrial, 15 ventricular, and 2 coronary sinus leads had to be extracted. The mean time from initial lead implantation was 94.3 ± 39.7 months. Complete procedural success was achieved in all patients with no major but one minor complication (pocket hematoma) occurring during lead extraction. Four patients with pacemaker dependency received epicardial leads, seven patients were treated in a two-step approach with endocardial leads, whereas one patient had no further CIED indication. No procedure-related mortality was seen. In-hospital survival was 91.7%. Valvular endocarditis surgery in combination with lead extraction using mechanical rotational sheaths is safe and feasible. It results in a high procedural success rate with prompt infection control by immediate removal of all infected lead materials.

P516Permanent his bundle pacing: conclusions from the one-year experience of a romanian center

Abstract Background Long term right ventricular pacing has been associated with an increased risk of heart failure development due to pacing induced cardiomyopathy. Therefore, alternatives of more physiological pacing have been evaluated. Amongst them, His bundle pacing (HBP) has emerged in the past two decades as the most physiological method of ventricular pacing due to synchronous activation of both ventricles through the intrinsic conduction system. Although there is an already consistent experience in the United States, China and western Europe regarding His bundle pacing, some countries in central and eastern Europe have little or no experience in this matter. We present the results of our one-year experience after implementing His bundle pacing in a tertiary cardiac pacing center in Romania. Material and methods Between July 2018 and October 2019, HBP using the current available dedicated delivery system was attempted in 50 patients with permanent cardiac pacing indications. Patient characteristics and procedural results were analyzed during implant and at 3 months, 6 months and 1 year follow-ups. Results The mean age of the patients was 70,14 ± 10,58 years and 58 % were male. The main indication for cardiac pacing was atrioventricular block (66%) and 96 % received a dual-chamber pacemaker. No ventricular back-up leads were used. The acute procedural success (selective or nonselective His bundle capture) was achieved in 40 patients (80%). The rest of the patients received either right ventricular or left bundle branch pacing. Selective His bundle pacing was seen in 15 out of 40 patients, with nonselective His bundle pacing in the rest. The acute His pacing threshold was 1.77 ± 1.06 V at 1 ms, the sensed R wave amplitude was 4.2 ± 2.27 mV and total fluoroscopy time was 15.95 ± 10.9 min. The paced QRS duration was very similar to the baseline QRS duration in patients without bundle branch block and significantly narrower in patients with bundle branch block morphology (126,6 ± 23 ms vs. 95,5 ± 21,65 ms, p &amp;lt; 0,001). The presence of a native QRS complex with a bundle branch block morphology was associated with an increased risk of procedural failure, longer fluoroscopy times and higher capture thresholds. Also, pacing threshold (1,91 ± 1,23 vs. 1,62 ± 0,84 V/1ms , p = 0,4) and fluoroscopy times (21,15 ± 10,35 vs. 10,75 ± 8,85 min, p = 0,002) were lower in the second half of the procedures as the learning curve was achieved. There were no significant changes in pacing and sensing thresholds at 3 months, 6 months and 1 year follow-ups. There was only one case of lead dislodgement a week after the procedure that required reintervention. Conclusion His bundle pacing is feasible and easy to implement in an experienced device implantation center, with a high procedural success rate. Improvement of the procedural parameters is achieved while advancing the learning curve. Proper patient selection could influence the outcomes of the procedure.

P1025Incidence and characteristics of pulmonary vein reconduction after second-generation cryoballoon-based pulmonary vein isolation: Impact of different ablation strategies

Abstract Funding Acknowledgements none Introduction The second-generation CB (CB2, Arctic Front Advance, Medtronic Inc., Minneapolis, USA) has demonstrated high procedural success rates, relatively short procedure times, high durability of PVI and convincing long-term clinical success rates. Nevertheless, data on the impact of different ablations protocols on durability after CB2 based PVI is limited. Purpose We aimed at comparing durability of pulmonary vein isolation (PVI) following three different ablation strategies utilizing the second-generation cryoballoon (CB2) in patients with recurrence of atrial fibrillation (AF) or atrial tachycardia (AT) undergoing repeat procedures. Methods In 192 patients a total of 751 PVs were identified. All PVs (751/751, 100%) were successfully isolated during index PVI. Thirty-one out of 192 (16%) patients were treated with a bonus-freeze protocol (group 1), 67/192 (35%) patients with a no bonus-freeze protocol (group 2), and 94/192 (49%) patients with a "time-to-effect"-guided ablation protocol without bonus freezes (group 3). Results Persistent PVI was documented in 419/751 (55.8%) PVs, and in 41/192 (21%) patients all PVs were persistently isolated. The number of patients with all PVs being persistently isolated was not significant between the groups (p = 0.594). The total rate of PV reconnection was not significantly different between the three groups (p = 0.134) and the comparison of individual PVs revealed also no differences for different ablation protocols (p-values for RSPV: 0.424, RIPV: 0.541, LSPV: 0.788, LIPV: 0.346, LCPV: 0.865). The procedure times were significantly reduced in non-bonus freeze ablation protocols and/or when applying individualized application times (group 1: 123.4 ± 31.5min, group 2: 112.9 ± 39.8 min, group 3: 86.67 ± 28.4 min, p &amp;lt;0.001). Conclusions A considerably high rate of persistent PVI was demonstrated in patients after index CB2-based PVI. No differences for durable PVI were detected for different ablation protocols. Therefore, individualized ablation protocols might be a beneficial ablation strategy during CB2-based PVI.

Real-World Usage of the WavelinQ EndoAVF System

Dependent on existing deep to superficial perforating venous branches, the WavelinQ EndoAVF System is a novel technique used to create an arteriovenous fistula (AVF) between ulnar or radial veins and concomitant arteries for dialysis access. We sought to examine a single center's success rates and short-term follow-up using this device. All consecutive patients undergoing placement of a WavelinQ AVF from October 2018 to July 2019 were included. Preoperative/intraoperative variables including demographics, preoperative/postoperative duplex ultrasonography, success rate of procedure, and subsequent endovascular/surgical procedures were obtained. Descriptive statistics and comparison of groups requiring subsequent intervention were performed. Thirty-five patients underwent placement of the WavelinQ AVF, with 32 (91%) patients having at least one documented follow-up. These patients were predominantly male (23/32, 72%) with an average age of 60.2 and 23 of 32 (72%) patients were on dialysis. Initial fistula creation success rate was 100%. Average procedural length was 120min, fluoroscopy time 9.6min, and contrast usage 52.2mL. Eight of 32 (25%) patients had perioperative complications (3 hematomas, 3 contrast extravasations, 1 resolved vessel spasm all resolving spontaneously, and 1 pseudoaneurysm requiring surgical repair). Thirteen of 32 (41%) patients underwent subsequent endovascular interventions to assist with maturation [9/32 (28%) branch coiling, 5/32 (16%) angioplasty/stenting, and 3/32 (9%) access thrombectomy] and 4 of 32 (13%) patients required subsequent surgical interventions (1 pseudoaneurysm repair, 1 revision of fistula, and 2 definitive AVF creation in thrombosed grafts). The majority of accesses (30/32, 94%) were ulnar-ulnar fistulas and overall patency at average follow-up of 73days was 88% (28/32) with average brachial artery inflow volume of 1,078cc/min and average cephalic vein (18/32) outflow volume of 447cc/min. Eleven of 23 (48%) patients on dialysis were successfully using the EndoAVF at follow-up. The WavelinQ AVF system has a high initial procedural success rate, although a significant portion of patients require subsequent endovascular procedures to aid in maturation. Further work on determining factors predictive of need for reintervention is necessary.

Systematic Scoring Balloon Lesion Preparation for Drug-Coated Balloon Angioplasty in Clinical Routine: Results of the PASSWORD Observational Study.

IntroductionScoring balloon angioplasty (SBA) for lumen gain prior to stent implantations or drug-coated balloon angioplasty (DCB) is considered an essential interventional tool for lesion preparation. Recent evidence indicates that SBA may play a pivotal role in enhancing the angiographic and clinical outcomes of DCB angioplasty.MethodsWe studied the systematic use of SBA with a low profile, non-slip element device prior to DCB angioplasty in an unselected, non-randomized patient population. This prospective, all-comers study enrolled patients with de novo lesions as well as in-stent restenotic lesions in bare metal stents (BMS-ISR) and drug-eluting stents (DES-ISR). The primary endpoint was the target lesion failure (TLF) rate at 9 months (ClinicalTrials.gov Identifier NCT02554292).ResultsA total of 481 patients (496 lesions) were recruited to treat de novo lesions (78.4%, 377), BMS-ISR (4.0%, 19), and DES-ISR (17.6%, 85). Overall risk factors were acute coronary syndrome (ACS, 20.6%, 99), diabetes mellitus (46.8%, 225), and atrial fibrillation (8.5%, 41). Average lesion lengths were 16.7 ± 10.4 mm in the de novo group, and 20.1 ± 8.9 mm (BMS-ISR) and 16.2 ± 9.8 mm (DES-ISR) in the ISR groups. Scoring balloon diameters were 2.43 ± 0.41 mm (de novo), 2.71 ± 0.31 mm (BMS-ISR), and 2.92 ± 0.42 mm (DES-ISR) whereas DCB diameters were 2.60 ± 0.39 mm (de novo), 3.00 ± 0.35 mm (BMS-ISR), and 3.10 ± 0.43 mm (DES-ISR), respectively. The overall accumulated TLF rate of 3.0% (14/463) was driven by significantly higher target lesion revascularization rates in the BMS-ISR (5.3%, 1/19) and the DES-ISR group (6.0%, 5/84). In de novo lesions, the TLF rate was 1.1% (4/360) without differences between calcified and non-calcified lesions (p = 0.158) and small vs. large reference vessel diameters with a cutoff value of 3.0 mm (p = 0.901).ConclusionsThe routine use of a non-slip element scoring balloon catheter to prepare lesions suitable for drug-coated balloon angioplasty is associated with high procedural success rates and low TLF rates in de novo lesions.

Real-World Experience With a Tapered Biodegradable Polymer-Coated Sirolimus-Eluting Stent in Patients With Long Coronary Artery Stenoses.

BackgroundTreatment of long coronary stenoses (LCS) with long tapered drug-eluting stents (LT-DES) would offer clinical and economic benefits. However, the feasibility of an interventional strategy based upon the systematic LCS treatment with an LT-DES has not been evaluated so far.MethodsWe performed a multicenter prospective study including consecutive patients with: 1) An LCS > 25 mm at coronary angiography; 2) An attempt to fix the LCS with a single BioMime Morph™ stent, a novel LT-DES available from 30 to 60 mm long. The primary efficacy endpoint was procedural success. The secondary safety endpoints were post-procedural TIMI3 flow, stent detachment during delivery, acute stent thrombosis and in-hospital mortality.ResultsFrom February 2017 to March 2018, we recorded 272 patients with an LCS and an attempt to deploy an LT-DES during percutaneous coronary intervention (PCI) (69.3 ± 11.4 years, 75.7% males, 25.7% diabetic and 43.8% with acute coronary syndromes, mean LCS length 48.8 ± 9.5 mm). LT-DES deployment was successful in 262 patients (96.3%), and failure occurred without stent detachment or other complications. Final TIMI3 flow was present in 270 (99.3%) patients. In-hospital death occurred in five patients (1.8%), with no case of acute stent thrombosis, recurrent myocardial infarction or repeated revascularization.ConclusionIn this real-world study, a strategy of fixing LCS with a single LT-DES was feasible and safe, with a high rate of procedural success and a low rate of in-hospital complications. More extensive randomized studies are warranted to assess the potential clinical and economic benefits of LT-DES.