Low-pressure Balloon Research Articles

N-of-1 Trial of Angina Verification Before Percutaneous Coronary Intervention

BackgroundIn stable coronary artery disease, 30% to 60% of patients remain symptomatic despite successful revascularization. Perhaps not all symptoms reported by a patient with myocardial ischemia are, in fact, angina. ObjectivesThis study sought to determine whether independent symptom verification using a placebo-controlled ischemic stimulus could distinguish which patients achieve greatest symptom relief from percutaneous coronary intervention (PCI). MethodsORBITA-STAR was a multicenter, n-of-1, placebo-controlled study in patients undergoing single-vessel PCI for stable symptoms. Participants underwent 4 episodes (60 seconds each) of low-pressure balloon occlusion across their coronary stenosis, randomly paired with 4 episodes of placebo inflation. Following each episode, patients reported the similarity of the induced symptom in comparison with their usual symptom. The similarity score ranged from −10 (placebo replicated the symptom more than balloon occlusion) to +10 (balloon occlusion exactly replicated the symptom). The primary endpoint was the ability of the similarity score to predict symptom relief with PCI. ResultsFifty-one patients were recruited, aged 62.9 ± 8.6 years. The median fractional flow reserve was 0.68 (Q1-Q3: 0.57-0.79), and the instantaneous wave-free ratio was 0.80 (Q1-Q3: 0.48-0.89). The median similarity score was 3 (Q1-Q3: 0.875-5.25). The similarity score was a strong predictor of symptom improvement following PCI: a patient with an upper quartile similarity score of 5.25 was significantly more likely to have lower angina frequency at follow-up (OR: 8.01; 95% credible interval: 2.39-15.86) than a patient with a lower quartile similarity score of 0.875 (OR: 1.31; 95% credible interval: 0.71-1.99), Pr(difference) >99.9%. ConclusionsSimilarity score powerfully predicted symptom improvement from PCI. These data lay the foundation for independent symptom mapping to target PCI to those patients most likely to benefit. (Systematic Trial of Angina Assessment Before Revascularization [ORBITA-STAR]; NCT04280575)

Efficacy and safety of intracoronary pro-urokinase combined with low-pressure balloon pre-dilatation during percutaneous coronary intervention in patients with anterior ST-segment elevation myocardial infarction

BackgroundThe efficacy and safety of low-pressure balloon pre-dilatation before intracoronary pro-urokinase (pro-UK) in preventing no-reflow during percutaneous coronary intervention (PCI) remains unknown. This study aimed to evaluate the clinical outcomes of intracoronary pro-UK combined with low-pressure balloon pre-dilatation in patients with anterior ST-segment-elevation myocardial infarction (STEMI).MethodsThis was a randomized, single-blind, investigator-initiated trial that included 179 patients diagnosed with acute anterior STEMI. All patients were eligible for PCI and were randomized into two groups: intracoronary pro-UK combined with (ICPpD group, n = 90) or without (ICP group, n = 89) low-pressure balloon pre-dilatation. The main efficacy endpoint was complete epicardial and myocardial reperfusion. The safety endpoints were major adverse cardiovascular events (MACEs), which were analyzed at 12 months follow-up.ResultsPatients in the ICPpD group presented significantly higher TIMI myocardial perfusion grade 3 (TMPG3) compared to those in the ICP group (77.78% versus 68.54%, P = 0.013), and STR ≥ 70% after PCI 30 min (34.44% versus 26.97%, P = 0.047) or after PCI 90 min (40.0% versus 31.46%, P = 0.044). MACEs occurred in 23 patients (25.56%) in the ICPpD group and in 32 patients (35.96%) in the ICP group. There was no difference in hemorrhagic complications during hospitalization between the groups.ConclusionPatients with acute anterior STEMI presented more complete epicardial and myocardial reperfusion with adjunctive low-pressure balloon pre-dilatation before intracoronary pro-UK during PCI.Trial registration2019xkj213.

Safety and Efficacy of Polyvinyl Alcohol Granules in Treating Type II and III Coronary Artery Perforation.

The success rate of polyvinyl alcohol (PAV) granules in the treatment of coronary artery perforation (CAP) was investigated to determine their safety and efficacy. Forty patients with II and III coronary artery perforations during percutaneous coronary intervention were divided into two groups. One group was only occluded by low pressure balloons (balloon occlusion group), and the other one was occluded with PVA granules during low-pressure balloon dilatation (PVA granules embolization group). Retrospective analysis of clinical data was used to compare the success rate and safety of various methods. The balloon embolization group had 16 cases (88.9%) of coronary perforation type II and 2 cases (11.1%) of coronary perforation type III. The PVA granules embolization group had 20 cases (90.9%) of coronary perforation type II and 2 cases (9.1%) of coronary perforation type III. Of the 18 patients in the balloon occlusion group, 13 were immediately occluded, with a success rate of 72.2%, while the remaining 5 required embolization or covered stents. 6 of the 18 patients had pericardial effusion, and two of them underwent pericardiocentesis. Among the 22 patients in the PVA granules embolization group, 21 were immediately blocked, with a 95.5% success rate, while the other was occluded by a covered stent. The results revealed that the success rate of transcatheter closure in the PVA granules embolization group was significantly higher than that in the balloon embolization group, and the risk of pericardial effusion and pericardiocentesis in the PVA granules embolization group was significantly lower than that in the balloon embolization group. In comparison to the simple use of low-pressure balloon occlusion, the use of PAV granules in the treatment of II, III coronary artery perforation has a high success rate and safety, and is a viable method for treating coronary artery perforation.

Effect of Limb Salvage by Excimer Laser Angioplasty Plus Low-Pressure Balloon Inflation in Chronic Limb-Threatening Ischemia Patients with Infrapopliteal Vessel Disease.

Patients with chronic limb-threatening ischemia (CLTI) often exhibit long, diffuse, totally occluded and heavily calcified infrapopliteal (IP) lesions. This study evaluated limb salvage after peripheral excimer laser atherectomy (PELA) plus low-pressure balloon inflation (LPBI) without stent deployment in CLTI patients with severe IP disease. We retrospectively evaluated 70 consecutive patients with 109 IP vessels who underwent PELA plus LPBI from 2010 to 2013. Technical success was defined as at least one IP straight-line flow being achieved below the malleolus. Binary logistic regression was performed to identify factors associated with 6-month limb salvage. Of the 109 IP vessels, 100 (91.7%) were totally occluded, and none of the patients received a stent. Of the 70 patients, 20% were octogenarians, and 85.8% had a Rutherford-Becker class 5 and 6. The technical success rate was 87.1% and 6-month limb salvage rate was 78.6%. Rutherford score was negatively correlated with clinical success (adjusted odds ratio 0.24; p = 0.028). No immediate major cardiovascular events were recorded during admission. PELA plus LPBI may be a treatment option for complex IP lesions in patients with CLTI. Higher Rutherford class was correlated with a lower 6-month limb salvage rate. However, a large-scale study with a control group is needed to clarify our results.

Safety and Tolerability of Direct Ischemic Postconditioning Following Thrombectomy for Acute Ischemic Stroke.

Experimental studies have demonstrated the neuroprotection of ischemic postconditioning (IPostC) in acute ischemic stroke by attenuating ischemia-reperfusion injury. This study aimed to investigate the safety and tolerability of direct IPostC in both a dog model and patients with acute ischemic stroke treated with thrombectomy. The study involved 2 parts. First, IPostC was induced by repeated balloon inflation and deflation in dogs, where a low-pressure balloon was navigated to the anterior spinal artery, and 4 cycles of 5-minute ischemia followed by 5-minute reperfusion were performed. Vascular injuries were assessed using angiography and vascular tissue specimens. Then, a 3+3 dose-escalation trial was conducted in patients with acute ischemic stroke following successful thrombectomy recanalization. Patients received direct IPostC with ischemia and reperfusion durations in progressive increments of 0, 1, 2, 3, 4, and 5 minutes ×4 cycles. Major adverse responses were defined as vessel perforation, rupture, dissection, reocclusion, severe vasospasm, thrombotic events, and rupture of the balloon. IPostC was investigated in 4 dogs. No vessel perforation or rupture, dissection, or vasospasm was observed under the angiography. Only 1 vessel experienced mild injury between the intima and the internal elastic membrane detected on a histopathologic slide. Then, 18 patients were recruited. The duration of IPostC was progressively escalated with no major response happened. No patient experienced agitation, discomfort, or other tolerability issues. Five patients (27.8%) experienced any intracranial hemorrhage after thrombectomy, and 1 (5.6%) was symptomatic. At 3-month follow-up, no patient died, and 9 patients (50%) achieved functional independence. Direct IPostC inducing by 4 cycles of 5-minute ischemia followed by 5-minute reperfusion is safe, feasible, and tolerable in patients with acute ischemic stroke treated with thrombectomy. Further investigations are needed to determine the safety and preliminary efficacy of direct IPostC. URL: https://www. gov; Unique identifier: NCT05153655.

Sodium Chloride Physiological Saline Solution Versus Water Preparations Injectable in the Use of Shockwave Intravascular Lithotripsy: A Single-Center Experience

Shockwave intravascular lithotripsy (IVL) coronary system is a very useful new technology for de novo severely calcified coronary artery plaques before percutaneous coronary intervention (PCI). The device uses a semi-compliant low-pressure balloon, integrated into a sterile catheter, to deliver by vaporizing fluid an expanding bubble that generates high-pressure ultrasonic energy by waves that create multiplane longitudinal micro-macro fractures in calcified plaques, which facilitate optimal stent placement and expansion, and luminal gain. The use of Shockwave IVL coronary system in our cardiac catheterization laboratory (Cath lab) at the "Clinique Saint-Hilaire" in Rouen, France, started in March 2019, with 42 procedures performed since this date: two patients in 2019, two patients in 2020, seven patients in 2021, 23 patients in 2022, and eight patients since the beginning of 2023. We had experienced problems at the beginning of our activity for the first 11 patients (two patients in 2019, two patients in 2020, and seven patients in 2021): after less than five pulses, the shock therapy stopped. We used initially for Shockwave IVL semi-compliant low-pressure integrated balloons a mixture of 50% contrast and 50% water preparations injectable (PPI). After changing water PPI by sodium chloride physiological saline solution, we never encountered this problem again for the following 31 patients (23 patients in 2022, and eight patients since the beginning of 2023). In fact, the proper functioning of Shockwave IVL system requires ions in balloon mixture in addition to the contrast. It is thanks to the ions contained in sodium chloride physiological saline solution that the spark necessary for shocks delivery after balloon inflation is produced. Water PPI or sodium chloride physiological saline solution is used in angioplasty balloons in a lot of Cath labs worldwide. It is therefore essential to disseminate in the worldwide Cath lab the obligation to put in Shockwave IVL semi-compliant low-pressure integrated balloons sodium chloride physiological saline solution, rather than water PPI for optimal performance, and the importance of Shockwave Medical reporting this to interventional cardiologists.

Midterm safety and outcome of balloon angioplasty of native aortic coarctation in neonates and young infants and initial experience of prepartial dilatation using high-pressure noncompliant balloon.

Background:Balloon angioplasty (BA) for aortic coarctation in neonates and infants remains controversial due to high recurrence rate and vascular complications.Aim:This study aimed to determine the safety and outcome of percutaneous treatment of coarctation in neonates and infants and to share the initial experience of strategy of prepartial dilatation with high-pressure noncomplaint balloon before final targeted dilatation using low-pressure compliant balloon.Materials and Methods:Retrospective analysis of records of all neonates and infants aged <6 months who underwent BA either using only low-pressure balloon (Group A) or those with prepartial dilatation using high-pressure noncomplaint balloon followed by low-pressure compliant balloon (Group B) between July 2017 and February 2020 was performed. Demographic, clinical, echocardiographic, interventional, and follow-up data were collected for all.Results:A total of 51 patients (41.2% neonates) were included in the study. Median age was 1 month 14 days (60.8% girls) and mean weight was 3.6 ± 1.5 kg. The mean peak trans-coarctation gradient was 53 ± 12 (34–80) mmHg. The final pressure gradient dropped to <10 mmHg in all cases of Group B and only in 26.3% (5) patients of Group A (P < 0.001). Recoarctation rate was 25.5% (13) overall and was significantly higher in Group A patients (P < 0.001), in those with borderline/mildly hypoplastic arch (P = 0.04) and in those with postprocedure gradient between 10 and 20 mmHg (P = 0.02). Median time to re-coarctation was significantly delayed in Group B (P < 0.001). There were no major complications or mortality in either group.Conclusions:BA in neonates and young infants has an excellent short and mid-term safety and efficacy. The recoarctation rate is significantly reduced as well as delayed with prepartial dilatation using high-pressure noncompliant balloon.

Effect of coarctation of aorta anatomy and balloon profile on the outcome of balloon angioplasty in infantile coarctation

ObjectiveCoarctation of the Aorta (CoA) is a relatively common cardiovascular disorder. The present study aimed to evaluate the effect of COA anatomy and high versus low-pressure balloons on the outcome of balloon angioplasty among neonates and infants.MethodsIn this retrospective study, the neonates and infants undergoing balloon angioplasty at Namazi hospital were enrolled. After balloon angioplasty, immediate data results were promptly recorded.Moreover, midterm echocardiographic information was collected via electronic cardiac records of pediatric wards and clinical and echocardiographic data at least 12 months after balloon angioplasty. Finally, data were analyzed using SPSS-20.ResultsIn this study, 42 infants were included. The median age at the time of balloon angioplasty was 1.55 (range 0.1–12) months and 66.7% of the patients were male. The mean pressure gradient of coarctation was 38.49 ± 24.97 mmHg, which decreased to 7.61 ± 8.00 mmHg (P < 0.001). A high-pressure balloon was used in 27, and a low-pressure balloon was used in 15 patients. COA's pressure gradient changed 30.89 ± 18.06 in the high-pressure group and 24.53 ± 20.79 in the low-pressure balloon group (P = 0.282). In the high-pressure balloon group, 14.81% and in the low-pressure group, 33.33% had recoarctation and need second balloon angioplasty (p < 0.021). The infant with discrete coarctation had a higher decrease in gradient and lower recoarctation.ConclusionRecoarctation rate was lower in the high-pressure balloon. The infant with discrete COA had a better response to the balloon with more decrease in gradient and lower recoarctation rate. Therefore, the stenotic segment anatomy needs to be considered in the selection of treatment methods.

A New Device for Managing Refractory Epistaxis in ICU Patients with COVID-19

Epistaxis is a common and a well-known symptom. Nasal packing is an effective treatment in most cases [1]. The COVID-19 disease treatment includes conventional or high flow nasal oxygen therapy and systemic anticoagulation [2]. Patients in intensive care unit may require therapeutic anticoagulation for venous thromboembolism, hyperinflammatory status, extracorporeal membrane oxygenation (ECMO) and multiple other pathologies. The use of therapeutic anticoagulation increases risk of nose bleeding, and its management may be challenging. CAVI-T (Figures 1 &amp; 2) is a new asymmetrical low-pressure balloon that have shown promising results to control epistaxis in emergency. We report herein the management of severe epistaxis in two COVID-19 patients admitted to ICU for severe respiratory failure.

Immediate outcomes of low-pressure balloon valvuloplasty for severe pulmonary valve stenosis in 20 dogs: a retrospective, single-center case series

IntroductionThe primary objective of this study was to describe the immediate post-procedural outcomes in dogs with severe pulmonary stenosis that were treated with low-pressure balloon valvuloplasty (BV) at a single institution. Animals, materials and methodsRetrospective case series; medical records of dogs that underwent BV performed with a balloon dilation catheter >20 mm in diameter and a burst pressure of less than 4 atm (atm) were retrospectively reviewed. Twenty animals were identified fitting the criteria. Pre-procedural and post-procedural echocardiograms and peri-procedural angiograms were reviewed. Procedural success was defined as greater than 50% reduction in echocardiographically derived transpulmonary systolic pressure gradient (TPPG) or post-procedural TPPG of less than 50 mmHg. ResultsThe median percent reduction from initial TPPG was 53% (range = 15−90%). Sixty percent of the dogs met the pre-specified criteria for a successful outcome. Post-procedural TPPG was not different based on valve types A or B (p=0.67), presence or absence of additional supravalvular (p=0.23) or subvalvular (p=0.83) obstructive components. DiscussionThe proportion of dogs that reach the successful outcome were not different based on valve type A or B. No relationship was noted between immediate outcomes and bodyweight or pulmonary annulus diameter. ConclusionDogs with severe pulmonic stenosis that underwent low-pressure BV had good immediate outcomes with no difference in outcome based on valve morphology. Further randomized controlled studies are needed to compare the outcomes of different strategies for BV in dogs with large-diameter pulmonary annulus.

Inflation volume-balloon diameter and inflation pressure-balloon diameter characteristics of commonly used bronchial blocker balloons for single-lung ventilation in children.

Balloon-tipped bronchial blocker catheters are widely used in pediatric thoracic anesthesia to establish single-lung ventilation. In clinical practice, their balloons demonstrate sudden expansion when inflated with air. In addition, there are concerns related to the high inflation pressures required to expand the balloons. This in vitro study assessed inflation volume- and inflation pressure-balloon diameter characteristics of the Fogarty arterial embolectomy catheters and Arndt endobronchial blockers. Balloon diameters were photographically assessed during unrestricted volume- and pressure-guided inflation, using air up to the maximum allowed inflation volume as indicated by the manufacturers. Inflation pressures required to open the blocker balloons and inflation pressures needed to expand them to maximum indicated diameter were measured. Volume-guided inflation demonstrated a late acute rise in diameter in Fogarty blocker balloons, whereas in the Arndt endobronchial blocker balloons almost linear inflation volume-to-diameter characteristics were observed. Pressure-guided inflation on the other hand demonstrated low-volume, high-pressure characteristics in the Fogarty blocker balloons, with inflation pressures required to expand the balloons to maximum diameters ranging from (mean (SD)) 636 (75) to 947 (152) cmH2 O. The inflation pressures required to open the Fogarty blocker balloons were even >1000cmH2 O. Inflation pressures required to expand the 5 F, 7 F, and 9 F Arndt endobronchial blocker balloons to maximum indicated diameter were much lower, namely at 218 (15), 252 (28), and 163 (8) cmH2 O. Based on these study findings, the balloons of Fogarty arterial embolectomy catheters represent high-pressure devices and do not permit stepwise controlled bronchial blockage. The Arndt endobronchial blockers have some advantages over the Fogarty blocker devices, but also represent high-pressure equipment and must be used with caution and limited duration. Manufacturers are asked to design pediatric endobronchial blocker catheters with truly high-volume, low-pressure balloons in accordance to age-related pediatric airway dimensions.

Preclinical Testing of a Combination Stone Basket and Ureteral Balloon to Extract Ureteral Stones.

We have developed the Peralta Stone Extraction System to increase the safety of ureteral stone extraction. The device combines a nitinol stone basket and low-pressure balloon into a single device. After visualization, the stone is captured in the tipless nitinol basket and enveloped by a low-pressure balloon. We tested the performance of device prototypes in a porcine model using stone mimics with diameters ranging from 4.2 to 6.2 mm. Stones extracted with the device required less force when compared with stones in a standard ureteral stone basket. The force reduction was most pronounced for stones greater than 4.2 mm in diameter, and when traversing a ureteral stenosis model. In conclusion, a combination stone basket and balloon device may provide a new and safer way to extract ureteral stones.

Use of covered stents in simultaneous management of coarctation of the aorta and patent ductus arteriosus

Objective:To report clinical and procedural characteristics of twelve patients who received a covered stent for the treatment of aortic coarctation and concurrent patent ductus arteriosus (PDA).Methods:A single center database was retrospectively evaluated to obtain data of patients with combined aortic coarctation and PDA. We selected patients in whom a covered stent was used for the treatment of both pathologies. The stent length was chosen so as to cover the entire length of the lesion from healthy to healthy tissue and also cover the ampulla of PDA.Results:The median age of the patients was 15 (range, 6.5-35) years. The diameter of the coarctated segment increased from a median of 8.4 (range, 2.6-10.8) mm to 16 (range, 9-24) mm (p<0.005), whereas the pressure gradient decreased from a median of 43 (range, 10-71) mm Hg to 0 (range, 0-8) mm Hg (p<0.005). Fourteen covered stents were used for 12 patients. Following deployment, seven stents were flared with larger and low-pressure balloons because of the gap between the distal end of the stent and the poststenotic dilated segment of the aorta, which caused residual PDA shunts and/or instability of the stent. After the procedure, no residual PDA shunt was present in any patient.Conclusion:To the best of our knowledge, this study includes the largest series of patients reported in literature in whom covered CP stents were used for simultaneous percutaneous treatment of coarctation and PDA. The procedure was successful and stable results were obtained during follow-up in all cases.

Central vein rupture during percutaneous transluminal angioplasty for central vein stenosis or occlusion in haemodialysis patients

Background: Endovascular treatments such as percutaneous transluminal angioplasty (PTA) and stent placements are becoming the standard method in managing haemodialysis access failure. Venous rupture is the most common complication during endovascular procedures. Complications during endovascular treatments of central venous stenosis or occlusion have been rarely reported.Objectives: To investigate the incidence and management of central vein rupture while performing PTA for central vein stenosis or occlusion in haemodialysis patients.Method: Between 1998 and 2013, PTA was performed using various techniques in haemodialysis patients for central vein stenoses (n = 2437) and occlusions (n = 666). When the guide wire passed through the stenosis or the occlusion, PTA was performed regardless of the presence of a venous rupture. The incidence of central vein rupture was analysed using the chi-square test according to the gender, location, right versus left, presence of thrombosis and stenosis versus occlusion. Percutaneous management of central vein rupture was also evaluated.Results: Central vein rupture occurred in 12 cases (0.39%). All ruptures occurred in the cases with occlusion. Only stenosis versus occlusion reflected a significant correlation (p &lt; 0.001) with central vein rupture. Central vein ruptures were managed by low-pressure balloon tamponade (n = 2), stent/stent-graft (n = 5) and balloon-mediated haemostasis blocking venous inflow followed by the observation (n = 5).Conclusion: Central vein rupture is a rarely occurring complication while performing PTA for central vein stenosis and occlusion, and the majority can be successfully managed by percutaneous techniques.

Customized Hinged Covered Metallic Stents for the Treatment of Benign Main Bronchial Stenosis

To address the limitations of silicone stents, we designed a hinged self-expandable covered metallic stent. The aim of this study was to evaluate the safety and efficacy of the customized stents in clinical applications. This was a retrospective analysis. Under conscious sedation and local anesthesia, the stents were implanted or removed by interventional radiologists, with fluoroscopic guidance. Of 24 patients with benign main bronchial stenosis, stents were successfully placed in 21 (87.5%). The low-pressure balloon before dilation failed in 1 case (4.17%) of left main bronchial cicatricial stenosis. In 2 other cases (8.33%), stent placement was abandoned. Stents were successfully removed between 29 and 103 days after the procedure. After stent removal, the follow-up lasted for at least 12 months. Restenosis occurred only in 1 case (4.55%) owing to bronchial collapse 3 days after stent removal. Dyspnea occurred in another case(4.55%) at 2 months after retrieval; recurrence was confirmed using bronchoscopy, leading to a left pneumonectomy. The described procedure is safe and easy to be performed and avoids the use of intubation, bronchoscopy, and general anesthesia.

Paediatric lung isolation

### Key points Lung isolation is required for a wide variety of pathology in paediatric patients. The varying size of the paediatric airway and size limitations of each lung isolation device poses a challenge to paediatric anaesthesiologists. The need for lung isolation includes: the prevention of contamination of one lung from the other due to haemorrhage or infection, the need to control the distribution of ventilation secondary to a bronchopulmonary fistula, a lung cyst or bullae, or severe hypoxaemia from unilateral lung disease. Extensive bronchopulmonary lavage may also necessitate lung isolation. Although lung isolation can assist in surgical exposure, in the paediatric population, surgical exposure for lung resections, mediastinal exposure, and thorascopy can often be accomplished by the CO2 pneumothorax and retraction of the operative lung without the need for lung isolation. This is most common in the young patient (<2 yr of age). Slinger1 teaches that there are the ‘ABCs’ of adult lung isolation: anatomy, bronchoscopy, and chest imaging. In paediatric lung isolation, there are still all the same ‘ABC’ considerations, with the addition of ‘D’—the varying diameter of the paediatric airway with age. ### Anatomy It has been long established that there are differences between the paediatric …

Sutureless Aortic Valve Implantation: Single Surgeon Experience

Objectives: Surgical aortic valve replacement (AVR) is the treatment of choice in patients with severe symptomatic aortic valve stenosis. In recent years, the number of high-risk patients being referred for surgical AVR has increased. A considerable proportion of these patients are deemed operable despite the high risk. In order to modify the risk predominantly associated with duration of cardiopulmonary bypass (CBP) and cross clamp (ACC) time, sutureless aortic valve technology have been developed. They bear the potential of easy implantation, reduced ACC, CPB time. We herein show our experience, focussing on ACC time, early mortality, morbidity, and valve haemodynamics. Methods: A sutureless valve was implanted following sternotomy, extracorporeal circulation, aortic cross clamping, cardioplegic arrest, and removal of the native valve. Optimal annular sealing was obtained with brief low-pressure balloon dilation without suturing. Between January 2012 and August 2015, sutureless aortic valve was used in 27 patients (mean age, 75.1 ± 5.3 years; mean additive EuroSCORE, 11.9 ± 4.1) with or without concomitant surgery. Haemodynamic parameters and clinical outcome were obtained retrospectively. Results: The patients received size S (10),M(13),L(3),XL(1) prosthesis, either as isolated(13) or combined procedures(14). Mean logistic euroSCORE risk evaluation was 33.1 ± 27.1%, mean aortic cross-clamp time was 51.1 ± 28.4 minutes (31.6 ± 9.0 minutes for isolated procedures). Mean implantation time was 6,8 ± 2.8 minutes. Haemodynamics at discharge showed good function of all sutureless valves with low transvalvular pressure gradients (mean 10.8 ± 4.1 mmHg). Thirty-day early mortality was 18.5% (5 patients). Conclusions: Sutureless valves are efficient and well-functioning devices that offer the advantage of considerable shortening of the duration of aortic cross clamping. Adequate follow-up studies are required to evaluate long-term outcome.

Glucagon-like peptide-1 derived cardioprotection does not utilize a KATP-channel dependent pathway: mechanistic insights from human supply and demand ischemia studies.

BackgroundGlucagon-like peptide-1 (7–36) amide (GLP-1) protects against stunning and cumulative left ventricular dysfunction in humans. The mechanism remains uncertain but GLP-1 may act by opening mitochondrial K-ATP channels in a similar fashion to ischemic conditioning. We investigated whether blockade of K-ATP channels with glibenclamide abrogated the protective effect of GLP-1 in humans.MethodsThirty-two non-diabetic patients awaiting stenting of the left anterior descending artery (LAD) were allocated into 4 groups (control, glibenclamide, GLP-1, and GLP-1 + glibenclamide). Glibenclamide was given orally prior to the procedure. A left ventricular conductance catheter recorded pressure–volume loops during a 1-min low-pressure balloon occlusion (BO1) of the LAD. GLP-1 or saline was then infused for 30-min followed by a further 1-min balloon occlusion (BO2). In a non-invasive study, 10 non-diabetic patients were randomized to receive two dobutamine stress echocardiograms (DSE) during GLP-1 infusion with or without oral glibenclamide pretreatment.ResultsGLP-1 prevented stunning even with glibenclamide pretreatment; the Δ % dP/dtmax 30-min post-BO1 normalized to baseline after GLP-1: 0.3 ± 6.8 % (p = 0.02) and GLP-1 + glibenclamide: −0.8 ± 9.0 % (p = 0.04) compared to control: −11.5 ± 10.0 %. GLP-1 also reduced cumulative stunning after BO2: −12.8 ± 10.5 % (p = 0.02) as did GLP-1 + glibenclamide: −14.9 ± 9.2 % (p = 0.02) compared to control: −25.7 ± 9.6 %. Glibenclamide alone was no different to control. Glibenclamide pretreatment did not affect global or regional systolic function after GLP-1 at peak DSE stress (EF 74.6 ± 6.4 vs. 74.0 ± 8.0, p = 0.76) or recovery (EF 61.9 ± 5.7 vs. 61.4 ± 5.6, p = 0.74).ConclusionsGlibenclamide pretreatment does not abrogate the protective effect of GLP-1 in human models of non-lethal myocardial ischemia.Trial registration Clinicaltrials.gov Unique Identifier: NCT02128022Electronic supplementary materialThe online version of this article (doi:10.1186/s12933-016-0416-3) contains supplementary material, which is available to authorized users.

Maximizing Lumen Gain With Directional Atherectomy

Purpose: To describe the use of a low-pressure balloon inflation (LPBI) technique to delineate intraluminal plaque and guide directional atherectomy in order to maximize lumen gain and achieve procedure success. Technique: The technique is illustrated in a 77-year-old man with claudication who underwent superficial femoral artery revascularization using a HawkOne directional atherectomy catheter. A standard angioplasty balloon was inflated to 1 to 2 atm during live fluoroscopy to create a 3-dimensional “lumenogram” of the target lesion. Directional atherectomy was performed only where plaque impinged on the balloon at a specific fluoroscopic orientation. The results of the LPBI technique were corroborated with multimodality diagnostic imaging, including digital subtraction angiography, intravascular ultrasound, and intra-arterial pressure measurements. Conclusion: With the LPBI technique, directional atherectomy can routinely achieve <10% residual stenosis, as illustrated in this case, thereby broadly supporting a no-stent approach to lower extremity endovascular revascularization.

Transmural coil embolization-alternative technique for management of arterial perforation during subintimal angioplasty.

Subintimal angioplasty of lower limb arterial occlusion carries a relatively higher risk of vessel perforation compared to transluminal angioplasty. Vessel perforation is a potentially life threatening complication which requires prompt recognition and management. They are usually managed by endovascular techniques such as low-pressure balloon tamponade, covered stents, and coil embolization of the ruptured artery. We describe a technique of treating vessel perforation following balloon angioplasty. Patient developed a large perforation of the proximal superficial femoral artery (SFA) after balloon inflation during subintimal angioplasty of complete SFA occlusion. Following failure of balloon tamponade in sealing the perforation, we successfully treated it by deploying an embolization coil at the site of perforation through the vessel wall followed by balloon tamponade. Our technique could be a useful relatively inexpensive alternative treatment option in the management of vessel perforation compared to covered stents.