Periprocedural Evaluation Research Articles

Esophageal Per-Oral Endoscopic Myotomy (E-POEM): Future Directions and Perspectives.

POEM is a mature procedure endorsed by societal guidelines as a first line therapy for achalasia and spastic esophageal disorders. Nonetheless, several questions remain, including expanding indications for POEM, periprocedural evaluation and management, and the optimal POEM technique to enhance clinical success while mitigating risk for reflux. There is uncertainty regarding several technical aspects of the POEM myotomy; though aggregating evidence supports the use of real-time impedance planimetry to guide the myotomy. While post-POEM reflux remains a concerning long term sequela, there is an increasing focus on the potential role of endoscopic anti-reflux interventions. Lastly, with the widespread adoption of POEM, we continue to witness ongoing efforts to standardize post-procedural care and training in this procedure. POEM is no longer a novel but rather established procedure. Yet, this technique has continued to evolve, with the aim of optimizing treatment success while reducing adverse events and risk for post-procedural reflux.

Accuracy of the simple 3D transthoracic echocardiography in the definition of tricuspid valve and right ventricle anatomy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The interest in the "forgotten" valve has re-emerged in recent years in consideration of the high mortality rate related to the highest degrees of TR and the recognition of a large amount of patients who remains under treated. Transcatheter tricuspid valve interventions (TTVI) represent a valuable option in high risk surgical candidates when specific anatomic criteria are met. Tailoring the most suitable therapeutic percutaneous strategy for each patient is crucial: an accurate screening aims to quantify regurgitation grade and fully understand the underlying mechanism. Transthoracic and transesophageal is used to assess jet location, leaflets anatomy and motion. ECG-gated Cardiac TC is necessary for the selection of annuloplasty or replacement techniques. Purpose Aim of the study is to compare three different imaging modalities as 3D transthoracic echocardiography (TTE), transesophageal one (TOE) and ECG-gated Cardiac CT for the definition of tricuspid valve anatomy, annular dimensions and right ventricle geometry in patients screened for TTVI. Methods Twenty-one (Age 79 ± 7 years, Female 72%) patients, referred with a diagnosis of at least severe TR in evaluation for percutaneous treatment, were prospectively enrolled in the study and underwent TTE, TOE and Cardiac CT. All measurements were performed in double blind by three different operators and compared. Results In the comparison between 2D/3D TTE and 2D/3D TOE no statistically significant differences were found regarding the evaluation of the valve anatomy, the site of regurgitation and the underlying mechanism (TTE vs TOE: 3D septo-lateral diam 45,8± 4,92 vs 45,87 ± 4,98 mm, p = 0.87; 3D antero-posterior diam 43,5 ± 4,58 vs 43,5 ± 4,53 mm, p = 0.59; Circularity index 0,75± 0,08 vs 0,76± 0,08, p = 0.98; 3D Annular area 16,48±3.9 vs 15,97±3,75 cm2, p = 0.77; Annular perimeter 14,82±1,62 vs 14,93±1,9 cm, p = 0.54). From the double-blind comparison between 3D TTE and Cardio CT, no differences emerged regarding anatomic annulus parameters (area 17,58± 3 vs 17.71±4,3 cm2, p = 0.1; perimeter 14,89±1,6 vs 14,29±1 cm, p = 0.5; maximum diameter 50,5 ± 5 vs 50,6 ± 5.1mm, p = 0.19; minimum diameter 40,25±3.8 vs 41.16± 4,9mm, p = 0.28). Similarly, in the study of right ventricular dimensions, obtained through 3D volumetric reconstruction, TTE was not statistically different to Cardiac CT (3DTTE vs CT: RVD1 51,14 ±2,54 vs 49,42 ± 5 mm, p = 0.5; RVD2 40,62±7,9 vs 40±11 mm,p = 0.7; RVL 72, 12±7 vs 72,12±11 mm, p = 0.8). Conclusions Three-dimensional trans-thoracic echocardiography showed an optimal performance to define tricuspid valve anatomy and right ventricle dimensions when compared with other imaging methods. 3D TT can be safely used for an overall first line in periprocedural evaluation of patients candidates for TTVI, allowing for elaborated study of the characteristics of TR through MPR reconstructions, annular and valvular anatomy, right chambers size and function.

Prognostic value of short-term trajectories of left ventricular ejection fraction in patients with first myocardial infarction and percutaneous coronary intervention

Aim. To assess periprocedural dynamics of left ventricular ejection fraction (LVEF) in patients with first acute myocardial infarction (AMI) and percutaneous coronary intervention (PCI) without heart failure (HF) in the medical history, as well as its prognostic value in the development of cardiovascular complications in the postinfarction period.Materials and methods. A prospective, single-center observational study included 131 patients with first AMI without HF in the past medical history and successful PCI. LVEF was assessed before PCI at admission and before discharge. In patients with reduced baseline LVEF of less than 50%, the criteria for its periprocedural improvement were chosen: 1) LVEF ≥ 50%; 2) ΔLVEF of more than 5%, but EF < 50%. The endpoints were hospitalization for the development of HF and death from cardiovascular disease in combination with the development of HF. The average follow-up period was 2.5 years.Results. At admission, LVEF was < 50% in 74 (56.5%) patients. At discharge, according to the criteria for LVEF improvement, the proportion of patients in this group was 40.5 and 14.9%, respectively. In 44.6% of cases, no increase in LVEF was noted. The predictors of the absence of periprocedural dynamics in LFEF included impaired regional contractility index > 1.94, left ventricular end-systolic volume > 57 ml, left ventricular end-diastolic diameter > 5.1 cm, pulmonary artery systolic pressure >27 mm Hg, NT-proBNP > 530 pg / ml, and E / A ratio > 1.06. During the follow-up period, 28 (21.4%) patients were hospitalized for the development of HF, 33 (25.2%) patients had a combined endpoint. The absence of periprocedural improvement in left ventricular contractility was independently associated with higher odds of hospitalization for HF (relative risk (RR) 3.5; 95% confidence interval (CI) 1.63–7.55; p = 0.001) and the combined endpoint (RR 2.6; 95% CI 1.28–5.48; p = 0.009) in the postinfarction period.Conclusion. In patients with first AMI and left ventricular systolic dysfunction, periprocedural evaluation of LVEF is reasonable to stratify the risk of adverse cardiovascular outcomes.

Straightened Segmentation in 4D Cardiac CT: A Practical Method for Multiparametric Characterization of the Landing Zone for Transcatheter Pulmonary Valve Replacement

Cardiac computed tomography angiography (C-CTA) is crucial in assessing the right ventricular outflow tract (RVOT) prior to a transcatheter pulmonary valve replacement (TPVR), as an incorrect evaluation can make the procedure more challenging and can lead to device-related complications. This study aimed to evaluate the feasibility and accuracy of 4D straightened segmentation for a landing zone analysis over anatomical segmentation. Seven pre-operative CTAs and seven post-operative CTAs were used to measure the cross-sectional area, circumference, and diameters at five selected planes as the landing zone for TPVR and compared these to the 4D straightened model with the anatomical model. Furthermore, the right ventricular volume, stent volume, and 4D ellipticity index were calculated from the 4D straightened model. The 4D straightened segmentation had comparable accuracy and efficacy for the measurements at the landing zone. The cross-sectional area and the circumference varied greatly at the RVOT and the basal plane of the pulmonary valve compared with the other three planes of the 4D straightened models from the pre-operative CTAs; however, only the values at the RVOT were found to vary greatly from the post-operative CTAs. The 4D straightened model can provide accurate measurements and is thus a useful method for the periprocedural evaluation of TPVR.

Independent role of circle of Willis for peri-procedural evaluation of carotid endarterectomy in patients with severe carotid stenosis

ObjectivesIn patients with severe carotid stenosis (CS), collateral circulation via circle of Willis (CoW) is considered a compensatory response to maintain blood flow. The aim of this study was to evaluate the impact of CoW in patients with severe CS throughout carotid endarterectomy (CEA). MethodsA database of patients (n = 124) undergoing CEA was sampled from 2013 to 2020. Severe CS was defined as 90–99% caliber stenosis and collateral circulation was identified by CoW opening. Baseline characteristics, Age-related white matter change (ARWMC) score, immediate neurologic events (INEs) and manifestations were recorded and compared. Correlation and regression analysis for CoW were further investigated. ResultsAll patients enrolled were divided into two groups regarding to the visualized CoW opening and complete CoW was noticed in 57 patients. The prevalence of complete CoW was higher among asymptomatic patients (n = 39, 68.4%), while higher percentage of TIA or previous stroke were noticed in incomplete CoW (n = 45, 67.2%). Patients with incomplete CoW had a significantly higher median ARWMC score and remarkable cerebral perfusion deficit (P < 0.05*). Totally, 4 INEs (6.0%) were noted in patients with incomplete CoW after CEA. Cerebral hyperperfusion syndrome (CHS) was noticed in 10 patients and early-phase of postoperative hypertension (EPOH) in 15 ones with incomplete CoW versus patients with complete CoW (14.9% and 22.4% vs 3.5% and 7.0%, P < 0.05). Correlation analysis showed strong relationship between CoW opening and peri-operative factors like pre-operative symptoms, ARWMC, CHS and EPOH (P < 0.05*). Overall, CoW opening was an independent predictor of both CHS and EPOH (95% CI, 0.021–0.715 and 0.060–0.949, P < 0.05*) with logistic regression. ConclusionsSufficient collateral circulation via CoW may promote ipsilateral cerebral perfusion and mitigate WMC in patients with severe CS. In addition, collaterals may improve the predictive power of the risk scale for post-procedural complications after CEA.

The Incidence of Endoscopic Retrograde Cholangiopancreatography-Related Complications in Patients With Liver Transplant: A Meta-Analysis and Systematic Review.

BackgroundExisting literature on post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with liver transplant remains scarce and largely inconsistent. We therefore aimed to systematically review and analyze the literature on complication rates associated with ERCP in patients with liver transplant.MethodsWe performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through March 2020 to identify all the studies that evaluated post-ERCP complications in patients with liver transplant. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird, and a pooled odds ratio (OR) and event rates were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.ResultsFourteen studies with a total of 1,787 patients were analyzed. In total, 3,192 ERCPs were performed on these patients. The pooled all-complication rate was 5.2% (95% confidence interval (CI): 0.035 - 0.075). Procedural complications analyzed included post-ERCP pancreatitis 3.4% (95% CI: 0.025 - 0.047), bleeding 1.1% (95% CI: 0.006 - 0.020), infections 0.2% (95% CI: 0.025 - 0.047), and cholangitis 0.8% (95% CI: 0.004 - 0.020). No cases of periprocedural death were reported. The pooled OR for post-ERCP pancreatitis in patients with liver transplant compared to patients without liver transplant was 1.289 (95% CI: 0.455 - 3.653, P = 0.633, I2 = 72.88%).ConclusionPost-ERCP complication rates in liver transplant patients are comparable to the general population and hence, peri-procedural evaluation and management may follow the current standards of care in this patient population.

107 The Prevalence of Endoscopic Retrograde Cholangiopancreatography-Related Complications in Patients With Liver Transplant: A Meta-Analysis and Systematic Review

INTRODUCTION: Biliary complications following liver transplantation are usually managed with endoscopic retrograde cholangiopancreatography (ERCP); however, the literature on post-ERCP complications remains poorly reported and largely inconsistent in this patient population. Hereby we aimed to systematically review and analyze the literature on complication rates associated with the performance of ERCP in patients with liver transplant. METHODS: We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May 2019 to identify all the studies that evaluated post-ERCP complications in patients with liver transplant. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird, and a pooled odds ratio (OR) and prevalence were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques. RESULTS: Fourteen studies with a total of 1787 patients were included in this analysis. In total, 3192 ERCPs were performed on these patients. The pooled all-complication rate was 5.2% (95% CI: 0.035–0.075) (Figure 1). Procedural complications analyzed included post-ERCP pancreatitis 3.4% (95% CI: 0.025–0.047), bleeding 1.1% (95% CI: 0.006–0.020), infections 0.2% (95% CI: 0.025–0.047), and cholangitis 0.8% (95% CI 0.004–0.020) (Figure 2a–d). No cases of periprocedural death were reported. The pooled OR for post-ERCP pancreatitis in patients with liver transplant compared to patients without liver transplant was 1.289 (95% CI: 0.455–3.653, P = 0.633, I2 = 72.88%) (Figure 3). CONCLUSION: The risk of post-ERCP complications has been a major concern for many endoscopists in patients with liver transplantation. This might be related to theoretical concerns of distorted anatomy and difficult cannulation, combined with a general lack of evidence on the true prevalence of these complications. Our study confirms that post-ERCP complication rates are comparable to the general population undergoing ERCP and hence, peri-procedural evaluation and management should be continued as per the standard of care in this patient population.

Planning Prostate Artery Embolisation: Is it Essential to Perform a Pre-procedural CTA?

A highly variable prostatic artery origin coupled with frequent anastomoses to adjacent organs makes prostate artery embolisation a challenging procedure. Despite CT angiography facilitating procedural planning, it is not performed in all centres. Therefore, we explored the utility of prostatic CT angiography by assessing its capacity to identify the prostatic arteries and highlight troublesome anastomoses. A retrospective review of patients undergoing prostate artery embolisation for symptoms of benign prostatic obstruction between June 2012 and October 2016 was conducted, with analysis of the pre-procedural CT angiography. CT findings were compared with subsequent intraprocedural angiography to assess the accuracy with which CT angiography predicts the origin of prostatic arteries and identifies anastomoses. In total, 110 patients underwent prostate artery embolisation, with pre-procedural CT angiography acquired in all patients, enabling assessment of 220 pelvic sides of hemiprostatic arterial supply. Mean dose length product was 808.4mGycm. CT angiography successfully identified prostatic arterial supply in 214/220 pelvic sides, an accuracy of 97.3%. Anastomoses of prostatic vessels were suggested by CT angiography in 52 pelvic sides. These were confirmed by angiogram in 49/52 sides (94.2%). CT angiography demonstrated a sensitivity of 59.0% and specificity of 94.2% for anastomoses detection. CT angiography prior to embolisation reliably predicts the arterial anatomy and facilitates procedural planning. Therefore, it should be a considered as a pre-procedural investigation for patients undergoing prostate artery embolisation. Sensitivity is low for predicting anastomoses, so careful periprocedural evaluation of the target vessels is still required.

Prediction of hyperperfusion phenomenon after carotid artery stenting and carotid angioplasty using quantitative DSA with cerebral circulation time imaging

BackgroundHyperperfusion syndrome after carotid interventions has a low incidence but it can lead to morbidity and mortality.ObjectiveTo evaluate the usefulness of quantitative DSA for predicting hyperperfusion phenomenon (HPP) after carotid...

Periprocedural Evaluation and Management against Cerebral Hyperperfusion Syndrome after Carotid Artery Stenting in Japan: A Nationwide Questionnaire Survey

Periprocedural Evaluation and Management against Cerebral Hyperperfusion Syndrome after Carotid Artery Stenting in Japan: A Nationwide Questionnaire Survey

Abstract 159: Posterior Communicating Artery Flow Diversion in Middle Cerebral Artery Stroke: Angiographic Evidence from IMS III

Background: Only 20% of adults have a “fetal” posterior communicating artery (PCOMM) with carotid flow to the posterior cerebral artery. Dynamic pressure changes at the circle of Willis due to proximal artery occlusion may restore such collateral blood flow patterns. We investigated the findings and implications of PCOMM blood flow in middle cerebral artery (MCA) stroke at angiography in IMS III. Methods: The angiography core lab prospectively evaluated PCOMM blood flow and collateral circulation in proximal MCA or M1 occlusion. Proximal or distal M1 occlusion was noted with PCOMM flow scored (0-2) on ipsilateral carotid injections before and after endovascular therapy, correlating PCOMM status with ASITN/SIR leptomeningeal collateral grade, TICI reperfusion and subsequent clinical outcomes. Results: 122 patients with M1 occlusion at angiography (60 proximal, 62 distal) had peri-procedural evaluation of PCOMM status and associated collateral grade. Ipsilateral carotid injections revealed PCOMM flow diversion in 87/122 (71%) prior to revascularization, including 41/60 (68%) in proximal M1 and 46/62 (74%) in distal M1 (p=0.61) occlusions. After treatment, PCOMM patency was noted in 86/122 (71%), with 40/60 (67%) in proximal M1 and 46/62 (74%) in distal M1 (p=0.48) occlusions. Decrease in PCOMM score after therapy was noted in 11/122 (9%); 9/11 (82%) had mTICI 2B-3 reperfusion compared to 48/111 (43%) mTICI 2B-3 reperfusion in those with PCOMM unchanged (p=0.03). PCOMM flow (n=85) was associated with worse ASITN/SIR collaterals (median 2, IQR 2-3) than those without (n=29; median 3, IQR 2-3), p=0.09. PCOMM patency before treatment had 90-day mRS median of 4 (2-6) versus 3 (1-4), p=0.37. Conclusions: PCOMM flow diversion is common in MCA stroke, revealing an inverse correlation with leptomeningeal collaterals and dynamic changes following reperfusion.

Current and Evolving Clinical Applications of Multidetector Cardiac CT in Assessment of Structural Heart Disease

Multidetector computed tomography (CT) has an established role in the evaluation of selected patients suspected of having coronary disease; however, in addition to coronary assessment, multidetector CT can be used to evaluate numerous noncoronary structures in the same examination. In particular, the use of multidetector CT to provide pulmonary and cardiac venous anatomic information prior to electrophysiology procedures is well established, and its important role in the periprocedural evaluation of patients undergoing percutaneous procedures, such as transcatheter aortic valve replacement and left atrial appendage device occlusion, is being increasingly recognized. Such advances have resulted in multidetector CT being increasingly used as a complementary imaging technique to echocardiography and magnetic resonance imaging for the comprehensive evaluation of cardiac structure and function in particular clinical situations. This review provides an overview of the noncoronary cardiac structures that can be evaluated with multidetector CT, and outlines the established appropriate clinical uses of multidetector CT in the assessment of structural heart disease, as well as evolving periprocedural clinical applications.

Periprocedural soluble P- and E-selectin levels fail as predictors of clinical restenosis in patients treated with elective coronary stenting

An increasing amount of basic scientific data indicates that adhesion molecules may be involved in the pathogenesis of vessel re-narrowing in patients undergoing coronary angioplasty. Furthermore, inflammation is suggested to be a pivotal mechanism linking atherosclerosis and restenosis. The aim of this study was to assess if periprocedural evaluation of soluble P-selectin (sP-selectin) and E-selectin (sE-selectin) possesses any additive value in the restenosis prediction to C-reactive protein (CRP) measurement. One hundred and nine stable angina patients were consecutively enrolled into the prospective cohort study. All participants were treated with single vessel coronary bare metal stenting. sP-selectin, sE-selectin and CRP were measured in peripheral venous blood samples collected before and 6, 24 h and 1 month after the procedure. Clinical follow-up visits were held 7 days(*), 1(*), 3, 6(*), and 12 months ((*)with an exercise test) after stenting. Any symptoms of restenosis were verified angiographically. Clinical restenosis occurred in 18 subjects. Concentrations of sP-selectin and sE-selectin did not differ between patients with and without clinical restenosis at any measuring point. In the latter group a decrease in sP-selectin and sE-selectin levels was observed 6 h after stenting. These findings when considered in all of the investigated subjects had no impact on the subsequent incidence of restenosis. An inflammatory response assessed as an increase in CRP level with the peak values at 24 h was noted in the whole population. However, it was significantly more pronounced in the restenosis group. Application of the Cox's proportional hazard model revealed a high CRP level 24 h after stenting and the history of coronary angioplasty concerning a nontarget lesion to be the only independent predictors of clinical restenosis. To conclude, the periprocedural evaluation of sP-selectin and sE-selectin in peripheral venous blood in patients undergoing elective coronary stenting provides no prognostic information in terms of clinical restenosis prediction, and the magnitude of the systemic inflammatory response triggered by coronary angioplasty assessed as an increase in CRP level and the history of coronary angioplasty concerning nontarget stenosis remain independent predictors of lesion re-narrowing.

Combined periprocedural evaluation of CRP and TNF-α enhances the prediction of clinical restenosis and major adverse cardiac events in patients undergoing percutaneous coronary interventions

To assess the value of serial C-reactive protein (CRP), serum amyloid A (SAA), tumor necrosis factor-alpha (TNF-alpha) and interleukin-10 (IL-10) evaluation in the risk stratification in patients undergoing percutaneous coronary intervention. The study was designed as a prospective cohort trial with a 1-year follow-up. Eighty patients (70 with stable angina, 10 with unstable angina) were enrolled. Blood samples were collected before the procedure and after 6 and 24 h, and 1 month. Clinical follow-up visits were performed (*with exercise test) 7 days* and 1*, 3, 6* and 12 months after the procedure. Any symptoms of restenosis were verified angiographically. Multivariate logistic regression analysis identified increased preprocedural TNF-alpha and CRP levels and elevated CRP concentrations evaluated 24 h after the procedure as significant predictors of both clinical restenosis and major adverse cardiac events (MACE), while high SAA values at 24 h accurately predicted clinical restenosis. Patients, who were in the highest tertile of, either, baseline TNF-alpha and/or baseline CRP/CRP at 24 h, were more prone to develop restenosis and MACE than stratified only on the basis of a single marker. Our data indicate that combined analysis of CRP and TNF-alpha might be an effective approach to the clinical restenosis and MACE prediction. Additionally, long-term outcome is markedly influenced by the periprocedural activation of inflammation.