Percutaneous mitral paravalvular leak (PVL) closure in patients with double mechanical valves presents substantial technical challenges when conventional transseptal antegrade approaches fail. Transapical puncture, while an alternative, carries significant risks including hemothorax and coronary injury. Safe and reliable left ventricular (LV) access without high-risk transapical puncture remains a critical unmet need in complex structural heart interventions. A 69-year-old woman with mechanical mitral and aortic valve replacements and persistent PVL despite prior percutaneous closure presented with recurrent heart failure symptoms. Transesophageal echocardiography demonstrated two moderate-to-severe PVL jets at the 7 o'clock position surrounding the previous occluder device. A Left Bundle Branch Area Pacing (LBBAP) delivery system was advanced from the left subclavian vein to create a controlled interventricular septal puncture under continuous unipolar pacing and electrocardiographic monitoring. The LBBAP-assisted interventricular septal crossing established a stable transventricular tract from right to left ventricle, enabling advancement of an 8.5 Fr steerable sheath. A separate transseptal puncture provided left atrial access. A veno-venous loop was created using a snare technique, facilitating deployment of two Amplatzer vascular plugs (8 × 7 mm AVP-II and 12 × 5 mm AVP-III) across the mitral PVL defects under transesophageal echocardiographic and fluoroscopic guidance. At follow-up, she remained asymptomatic, with no residual ventricular septal flow on imaging. This first reported case of LBBAP-assisted interventricular septal access for mitral PVL closure demonstrates feasibility and safety as an alternative when conventional approaches are not viable. This technique avoids transapical puncture risks and may expand therapeutic options for anatomically challenging structural heart interventions, particularly in patients with double mechanical valves (NCT07129122).

Transcatheter structural heart interventions, including aortic, mitral and tricuspid valve replacement or repair, and patent foramen ovale, atrial septal defect, and left atrial appendage closure, have dramatically expanded over the past two decades, providing substantial improvements in both clinical outcomes and quality of life. These interventions are performed in a high-risk patient population, which is at risk for both thrombotic and bleeding complications. The introduction of prosthetic devices into the arterial or venous circulation under heterogeneous hemodynamic conditions inevitably increases the risk for thrombotic events and thromboembolic complications. Consequently, the selection of antithrombotic therapy (AT) regimen and its duration is complex and should be tailored to each patient's risk profile, balancing the expected risk and benefits. This state-of-the-art review critically examines the thrombotic risks inherent to transcatheter structural heart interventions, synthesizes available evidence and current guidelines recommendations on antithrombotic management, and defines persisting gaps in knowledge while discussing the most relevant ongoing clinical trials.

Acute Distal Limb Ischemia after Large-Bore Arterial Access: An Expert Review and Consensus Recommendations.

Incidence and Associated Patient Characteristics of Gastrointestinal Bleeding Following Transesophageal Echocardiography in Transcatheter Structural Heart Interventions and Cardiac Surgery: A Descriptive Epidemiological Study.

Noonan syndrome (NS) is an autosomal dominant genetic disorder associated with a high incidence of cardiovascular disease. We investigated pulmonary hypertension (PH) in patients with NS, characterizing the prevalence, genetic, and clinical features including hemodynamics, cardiovascular interventions, and transplant-free survival.A retrospective, descriptive cohort study was conducted among pediatric patients with NS who underwent cardiac catheterization. Patient demographic, clinical, and hemodynamic data were collected for cohorts of patients with and without PH.We identified 87 patients with NS who had undergone cardiac catheterization including hemodynamics at Boston Children's Hospital between 2000 and 2020. Of them, 59 (68%) had a NS-associated genetic mutation in the RAS-MAPK signaling pathway, while 28 (32%) had a clinical diagnosis of NS. In the cohort, 11/87 (13%) had PH. There were significant differences in NS-associated genetic mutations; variants in RAF1 (p = 0.013) and KRAS (p = 0.015) were more common among PH patients. Hypertrophic cardiomyopathy (p = 0.009) was more common in PH patients, while valvar, subvalvar, or supravalvar PS (p = 0.011) was less common. PH patients had more aortic-valve interventions (p = 0.025) and fewer valvar right-sided heart interventions (p = 0.037). Transplant-free survival was lower in the PH group than the non-PH group (p = 0.004).There are novel features to cardiovascular outcomes for genetically defined subsets of patients with NS, including significant differences in the NS-associated causative genes, associated hypertrophic cardiomyopathy, structural heart disease, interventions, and transplant-free survival.

Low Contrast Photon-Counting Detector CT Using Spectral Information to Enhance Structural Heart Intervention Planning.

Percutaneous left atrial appendage occlusion (LAAO) is frequently performed with an interventional echocardiographer (IE) in close proximity to the patient and radiation source, increasing the risk for occupational radiation exposure. Yet optimal radiation shielding methods for IEs remain unknown. To assess whether using a suspended lead suit reduces IE radiation dose compared with traditional lead apron shielding during LAAO procedures. In this blinded cross-sectional study, IE radiation exposure data were prospectively collected during all LAAO procedures conducted for adults at a single quaternary care center from February 21 to August 22, 2023. Head-level dosimeters were worn by IEs who were using suspended lead suits during sequential LAAO procedures conducted at the center. Use of a suspended lead suit or traditional lead apron radiation protection device. The primary outcome was measured personal dose equivalents at head level to IEs per case using real-time radiation dosimeters. Dosimeter-derived physician radiation doses and procedural radiation (dose area product) were compared with a control group of 30 sequential historical LAAO cases performed with IEs wearing traditional lead aprons from July 1, 2016, to January 31, 2018. Overall, 125 patients (mean [SD] age, 78 [8] years; 77 [61.6%] male) were included. Among 95 cases in which IEs used suspended lead suits, the median (IQR) radiation dose was 0.0 (0.0-0.3) μSv, which was significantly lower than 30 cases in which IEs wore traditional lead aprons (median [IQR], 10.6 [5.8-24.1] μSv; P < .001). Radiation doses were undetectable in 60% of IEs (57of 95) using suspended lead suits compared with 0% of IEs (0 of 30) using traditional lead aprons (P < .001). Radiation doses of at least 20 μSv were observed in 0 of 95 cases (0%) with suspended lead suits vs 9 of 30 cases (30%) with traditional lead aprons (P < .001). Similar associations were noted in exploratory analyses adjusting IE radiation doses for procedural dose area product (mean [IQR], 0.0 [0.0-0.0] μSv/Gy × cm2) for suspended lead suits vs traditional lead aprons (mean [IQR], 0.6 [0.3-1.0] μSv/Gy × cm2; P < .001). In this cross-sectional study, the use of suspended lead suits was associated with large reductions in head-level radiation doses to IEs compared with the use of traditional lead aprons during LAAO cases. These findings have important ramifications for the risk of occupational radiation exposure to IEs and potential shielding mechanisms during structural heart interventions.

Tirzepatide therapy reduces subclinical leaflet thrombosis and paravalvular leak after transcatheter aortic valve replacement in obese patients: The TAVR-MET trial.

Secure the Plug: Ultimate Structural and Intervention Complex Paravalvular Leak Closure and Simultaneous Left Atrial Appendage Closure – A Case Report

Transcatheter heart interventions are expanding, and structural procedures are becoming more complex. This makes detailed visualisation and characterisation of cardiac anatomy and pathology increasingly important. As a result, there is a growing interest in interventional imaging for procedural guidance. Specifically, there is an increasing interest in using intracardiac echocardiography (ICE) as a complementary or alternative tool to transoesophageal echocardiography. Furthermore, new-generation three-dimensional matrix array ICE probes provide the possibility of obtaining multiplanar reconstruction imaging, playing a crucial role in structural heart interventions. To date, we still need guidelines that summarise the technical details of the most used ICE probes and that standardise procedure protocols. The purpose of this expert review is to provide an overview of ICE technology, describe the technical characteristics of the available probes, and present a review by a group of experts on their use in guiding structural heart interventions based on global clinical experience.

Structural heart disease (SHD) encompasses a wide range of congenital and acquired cardiac abnormalities, increasingly treated with transcatheter interventions. Echocardiography plays a crucial role in optimising these procedures, providing high-resolution imaging for pre-procedural planning, real-time guidance and post-intervention assessment. The shift from two-dimensional to advanced three/four-dimensional (3D/4D) echocardiography has significantly enhanced the visualisation of complex cardiac structures, improving procedural success and patient safety. The purpose of this review article is to provide an overview of the vital role of echocardiography in key structural heart interventions, including mitral transcatheter edge-to-edge repair, transcatheter aortic valve replacement, paravalvular leak closure, left atrial appendage occlusion and atrial septal defect closure. It highlights the integration of 3D/4D imaging and advanced Doppler techniques in refining procedural precision, optimising decision-making, and improving patient outcomes. The evolving field of interventional echocardiography continues to shape SHD management, making more minimally invasive treatments available to patients.

Polyurethane-based implantable devices (PUIDs) delivered via catheter are increasingly used in structural heart interventions; however, limited in vivo data exist regarding their long-term biostability and biological safety. This study evaluated a balloon-shaped implant made of Pellethane®, a polyether-based polyurethane, designed as a three-dimensional intracardiac spacer and deployed via percutaneous femoral vein access. The device was chronically positioned adjacent to the tricuspid valve annulus in seven pigs for 24 weeks. Explanted devices and surrounding tissues were evaluated through material characterization (SEM, GPC, FT-IR, and 1H-NMR) and histological analysis. SEM and FT-IR confirmed preserved surface morphology and chemical bonds, GPC showed stable molecular weight, and 1H-NMR revealed intact urethane and ether linkages. Materials characterization revealed no evidence of hydrolytic or oxidative degradation, indicating structural stability of the devices. Histological analysis showed stable device positioning with minimal thrombosis or inflammatory response. Biocompatibility was confirmed via ISO 10993-1:2018 Standard (International Organization for Standardization (ISO): Geneva, Switzerland, 2018), and extractable substances were evaluated under exhaustive extraction conditions specified by ISO 10993-18:2020 (International Organization for Standardization (ISO): Geneva, Switzerland, 2020), with no toxicologically significant findings. These findings support the long-term biostability and biological safety of the PUIDs in dynamic cardiac environments, informing future design criteria for catheter-delivered cardiovascular devices.

This paper presents a robotic transesophageal echocardiography (TEE) system that replicates all essential degrees of freedom available in manual TEE procedures. The developed robotic system advances dual-subsystem architectures through enhanced mechanical design and deep learning-based kinematic modeling. Building upon previous designs that manipulate the TEE probe from both handle and gastroscope tube, our system integrates with a teleoperated UR5 manipulator to accommodate both supine and left lateral decubitus patient positions, addressing the full spectrum of clinical TEE procedures. The system features 6 DOF at the probe handle and 2 DOF at the gastroscope tube. Together, these create optimal gastroscope tube geometry, minimizing cable tension asymmetry and friction-induced nonlinearities inherent in cable-driven mechanisms. The primary contribution is a data-driven kinematic model using recurrent neural networks with LSTM units that overcomes fundamental limitations of analytical approaches for continuum manipulators. Trained on 42,000 synchronized pose-command pairs collected across three gastroscope tube configurations (0°, 45°, 90° bends), the model effectively captures dead zones, hysteresis, and coupling effects between steering mechanisms. Experimental validation demonstrates strong position tracking across all three gastroscope tube configurations. The model achieves RMSE of 1.267 mm for the 0° configuration, 1.209 mm for the 45° configuration, and 1.194 mm for the 90° configuration. Mean orientation errors are 7.064° at 0°, 8.503° at 45°, and 4.947° at the clinically critical 90° configuration. The model exhibits coordinate frame independence with only 0.06 mm RMSE difference between original and rotated datasets. This confirms true kinematic learning rather than coordinate-specific patterns. With 1.8 ms inference time, the system achieves real-time performance essential for clinical deployment. This integration of robotic system design with deep learning establishes a foundation for semi-autonomous TEE systems. The developed system can support both diagnostic TEE examinations and TEE-guided structural heart interventions.

A right aortic arch withmirror-image branching is a rare congenital anomaly resulting from the abnormal regression ofthe embryonic left aortic arch. This variant, in which the aortic arch courses to the right of the trachea and gives rise to its branches in a mirrored configuration compared to the standard left-sided arch, can present unique challenges during cardiovascular interventions such as transcatheter aortic valve replacement (TAVR). We describe a 75-year-old male undergoing evaluation for TAVR who was incidentally found to have a right aortic arch with mirror-image branching. This anomaly, characterized by a mirrored branching pattern of the arch vessels, required tailored imaging and procedural considerations. The patient successfully underwent TAVR through the right aortic arch without complications, demonstrating the adaptability of contemporary structural heart interventions. This patient presented with an embryonic right aortic arch with mirror-image branching (RAA-MIB) and persistence of the left sixth arch. Given the potential technical challenges in catheter navigation that the unique anatomy of this aortic arch poses, it is critical to understand these embryological variations for successful procedural planning and execution. Clinical implications include a potentially increased risk of stroke and dissection. Advances in imaging modalities continue to enhance our ability to diagnose and manage rare aortic arch anomalies, ultimately improving patient outcomes.

Intracardiac echocardiography (ICE) is increasingly recognized as a valuable imaging modality in structural heart interventions, offering high-resolution, real-time visualization from within the cardiac chambers. Originally developed for electrophysiologic procedures, ICE has expanded its use across a broad spectrum of structural interventions, including atrial septal defect (ASD) and patent foramen ovale (PFO) closure, left atrial appendage occlusion (LAAO), transseptal puncture guidance, transcatheter edge-to-edge repair (TEER), balloon mitral valvuloplasty, and both mitral and tricuspid valve therapies. This review outlines the current role and technical principles of ICE, with an emphasis on catheter design, image acquisition protocols, and the emerging potential of 3D ICE. Comparisons with transesophageal echocardiography (TEE) and fluoroscopy are discussed, highlighting ICE's ability to support minimally invasive, sedation-sparing procedures while maintaining procedural precision. We provide a focused analysis of ICE-guided applications in specific clinical scenarios, emphasizing its role in anatomical assessment, device navigation, and intra-procedural monitoring. Data from recent clinical studies and registries are reviewed to assess safety, feasibility, and outcomes. Practical considerations including operator learning curve, workflow integration, and limitations such as cost and field of view are also addressed. Lastly, we explore future directions including advanced 3D imaging, fusion imaging, artificial intelligence integration, and robotic catheter systems.

BackgroundIntracardiac echocardiography (ICE) has become a critical imaging modality in adult congenital heart disease (ACHD) interventions, offering high-resolution intracardiac imaging without the need for intubation. In transcatheter pulmonary valve replacement (TCPVR), ICE may overcome limitations of traditional imaging, particularly in visualizing the right ventricular outflow tract (RVOT) and pulmonary valve.ObjectivesThis study aimed to evaluate the feasibility, safety, and clinical utility of four-dimensional (4D) ICE in ACHD patients undergoing TCPVR.MethodsBeginning in February 2023, we prospectively enrolled all patients undergoing TCPVR at a tertiary ACHD center. Patients underwent preprocedural imaging and clinical evaluation. 4D ICE was used pre- and post-valve implantation to assess cardiac anatomy and valve function. Patients without valve implantation or 4D ICE imaging were excluded.ResultsOf 55 referred patients, 45 underwent successful TCPVR with 4D ICE. The mean age was 42.6 ± 13.6 years, and 51 % were male. 4D ICE confirmed procedural indications, provided comprehensive anatomic and functional assessment, and detected post-implantation regurgitation in 35.6 % of cases, significantly more than angiography (11.1 %) or transthoracic echocardiography (4.4 %). Incidental but clinically relevant findings were identified in 33.3 % of patients, influencing management in 15.6 %. No ICE-related complications occurred.Conclusions4D ICE is a feasible, safe, and clinically valuable imaging tool during TCPVR in ACHD patients. It enhances procedural guidance, detects early valve-related complications, and identifies unexpected findings that affect management. Its integration into structural heart interventions may significantly improve outcomes, especially as technology continues to evolve.

The FDA’s 2025 Early Alert regarding air embolism risks associated with the WATCHMAN Access System used in left atrial appendage occlusion (LAAO) procedures highlights important concerns related to anesthetic technique for this procedure. Despite advances in minimally invasive cardiac interventions and a shift toward sedation, recent reports of catastrophic air embolism underscore physiologic vulnerabilities when negative intrathoracic pressures occur during spontaneous ventilation, particularly during transseptal procedures. The FDA identified over 120 serious injuries and 17 deaths linked to preventable air embolisms. Anesthesia professionals play a key role in mitigating these risks and promote safer practice in the expanding field of structural heart interventions.

BackgroundWith the rise of structural heart interventions (SHIs), interventional echocardiographers (IEs) face significant radiation exposure in catheterization laboratories. However, US-specific radiation safety practices remain understudied. This study aims to address radiation safety practices and concerns among US IEs, focusing on occupational risks and sex-specific challenges.MethodsA 21-item online survey was conducted from March to June 2025, targeting US IEs through a multifaceted recruitment strategy. It assessed demographics, SHI frequency, radiation monitoring, shielding practices, and reproductive health concerns. Descriptive statistics summarized responses, with sex-specific analyses for female IEs.ResultsOf 69 respondents (64% [n = 44] men, 36% [n = 25] women), 88% (n = 61) worked in tertiary care settings and 46% (n = 32) guided SHIs several times weekly. Key gaps were identified, including 18% (n = 17) not using dosimeters, 64% (n = 44) never receiving exposure notifications, and 80% (n = 55) lacking awareness of their personal annual radiation dose. In addition, 30% (n = 21) had no radiation safety training, and 75% (n = 52) reported insufficient radiation protection in their catheterization laboratory. Reproductive health concerns affected 71% (n = 49) of IEs. Among female IEs, 56% (n = 14) reported an influence on pregnancy planning, 32% (n = 8) noted career concerns owing to maternity, and 63% of those who had had a pregnancy (n = 12/19) performed SHIs during pregnancy, with 7% taking no additional precautions.ConclusionsUS IEs face critical radiation safety gaps, including inadequate monitoring, training, and shielding, with pronounced reproductive and career concerns among female IEs. Tailored protocols, enhanced shielding, and pregnancy-specific precautions are urgently needed to ensure the safety and well-being of IEs.

With rising life expectancy, the population of older adults over the age of 65 is rapidly expanding, with women comprising the majority. Structural heart disease is common in this group, and transcatheter interventions have transformed its management. Optimal outcomes require careful consideration of sex-specific differences. This review examines transcatheter structural heart interventions in older adults with a focus on sex-based outcomes, procedural planning, and current knowledge gaps.

The vein and ligament of Marshall (VOM and LOM) are embryological remnants that have gained increasing recognition due to their anatomical complexity, arrhythmogenic potential, and relevance during catheter ablation and structural heart interventions. This review summarizes current evidence on their embryology, morphology, anatomical variability, imaging characteristics, and clinical implications. A structured literature search across PubMed, Embase, and Scopus identified anatomical, histological, electrophysiological, and interventional studies. The VOM is present in most hearts, but its topographic variants and ostial positions show substantial interindividual diversity. The LOM displays a segmental architecture with distinct muscular and fibrotic components that interface with the atrial myocardium and the coronary sinus, providing a substrate for atrial fibrillation. Advances in cardiac imaging have improved delineation of the VOM-LOM region, enhancing pre-procedural assessment and guidance for ethanol infusion and ablation strategies. Recognition of the variability and functional significance of these structures is essential for optimizing procedural outcomes and avoiding complications. Taken together, the VOM and LOM represent key atrial venous remnants whose detailed characterization contributes to a deeper understanding of atrial arrhythmogenesis and contemporary interventional electrophysiology.