Transaortic Approach Research Articles

Mitral valve repair using edge-to-edge technique in various situations: real-world experiences.

Edge-to-edge (E2E) mitral valve repair (MVP) is a versatile technique used in various situations for mitral regurgitation (MR). This technique has been regaining attention, given the increasing use of the MitraClip procedure. This real-world study evaluates the durability of the E2E technique in different settings. From January 2002 to May 2015, a total of 303 patients with at least moderate MR who underwent E2E MVP were identified. Patients undergoing isolated MVP (n = 133) and concomitant coronary artery bypass grafting or other valvular procedures (N = 170) were included. Cox proportional hazards modelling was used to evaluate the risk factors for cumulative survival, or MV event (i.e. MV reintervention or MR recurrence) while event-free survival-defined as time to composite outcome of either death or MV event-was determined using competing risk Kaplan-Meier analysis. Median follow-up duration was 6.9 (interquartile range 5.8) years. The most common MR aetiology was myxomatous (34%), followed by Barlow's disease (27.7%), and ischaemic (21.5%). E2E MVP was performed for the following indications: persistent MR (51.5%), systolic anterior motion prophylaxis (22.1%), transaortic approach (17.5%) and systolic anterior motion treatment post-MVP (8.9%). Concomitant ring annuloplasty was performed in 224 patients (73.9%). Operative mortality was 3.6% and MV event rate was 18.5%. Significant predictors of decreased survival included age, renal insufficiency, peripheral vascular disease and ischaemic MR aetiology (all P < 0.050). No ring annuloplasty (HR 2.79; P < 0.001) was the only significant predictor of MV events. Estimated event-free survival for the overall cohort was 8.5 years, and shortest for functional (non-ischaemic; 6.6 years) and ischaemic aetiology (5.5 years). E2E repair is a versatile MVP technique, which can be used in prevention and treatment of systolic anterior motion, transaortic approach or with concomitant techniques, with reasonable outcomes. Ischaemic aetiology and absence of ring annuloplasty were associated with worse cumulative survival and MV event rates, respectively, which raises some concern in light of the expanding indication for MitraClip system.

Application of transseptal puncture to radiofrequency catheter ablation in children with left accessory pathway induced paroxysmal supraventricular tachycardia

Objective To explore the value of transseptal puncture for left-sided accessory pathway in radiofrequency catheter ablation in children with paroxysmal supraventricular tachycardia(PSVT). Methods Thirty-three patients with PSVT who had underwent radiofrequency catheter ablation in the First Affiliated Hospital, Sun Yat-Sen University from January 2012 to December 2017 were retrospectively analyzed.All the cases were treated by transaortic approach(transaortic group) or transseptal approach(transseptal group). The immediate success rates, total fluoroscopy time and radiation exposure between 2 groups were compared, and the perioperative complications and recurrence rates were observed between 2 groups. Results Thirty-three cases of children were enrolled, 22 cases were male and 11 cases were female.Nineteen cases were treated by transaortic approach(transaortic group), while 18 cases were treated by transseptal approach(transseptal group), including 4 recurrent cases in the transaortic group who were switched to transseptal approach because of previous treatment failure.The age was (10.16±3.06) years and (10.67±2.20) years, and the weight was (37.68±14.28) kg and (37.33±8.64) kg, respectively.There were no significant diffe-rences in age and weight statistics between 2 groups(all P>0.05). The total fluoroscopy time was (20.16±11.41) minutes and (12.56±5.23) minutes, and the median dose of radiation exposure was 67.0 mGy and 33.5 mGy, respectively.The postoperative recurrence rate was 21% (4/19 cases) and 0 (0/18 cases), respectively.There were significant differences in total fluoroscopy time, radiation exposure and recurrence rate statistics between 2 groups(t=2.627, Z=-2.31, χ2=4.249, all P<0.05). No complications were found in both 2 groups. Conclusions It is safe and feasible by transseptal puncture for left-sided accessory pathway in radiofrequency catheter ablation in children with PSVT.Radiofrequency catheter ablation by transseptal approach could significantly reduce the postoperative recu-rrence rate, and should be the first choice for left-side accessory pathway in children. Key words: Child; Paroxysmal supraventricular tachycardia; Transseptal puncture; Left-sided accessory pathway; Catheter ablation

Surgical repair of a ruptured congenital sinus of Valsalva aneurysm: 10-year experience with 286 cases.

Surgical intervention is the main treatment for a ruptured congenital sinus of Valsalva aneurysm (SVA). However, reports on the surgical experience are scarce. We retrospectively analysed the cases of our centre to summarize our 10-year experience. A total of 286 patients who were diagnosed with a congenital ruptured SVA and underwent surgical repair between 2007 and 2016 were identified for the analysis. Follow-up data (mean ± standard deviation: 49.6 ± 34.9 months) were obtained from outpatient department records and telephone calls. The SVAs originated from the right coronary sinus (79.7%), the non-coronary sinus (19.6%) and the left coronary sinus (0.7%) but ruptured into the right ventricle (58.4%) and the right atrium (41.3%). The most commonly associated deformities were a ventricular septal defect (46.3%), aortic valve regurgitation (33.2%) and tricuspid regurgitation (20.3%). The SVA defect was closed by direct suturing (9.1%) or patching (90.9%) through an incision in the cardiac chamber involved or a transaortic approach. The mean postoperative hospital stay duration was 7.2 days, and 98.6% of the patients were discharged in New York Heart Association functional class I or II. The incidence rate of short-term complications was 5.7%. There were 4 late deaths, and 9 patients required rehospitalization due to surgery-related events. The estimated 10-year survival rate was greater than 90% according to the Kaplan-Meier survival curve. Surgical repair is an effective and safe treatment for a ruptured SVA. The majority of patients who undergo surgical repair can survive for a long time.

Percutaneous closure of patent ductus arteriosus with the Nit-Occlud® patent ductus arteriosus device in 268 consecutive cases.

Background:The pfm Nit-Occlud® patent ductus arteriosus (PDA) device is well established for interventional closure of PDA. However, there are still limited data concerning its efficacy and follow-up in larger patient groups.Aims:This study aimed to evaluate the safety and efficacy of the Nit-Occlud® PDA device, implanted both through transpulmonary and transaortic approach, in a large cohort.Methods:From July 2008 to December 2015, 268 consecutive patients were admitted for transcatheter closure of a PDA and were treated with the Nit-Occlud® coil. Clinical, echocardiographic, and angiographic data were evaluated.Results:The median age was 5.2 years (range, 5 months to 62 years), and the median weight was 19.3 kg (range: 5.5–97 kg). Ten (3.7%) patients had weight <10 kg. The most common ductus types treated were Krichenko Type E and A (44.0% and 33.2%, respectively). Twelve (4.5%) patients were treated for residual shunting after surgical PDA closure. The median diameter at the narrowest point was 1.5 mm (range: 0.4–4 mm), the median size of the ampulla was 5 mm (range: 1–15 mm), and the median length was 9 mm (range: 2–25 mm). Device implantation could be successfully achieved in all cases. Closure rates documented immediately after the procedure, at 3–10 days, 1 month, and 6 months after intervention were 62%, 95.1%, 97.8%, and 98.5%, respectively. With the exception of one minor thromboembolic event, there were no procedure-related complications.Conclusion:Closure of PDA with various anatomic variations and sizes can be performed effectively and safely using the Nit-Occlud® coil.

Left ventricular decompression in veno-arterial extracorporeal membrane oxygenation.

Despite the survival benefit of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for treatment of refractory cardiogenic shock, it can also have potentially deleterious effects of left ventricular overload and pulmonary edema. The objective of this review was to investigate the current evidence on the incidence, diagnosis, risk factors, prevention, and interventions for left ventricular overload in adult and pediatric VA-ECMO patients. Five electronic databases, including MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews, were searched for original published studies from their dates of inception to January 2018. All types of adult and pediatric studies that investigated LV overload in VA-ECMO and were published in the English language were reviewed. Exclusion criteria included abstracts and conference presentations. The reported incidence and sequelae of LV overload in VA-ECMO are highly variable, with presentations ranging from pulmonary arterial diastolic pressures of greater than 25 mmHg and LV distention on echocardiography, to severe pulmonary edema, LV thrombosis, and refractory ventricular arrhythmias. Currently, there are no standardized diagnostic criteria or guidelines for the type and timing of intervention for LV overload. Techniques for LV decompression have included direct surgical LV venting with catheter insertion via sternotomy or a minimally invasive incision; percutaneous catheterization via a transaortic, transseptal, or transpulmonary approach; ventricular assist devices; and intra-aortic balloon pumps. Left ventricular volume distention is a significant problem in VA-ECMO patients, with sequelae including myocardial ischemia, severe pulmonary edema, and intracardiac thrombosis. Further research is required on its incidence, diagnostic criteria, and risk factors, as well as the optimal timing and method for LV decompression, given the diversity of surgical and percutaneous techniques that are available.

Diagnostic yield and safety of EUS-FNA biopsy in sub-aortic and para-aortic lymph node stations with the trans-aortic approach: a case series and literature review

ABSTRACTBackground: Sub-aortic (station 5) and para-aortic (station 6) lymph nodes are not easily accessible due to the interposition of the aorta and the left pulmonary artery. Taking a biopsy from those stations could be of value when there are no other mediastinal lymph node stations or when biopsy in other sites failed to reach a diagnosis. Surgery is the gold standard technique in the evaluation of those stations; endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been proposed as a minimally invasive technique through the trans-aortic approach, with an acceptable diagnostic yield and safety profile.Objective: To evaluate diagnostic accuracy and safety of the trans-aortic EUS-FNA in lymph node stations 5 and 6.Methods: We reviewed all patients who underwent trans-aortic EUS-FNA from 2010 to 2017, for mediastinal lymph node enlargement or positron emission tomography/computed tomography (PET/CT) positivity (integrated 2-deoxy-2-fluoro-d-glucose). Demographic characteristics, lesion site and size, needle, final diagnosis, and complications were collected.Results: A total of 11 patients were included, 5 males, mean age 59 years. Samples were inadequate in two cases, a diagnosis of lung cancer was reached in four patients (two adenocarcinoma and two squamous cell carcinoma) and five cases were negative for malignancy (one confirmed by surgery, two were found to be cancer at percutaneous lung biopsy and transbronchial biopsy, one patient received a diagnosis of Langerhans cell histiocytosis by transbronchial lung cryobiopsy, and one patient was lost at follow-up). The sensitivity for malignancy was 57%, and the overall diagnostic accuracy was 45%. No complications occurred.Conclusions: Trans-aortic EUS-FNA could be proposed as a valuable and safe approach for taking biopsy from mediastinal lymph node stations 5 and 6.

Transcatheter Aortic Valve Replacement: Alternative Access beyond the Femoral Arterial Approach.

Aortic stenosis is the most prevalent valvular cardiovascular disease affecting the population over the age of 65 years. Transcatheter aortic valve replacement (TAVR) was developed as a minimally invasive surgical intervention to treat aortic stenosis in patients at high risk for surgical complications. Although the most commonly used approach for placement of a transcatheter aortic valve is in retrograde fashion via a transfemoral approach, narrowed luminal diameters, extensive atherosclerotic disease, or significant tortuosity may limit use of this route. In these patients, alternative methods including subclavian, transaortic, and transapical approaches should be considered. An understanding of these access routes and their respective indications and contraindications allows the radiologist to provide additional preprocedure measurements and images to help guide placement of the valve. ©RSNA, 2018.

OC41 MID-TERM RESULTS OF TRANSCATHETER AORTIC VALVE IMPLANTATION BY TRANS-CAROTID APPROACH UNDER LOCO-REGIONAL ANAESTHESIA. SINGLE CENTER EXPERIENCE

Background and Aim: Trans-carotid access with loco-regional anesthesia has been developped as peripheral approach for transcatheter aortic valve implantation (TAVI) in alternative to transthoracic more invasive accesses for patients with transfemoral contraindications, high vascular risk and severe comorbidities. In this study, we report our experience and mid-term results in trans-carotid TAVI under loco-regional anesthesia by cervical block. Methods: Thirty patients were selected by the Heart Team of our institution for trans-carotid TAVI between September 2014 and December 2017. Mean age was 83.6 ± 6, 9 years old. the Logistic EuroSCORE was 21,7 ± 12,2, EuroSCORE 2 was 7.7 ± 5,2 and STS Score was 21,1 ± 8,8. The carotid approach was performed through a small low longitudinal cervicotomy with loco-regional anaesthesia by cervical block. Results: The transcatheter Edwards SAPIEN 3 valves (Edwards Lifesciences, Irvine, California) (n = 27; 90%) and the Medtronic Corvalve Evolut R (Medtronic, Inc., Mineapolis, Minnesota) (n = 3;10%) were used. All patients were successfully implanted. Two procedural not-access related deaths were registered, no vascular access complications occurred. There was one in-hospital minor stroke. Two patients required a pacemaker implantation for atrioventricular block. Post-operative echocardiogram showed satisfactory transvalvular gradients without significant paravalvular leak. At late follow-up (mean 12,3 ± 9,2 months) two non-cardiac deaths and one major stroke were registered and functional NYHA class improved. Conclusions: Carotid artery access for TAVI is a safe and feasible access compared to trans-apical and trans-aortic approaches. It can be realized under loco-regional anaesthesia with continuous clinical monitoring of neurological status. This approach should be considered a valid alternative for TAVI in patients with unfavourable vascular access.

Health-related quality of life following transcatheter aortic valve implantation using transaortic, transfemoral approaches and surgical aortic valve replacement-a single-center study.

ObjectiveTo evaluate short- and long-term changes in quality of life (QoL) in patients undergoing transcatheter aortic valve implantation (TAVI) and to assess differences in patient QoL when using the TAVI transaortic (TAVI TAo) approach compared with the transfemoral approach (TAVI TF) and surgical aortic valve replacement (SAVR).MethodsNinety-seven patients were assessed. Thirty-two patients underwent TAVI TAo, 31 underwent TAVI TF and 34 patients underwent SAVR. QoL was assessed using the EQ-5D-3L questionnaire at baseline, after one month and one year.ResultsMean patient age was 80 years (range, 61–92 years) and the mean logistic EuroSCORE was 12.45% (range, 1.39%–78.98%). Declared health state at baseline was significantly lower in TAVI TF (P < 0.001) and after one month there were no differences between the three groups (P = 0.99). After one year, SAVR patient results of the EQ-5D-3L index value were lower in comparison to both TAVI patient groups (P < 0.05). The analysis also showed significant differences between the results of EQ-5D-3L index value over the one month and one year follow-up (TAVI TAo, P < 0.001; TAVI TF, P < 0.05; SAVR, P < 0.05). In all groups, the values significantly increased after one-month and one-year of follow-up in comparison to baseline value. Significant differences were also demonstrated between Visual Analogue Scale values (VAS).ConclusionsA significant improvement in QoL was observed in all three patient groups. Regardless of the TAVI approach, EQ-5D-3L and VAS values were significantly increased after one-month and one-year follow up; the SAVR patients however, reported lower health status when compared to the TAVI patients.

Comparison of Transaortic and Subclavian Approaches for Transcatheter Aortic Valve Replacement in Patients with No Transfemoral Access Options

ABSTRACT Background: To compare outcomes among transcatheter aortic valve replacement (TAVR) performed via transaortic (TAo) and subclavian (SCL) approaches. Many patients are not amenable for TAVR via the transfemoral route due to peripheral vascular disease. Limited data exist regarding safety and procedural feasibility of TAVR via TAo and SCL routes. Methods: Single-center study comparing patients treated with CoreValve® and Sapien XT® from May 2013 to August 2015 via subclavian (SCL) or transaortic (TAo) approach. All patients were deemed inappropriate for transfemoral access. Baseline characteristics, procedural feasibility, and outcomes were compared. Results: A total of 27 (53%) patients underwent TAVR via the TAo approach and 24 (47%) via the SCL approach. Society of Thoracic Surgeons (STS) risk scores and patient age were similar: 11.33 versus 8.66; p = 0.13 and 84.7 years versus 82.6 years; p = 0.3, respectively. All patients in the SCL group received self-expandable valves. Overall vascular complications were low in both groups (SCL = 4.2% vs. TAo = 3.7%). Length of hospital stay was marginally longer in the TAo group (mean 7.25 vs. 6.2 days, p = 0.119). There was a trend towards increased mortality associated with TA access (11.1% vs. 4%, p = 0.36) at 30 days that was significant after 12 months (33.3% vs. 8.3%, p = 0.03). Conclusion: Our data shows a relatively low incidence of complications and comparable outcomes in these two groups. SCL or TAo access can be utilized as alternatives in patients with prohibitive ileofemoral anatomy, however, based on our limited data, subclavian access with self-expanding valves offers better outcomes.

Propensity-matched comparison of clinical outcomes after transaortic versus transfemoral aortic valve replacement

We aimed to compare the long-term outcomes of transaortic (TAo-AVR) and transfemoral (TF-AVR) transcatheter aortic valve replacement. Between January 2012 and December 2015, consecutive TAo-AVR and TF-AVR cases were compared using a propensity score-matching analysis. Primary endpoints were 30-day and one-year mortality; 644 TAVR patients were included (163 TAo-AVR and 481 TF-AVR). Peripheral artery disease (31.9% vs. 5%, p<0.001) and coronary artery disease (50.0% vs. 39.3%, p=0.009) were more frequent in TAo-AVR patients. The Society of Thoracic Surgeons scores were not different (6.9% vs. 6.5%, p=0.243). Propensity matching identified 124 well-matched patient pairs. Thirty-day and one-year mortality rates were similar in the overall population of TAo-AVR and TF-AVR patients (7.3% vs 7.6%, p=0.8 and 18.4% vs. 15.8%, p=0.6, respectively), and in the matched cohort (7.3% vs. 6.5%, p=0.8 and 15.3% vs. 16.1%, p=0.8, respectively). Transaortic access was associated with higher risk of new onset of atrial fibrillation (NOAF) (24.4% vs. 9.6%, p=0.012), life-threatening bleedings (6.5% vs. 0.8%, p=0.036) and transfusion (41% vs. 16.7%, p<0.001). No significant differences were observed between the respective 30-day and one-year mortality rates of TAo-AVR and TF-AVR patients. The transaortic approach thus constitutes a valid alternative to TF-AVR, but is associated with higher rates of NOAF, bleedings, and transfusion.

Aortic and innominate routes for transcatheter aortic valve implantation

ObjectivesThis study aimed at evaluating the efficacy and safety of the transaortic approach for the transcatheter aortic valve implantation procedure using balloon-expandable and self-expanding devices. MethodsFrom January 2012 to December 2016, the transaortic-transcatheter aortic valve implantation procedure was performed in 206 consecutive patients at the Rangueil University Hospital. All procedures were performed by a multidisciplinary heart team. The ascending aorta (27%) or innominate artery (73%) was exposed through a J-type manubriotomy. Events were adjudicated according to Valve Academic Research Consortium-2 criteria. ResultsMean age and logistic European System for Cardiac Risk Evaluation II were 83.9 ± 6.7 years and 16.8% ± 10.8%, respectively. Balloon-expandable and self-expanding valves were implanted in 59.7% and 40.3% of patients, respectively. Device success rate was 98.1%. Thirty-day overall mortality, cardiovascular mortality, cerebrovascular event, myocardial infarction, and permanent pacemaker implantation rates were 5.3%, 4.4%, 1.5%, 1.0%, and 9.7%, respectively (1-year rates: 15.5%, 9.2%, 3.9%, 3.4%, and 10.2%, respectively). Life-threatening bleeding and major vascular complications (7.3% and 3.9%, respectively) were not related to the central access site in approximately half of the cases. Multivariable Cox regression analysis identified preoperative renal failure as an independent predictor of overall mortality (odds ratio, 2.82; 95% confidence interval, 1.73-4.59; P < .0001). At the 1-year follow-up, most patients had experienced improved functional status and 98.4% of them were free of moderate to severe paravalvular leak. ConclusionsIn a higher-risk subgroup within the patient population receiving transcatheter aortic valve implantation, transaortic-transcatheter aortic valve implantation was successfully performed in 98.1% of cases, with high functional improvement and low rates of mortality and adverse events, especially neurologic complications.

What is the role of apical ventriculotomy in children and young adults with hypertrophic cardiomyopathy?

The transapical approach has been utilized in adult HCM patients with either midventricular obstruction or a small LV cavity; however, there are little data on its use in children. We retrospectively reviewed all patients (age <21 years) with HCM who underwent a transapical myectomy from January 2002 to December 2016. Indication for surgery was midventricular obstruction in 19/23 (83%) and small LV cavity in 4 (17%). Preoperative symptoms included: dyspnea (96%), chest pain (65%), presyncope (61%), and syncope (35%). The mean age at the time of operation was 14 ± 4.0 years (range, 4-20). Overall, 23 patients (12 males) underwent transapical myectomy. A concomitant transaortic approach was performed in 16/19 (84%) with obstruction. The intraventricular gradient decreased from 71 mm Hg (IQR 44-92 mm Hg) preoperatively to 18 mm Hg (IQR 8-34 mm Hg, P < .0001) after myectomy. In patients with a small LV cavity, the mean left ventricular end diastolic dimension (LVEDD) increased from 40 ± 3 mm to 46 ± 3 mm (P = .05) after myectomy. There were no early deaths. Postoperative morbidity included complete heart block in 3 patients, 2 of which required pacemakers. Median follow up was 3.5 years (IQR 1.6-5.6). Symptoms improved in 95% of patients; the number of patients in NYHA class 3 or 4 heart failure decreased from 10/23 (43%) preoperatively to 3/23 (13%) postoperatively (P < .0001). Overall survival at 5 years postsurgery was 100%. Transplant-free survival was 91% and 87% at 1 and 5 years, respectively. In children with HCM, transapical myectomy is an effective adjunct to a transaortic approach to abolish midventricular obstruction and it effectively increases LV stroke volume in patients with small LV cavities and nonobstructive HCM. It may be beneficial for these patients with significant symptoms and who have failed medical therapy as a treatment alternative to cardiac transplantation.

Non-transfemoral access sites for transcatheter aortic valve replacement

Transfemoral access is currently the standard and preferred access site for transcatheter aortic valve replacement (TAVR), though novel approaches are emerging to expand treatment options for the increasing numbers of patients with a contraindication for the traditional route. Previous publications have provided comparisons between two TAVR access sites, primarily transfemoral versus one of the novel approaches, while others have compared three or four novel approaches. The aim of this report is to provide a comprehensive summary of publications that analyse and compare the six non-transfemoral access sites currently described in the literature. These include the transapical, transaortic, axillary/subclavian, brachiocephalic, transcarotid, and transcaval approaches. Though there remains little consensus as to the superiority or non-inferiority of TAVR approaches, and there has yet to be randomized clinical trials to support published findings, with careful patient and procedural selection, outcomes for novel approaches have been reported to be comparable to standard transfemoral access when performed by skilled physicians. As such, choice of procedure is primarily based on registry data and the judgement of surgical teams as to which approach is best in each individual case. As TAVR continues to be an increasingly widespread treatment, search for the optimal access site will grow, and focus should be placed on the importance of educating surgeons as to all possible approaches so they may review and chose the most appropriate technique for a given patient.

Cerebral Protection During Catheter Ablation of Ventricular Tachycardia in Patients With Ischemic Heart Disease.

BackgroundCatheter ablation of ventricular tachycardia (VT) is associated with the risk of cerebral embolism. The origin of periprocedural brain embolism in the setting of VT ablation is often unknown and strategies to avoid it are sparse. The aim of this study was to assess the safety and feasibility of an endovascular 2‐filter‐based cerebral protection system (CPS) in left ventricular VT ablation procedures in patients with ischemic heart disease. Furthermore, histopathological correlates of periprocedural embolization were investigated.Methods and ResultsIn this pilot study, 11 patients with ischemic heart disease and sustained VT underwent left ventricular catheter ablation under CPS surveillance. The placement of the CPS was conducted before the ablation procedure via the right radial artery. The VT ablation procedure was performed via a combined transaortic and transseptal approach. All VTs were successfully ablated. Placement and retrieval of the CPS was successful and safe in all cases. No periprocedural complications related to the CPS were observed and no periprocedural transient ischemic attack or stroke occurred. Debris captured by the CPS was detected in all patients. Histology revealed that acute thrombus was the most common type of debris (91%), followed by arterial wall tissue (73%) and foreign material (55%). Less frequently found were myocardium (27%), calcification (9%), necrotic core (9%), and valve tissue (9%).ConclusionsCerebral protection during VT ablation seems to be safe and feasible. Ablation procedures of VT are associated with embolization of embolic debris, which was found in every patient.

Transseptal or retrograde approach for transcatheter ablation of left sided accessory pathways: a systematic review and meta-analysis

BackgroundTranscatheter ablation is the most effective treatment for patients with symptomatic or high-risk accessory pathways (AP). At present, no clear recommendations have been issued on the optimal approach for left sided AP ablation. We performed this meta-analysis to compare the safety and efficacy of transaortic retrograde versus transseptal approach for left sided AP ablation. Methods and resultsMEDLINE/PubMed and Cochrane database were searched for pertinent articles from 1990 until 2016. Following inclusion/exclusion criteria application, 29 studies were selected including 2030 patients (1013 retrograde, 1017 transseptal) from 28 observational single Centre studies and one randomized trial. Patients approached by transseptal puncture presented a significantly higher acute success (98% vs. 94%, p = 0.040). The incidence of late recurrences (p = 0.381) and complications (p = 0.301) did not differ among the two groups, but the pattern of complications differed: vascular complications were more frequent with transaortic retrograde approach, while cardiac tamponade was the main transseptal complication. No difference was noted in terms of procedural duration and fluoroscopy time (p = 0.230 and p = 0.980, respectively). Meta-regression analysis showed no relation between year of publication and acute success (p = 0.325) or incidence of complications (p = 0.795); additionally, no direct relation was found between age and acute success (p = 0.256) or complications (p = 0.863). ConclusionsLeft sided AP transcatheter ablation is effective in around 95% of the cases, with a very limited incidence of complications. Transseptal access provides higher acute success in achieving AP ablation; late recurrences are rare but observed similarly following both approaches. Retrograde approach is affected by a relatively high incidence of vascular complications.

Transcatheter Aortic Valve Replacement by a Novel Suprasternal Approach

Transcatheter aortic valve replacement (TAVR) provides therapy for patients with severe aortic stenosis at extreme, high, or intermediate surgical risk. Transfemoral access has been the preferred access route; however, this approach is not suitable for many TAVR candidates. A suprasternal approach may allow for earlier ambulation and shorter hospital stay as compared with other, nontransfemoral approaches. A total of 11 patients with unsuitable transfemoral access underwent suprasternal TAVR. Propensity matching was used to compare suprasternal patients to patients undergoing transaortic, transapical, and trans-subclavian TAVR. Groups were well matched for baseline characteristics. A self-expanding valve device was used in 6 (54.5%) and a balloon-expandable valve in 5 (45.5%) of the 11 patients treated by the suprasternal route. Suprasternal and trans-subclavian patients were able to ambulate earlier than patients treated by the transaortic route, a median 1.6 days (interquartile range [IQR]: 0.9 to 1.8), 1.6 days (IQR: 0.9 to 2.7), and 3.9 days (IQR: 1.9 to 4.5) after the procedure for suprasternal, trans-subclavian, and transaortic patients, respectively (p= 0.001). Length of hospitalization was shorter for patients treated by suprasternal or trans-subclavian access in comparison with patients treated by the transaortic or transapical approach: median 4 days (IQR: 3 to 8) and 4 days (IQR: 4 to 8) versus 8 days (IQR: 6 to 14) and 6 days (IQR: 7 to 11) for suprasternal and trans-subclavian versus transaortic and transapical, respectively (p= 0.01). Suprasternal and trans-subclavian access are associated with earlier ambulation and shorter hospitalization than other nontransfemoral TAVR routes, without an increase in complications. Further study is required to determine if suprasternal is the alternative access of choice for TAVR patients with poor transfemoral vasculature.

Large Aorto-Pulmonary Window (APW) associated with severe pulmonary hypertension: A case report

Background: APW is a rare congenital cardiac abnormality, accounting for 0.2% to 0.6% of patients. Hence the reported surgical experience is minimal. It is a communication b/w pulmonary artery (PA) and the ascending aorta (Ao), in the presence of two separate semi lunar valves. Heart failure and irreversible pulmonary hypertension are the fearsome outcomes of untreated APW. Therefore, surgical closure is the first-line curative choice. We present a case of young boy who presented late in age (his second decade of life) with severe signs and symptoms. Case Presentation: A 12-year-old male patient from Baluchistan (balochi) presented with complaints of high grade fever for one week, palpitations since 12 days, along with past history of shortness of breath. On examination patient was anemic, cyanosed with raised JVP. On precordial examination apex beat was localized at the 6th intercostal space shifted to mid-axillary line. S1 was normal but S2 was loud with prominent pulmonary component. Grade IV/VI continuous murmur was heard in the left upper sterna border. Chest X-ray showed cardiomegaly with prominent pulmonary artery (PA) and bilateral lung congestion. Echocardiography showed enlarged and hypertrophied right ventricle associated with dilated PA and a large APW was seen with severe pulmonary artery pressure (PAP) of 102 mmHg. Diagnosis of APW was confirmed on cardiac catheterization. Furthermore, cardiac CT was performed which showed type I APW with severe PH and large patent PDA (patent ductus arteriosus). Patient then underwent repair of APW associated with reactive pulmonary hypertension that had a complete repair utilizing a trans-aortic approach. PDA was also ligated during the same procedure. Patient symptoms remarkably improved with a reduction PAP (40mmHg) after surgery and at 6 weeks follow-up. Follow-up echocardiography showed complete closure of the APW, and pharmacological therapy was no longer required in the patient. Conclusion: APW should be suspected in any child, who comes with repeated chest infections and signs of congestive heart failure. It should be surgically corrected early, in order to prevent the development of obstructive pulmonary vascular disease. There is conflict of interest.

Combined transaortic and transapical approach to septal myectomy in patients with complex hypertrophic cardiomyopathy

ObjectivesResidual midventricular obstruction after transaortic myectomy may lead to recurrent symptoms and reoperation in patients with hypertrophic cardiomyopathy and long-segment septal hypertrophy. A combined transaortic and transapical approach to septal myectomy during initial operation allows for the complete relief of subaortic and midventricular gradients and may reduce the risk of poor late functional results. MethodsWe analyzed the early outcomes of 86 patients aged 18 years or more who underwent combined transaortic and transapical septal myectomy for left ventricular outflow tract obstruction due to systolic anterior motion and midventricular obstruction or cavitary obliteration due to apical hypertrophic cardiomyopathy. ResultsMidventricular obstruction was present in 59 patients (68.6%); 12 patients (14.0%) had cavitary obliteration, and 15 patients (17.4%) had a combination of both. Overall, median (25th, 75th percentile) prebypass and postbypass directly measured intracavitary gradients were 85 mm Hg (48, 125) and 4 mm Hg (0, 10.8), respectively; median predischarge transthoracic left ventricular outflow tract and midventricular gradients were 0 mm Hg (0, 0) and 0 mm Hg (0, 8.5). Median crossclamp and perfusion times were 35 minutes (27, 44) and 48.5 minutes (40, 64). The 30-day and 1-year survivals were both 95%, with 2 early deaths. Functional status beyond 30 days postoperatively was available in 42 patients, and 41 patients reported improvement in symptoms and were in New York Heart Association class I/II. ConclusionsCombined transaortic and transapical septal myectomy is an effective and reasonably safe approach for patients with hypertrophic cardiomyopathy with complex septal hypertrophy. This method may prevent residual midventricular obstruction and permits myectomy to augment diastolic filling and improve left ventricular stroke volume in patients with apical hypertrophic cardiomyopathy.

Transcatheter aortic valve replacement using the transaortic approach

Transcatheter aortic valve replacement using the transaortic approach