Ventricular Outflow Obstruction Research Articles

Ruptured Aneurysm of the Sinus of Valsalva Causing Pulmonary Embolism: A Rare Association.

Aneurysms of the sinus of Valsalva are rare. Unruptured sinus of Valsalva aneurysm is usually asymptomatic and rarely presents as right ventricular outflow obstruction, myocardial infarction as a result of coronary artery compression, conduction disturbances, or endocarditis. They have only been reported as the presumed source of embolism in six cases. We report a patient with right sinus of Valsalva rupture to the right atrium and embolization of aneurysm contents to the pulmonary vasculature.

Fourth Ventricular Outflow Obstruction in an Infant with Ileal Atresia and Laryngomalacia: Endoscopic Management

AbstractFourth ventricle outflow obstruction (FVOO) is a rare cause of obstructive hydrocephalus. In this study, we described a case of idiopathic FVOO with ileal atresia and laryngomalacia which was managed with endoscopic third ventriculostomy (ETV) and re-endoscopy. We also described the techniques of fenestration of Liliequist membrane and partial removal of arachnoid membrane over dorsum sella (DS) to prevent closure of fenestration and recurrence of hydrocephalus. The patient was a 4-month-old infant presented with progressively increasing head size, feeding difficulty, respiratory distress, and tense fontanel. The infant had a history of laparotomy for ileal atresia. CT scan showed panventriculomegaly due to FVOO. ETV with fenestration of Liliequist membrane was done on emergency basis. After operation, the patient improved clinically and radiologically. Four weeks later, the patient returned with recurrent hydrocephalus. Endoscopic reoperation showed closure of fenestration in arachnoid membrane (Lilieqiest membrane). Endoscopic refenestration with partial excision of arachnoid on DS was done. The patient again recovered radiologically and clinically till last follow-up. In idiopathic FVOO, ETV with wide fenestration of Liliequist membrane, preferably with partial removal of arachnoid on DS, may be very useful in treating hydrocephalus (HCP) and preventing recurrent HCP even in infants.

Pacemaker implantation in patients with major depression, should it be of concern? A case report and literature review

BackgroundPsychological adaptation after cardiac pacemaker implantation is a challenge for patients with mental illness.Case presentationHere we report a self-harming patient with a psychiatric disorder. A 73-year-old female patient with 16-year coronary heart disease and a 4-year depression was admitted to our hospital for a coma. Two months earlier, the local hospital confirmed that the patient had a second-degree sinoatrial (SA) block (type 2) as well as basal septal hypertrophy with the left ventricular outflow obstruction. Therefore, metoprolol sustained-release tablets 95 mg QD and diltiazem sustained-release tablets 90 mg QD was given as treatment after a pacemaker was implanted. However, the patient had continued complaining about discomfort due to the pacemaker implanted after being discharged from the hospital. Two months later, she attempted to commit suicide by removing her pacemaker and taking 80 sleeping pills. After a series of treatments, the patient improved and was discharged without a pacemaker re-implantation. With continued anti-depression treatment and strengthen family supervision, the patient’s condition is stable now.ConclusionsA suicide attempt by intentionally removing the permanent pacemaker system was rarely reported. In bradycardia patients with a history of psychological or psychiatric disease, careful evaluation should be done before and after implantation of the pacemaker.

The Carpentier-Edwards Classic and Physio Annuloplasty Rings in Repair of Degenerative Mitral Valve Disease: A Retrospective Study.

BackgroundPhysio ring (SR) is considered an improved version of the Classic rigid ring (RR). Today, SR is more widely used in mitral valve (MV) repair. We sought to compare the long-term outcomes of repair with RR and SR in degenerative mitral valve disease.MethodsIn a computerized registry of our institution, 306 patients had MV repair with either RR (139 patients) or SR (167 patients) ring between 2005 and 2015. Fifteen of them had concomitant tricuspid valve repair. Ninety-two (30.1%) had Barlow's disease and 214 (69.9%) had fibroelastic deficiency. The patients had similar demographic and echocardiographic characteristics.ResultsThere were 4 (1.3%) operative mortalities. Mean follow-up time was 107.4 ± 13.2 months. Left ventricular end diastolic and end systolic diameters significantly improved in both groups but not between groups. Survival at 10 years was 84.6% (93.1% in RR and 91.5% in SR; p = 0.177) and 10-year freedom from recurrent MR ≥ 2+ was 74.5% (88.2% in RR and 86.3% in SR; p = 0.110). Reoperations for repair failure were 8 in RR and 6 in SR. By Cox regression analysis, Barlow's disease and preoperative MR = 4+ were predictors of repair failure. Old age (≥70 years), NYHA functional class IV and pulmonary artery systolic pressure (≥40 mmHg) were predictors of poor survival by univariate analysis.ConclusionLong-term outcomes of repair for degenerative MV disease with the Classic and Physio rings are comparable. We also reiterate the importance of large size annuloplasty rings for Barlow's disease to avoid the incidence left ventricular outflow obstruction.

Evaluation of N-terminal prohormone of brain natriuretic peptide and cardiac troponin-I levels in cats with systolic anterior motion of the mitral valve in the absence of left ventricular hypertrophy

ObjectivesTo identify the prevalence of systolic anterior motion of the mitral valve (SAM) in apparently healthy cats in the absence of left ventricular hypertrophy (LVH) and examine the relationship between specific cardiac biomarker concentrations and echocardiographic parameters in these individuals. Animalseighty client-owned cats. Materials and methodsretrospective study; inclusion criteria were the presence of SAM on conscious echocardiography and concurrent measurement of plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and serum cardiac troponin-I (cTnI). Cats were excluded if they had LVH, left atrial enlargement or systemic disease. The percentages of cats with NT-proBNP and cTnI concentrations above the normal reference range were calculated. The correlation between each biomarker concentration and left ventricular myocardial wall thickness, left atrial size and maximum left ventricular outflow tract velocity was evaluated. ResultsThirty-four of 80 patients with SAM showed no evidence of cardiac remodelling (LVH or left atrial enlargement). Of these patients, 30 of 34 had elevated NT-proBNP, and cTnI was elevated in 13 of 27 (48.1%) cats where this biomarker was measured in association with the NT-proBNP assay. A positive correlation was observed between concentration of plasma NT-proBNP and maximum left ventricular outflow tract velocity (rs = 0.67, p<0.0001). No significant correlations were found between the concentration of biomarkers and the remaining echocardiographic parameters. ConclusionsSAM is frequently observed in cats even in the absence of cardiac remodelling, and these individuals often demonstrate elevated plasma NT-proBNP and serum cTnI concentrations. Plasma NT-proBNP elevation is correlated with the severity of the left ventricular outflow obstruction caused by SAM.

Left Ventricular Outflow Obstruction After TAVR Due to Systolic Anterior Motion Successfully Treated With Cardiac Pacing

Abstract Left ventricle outflow tract obstruction can have catastrophic hemodynamical consequences. Patients with severe aortic stenosis undergoing transcatheter aortic valve replacement are at risk of developing this serious complication in the postprocedural period. We present how a drug refractory left ventricle outflow tract obstruction, observed in a 76 year old female after transcatheter aortic valve replacement, was successfully treated with permanent atrioventricular pacing. After the procedure we observed an increase of gradients in left ventricle outflow tract to maximal gradient 96mmHg and mean gradient 46mmHg. The mechanism of left ventricle outflow tract obstruction was systolic anterior motion of the mitral valve. Despite fluids and increased dose of beta-blocker the was no improvement on control echocardiography. A decision to implant a dual chamber pacemaker was made in order to try do decrease the gradients. An immediate decrease in left ventricle outflow tract gradients after activation of sequential pacing with short atrioventricular delay was observed. Awareness of this method may prove helpful to cardiothoracic anesthesiologists treating patients after transcatheter aortic valve replacement

Tricuspid Regurgitation in Adults after Repair of Right Ventricular Outflow Obstructive Lesions

We determined the prevalence and factors associated with tricuspid regurgitation (TR) in adults with repair of right ventricular (RV) outflow obstruction. A total of 256 patients (128 males) were studied at 25.7 ± 7.2years after surgery, of whom 179 had repaired tetralogy of Fallot (TOF), 31 had pulmonary atresia with intact ventricular septum (PAIVS), and 46 had pulmonary stenosis (PS). The mitral and tricuspid annulus diameters, maximum right atrial (RA) area, RV end-systolic and end-diastolic areas, and tricuspid and pulmonary regurgitation were assessed using echocardiography. The prevalence of moderate-to-severe TR was 20.7%. Subgroup analysis revealed that prevalence was greater in patients with repaired TOF (20.7%) and PAIVS (35.5%) than PS patients (10.9%). As a group, severity of TR was found to be correlated with RA area (r = 0.35, p < 0.001), RV end-diastolic (r = 0.28, p < 0.001) and end-systolic (r = 0.22, p = 0.001) areas, and tricuspid valve annulus diameter (r = 0.15, p = 0.022). Moderate-to-severe TR was associated with development of cardiac arrhythmias with an odds ratio of 2.9 (95% CI 1.1 to 8.1, p = 0.031). Multivariate analysis revealed maximum RA area (β = 0.36, p = 0.016) as an independent determinant of severity of TR. Moderate-to-severe TR occurs in about one-fifth of adults with repaired TOF, PAVIS, and PS and is associated with RA dilation and risk of development of cardiac arrhythmias.

Recurrent takotsubo syndrome with worsening of left ventricular outflow obstruction during haemodialysis: a case report.

BackgroundThe recurrence rate of takotsubo syndrome (TS) has been reported as 1.8% per patient-year while left ventricular outflow tract (LVOT) obstruction is comorbid in 10–25% of all instances of TS. The clinical course of recurrent TS with associated LVOT while on haemodialysis has rarely been reported.Case summaryThis case report involves a 60-year-old female patient receiving regular haemodialysis who was admitted for chest pain during ballroom dancing. Four years prior, she had suffered TS, and fully recovered after the hospitalization. An emergent coronary angiogram done during the second hospitalization showed no significant stenosis, and left ventriculography demonstrated mid-apical akinesia and basal hyperkinesia. Based on these findings, we diagnosed the recurrence of TS. Later in the admission, chest pain reappeared with the start of haemodialysis. A transthoracic echocardiogram demonstrated mean pressure gradient (PG) of LVOT was 58 mmHg, with systolic anterior motion of the mitral valve and basal-wall hyperkinesia. The main aetiology for her symptoms was considered as an exacerbation of LVOT obstruction due to removing intravascular volume by haemodialysis. After starting landiolol at 3 μg/kg/min, PG of LVOT and symptoms gradually improved with uptitration of landiolol. Finally, her chest pain resolved when mean PG of LVOT was down to 38 mmHg using 10 μg/kg/min of landiolol.DiscussionTo our knowledge, this is the first report of a recurrent TS case comorbid with LVOT obstruction while on regular haemodialysis. Landiolol, the ultrashort-acting beta-blocker, may be a promising therapeutic option for rapid recovery of increased PG due to LVOT obstruction.

Hypertrophic Cardiomyopathy in “Real-World” Community Cardiology Practice

Differences in presentation and natural history of hypertrophic cardiomyopathy (HC) between community cardiology practice and referral centers has been a source of considerable uncertainty. We report here a cross-sectional analysis of 253 consecutive HC patients from a "real-world" clinical cardiology setting. When compared with a highly selected referral center cohort, patients in clinical practice proved to be similar with regard to disease expression such as left ventricular (LV) wall thickness, outflow obstruction, and natural history, including stable and largely benign clinical course with no or mild symptoms (61% in community practice vs. 55% in referred patients, p = 0.23), occurrence of atrial fibrillation (22% vs. 24%, p = 0.75) and nonfatal sudden death (SD) events (3% vs. 4%, p = 0.8). In contrast, progressive heart failure symptoms were most common in the referral cohort (36% vs. 26%, p = 0.04). In clinical practice, SD was prevented by prophylactic implatable cardioverter defibrillators (ICD) in 5 of 44 patients (11%), although risk was overestimated in 6 patients who were implanted with ICDs in the absence of risk markers (14%). In 16 of 61 (26%) severely symptomatic drug-refractory patients with LV outflow obstruction, recommendation for surgical myectomy (or alcohol septal ablation) was delayed. In conclusion, clinical characteristics and course of HC patients in community practice were generally similar to those in HC referral centers. Community cardiologists managed HC patients predominantly in concert with guideline-based strategies, although risk for SD could be overestimated, and the significance of outflow obstruction with timely reversal of refractory heart failure by intervention was underappreciated.

Current state of the roles of alcohol septal ablation and surgical myectomy in the treatment of hypertrophic obstructive cardiomyopathy.

Hypertrophic cardiomyopathy is a genetically determined disorder resulting in left ventricular hypertrophy. In a majority of the estimated 20 million people affected worldwide, left ventricular outflow obstruction is present at rest or with provocation. The presence and degree of obstruction influence the symptomatic presentation, treatment strategies and prognosis of affected individuals. Pharmacologic therapy with beta-adrenergic blocking drugs and calcium channel blockers is the principal treatment strategy in symptomatic patients with left ventricular outflow obstruction but is ineffective in many patients. When symptoms of exertional shortness of breath, chest pain and/or syncope prove refractory to medical therapy and there is persisting left ventricular outflow obstruction, or when there is drug intolerance, septal reduction strategies (surgical myectomy and alcohol septal ablation) are quite effective. Selection of the optimal septal reduction strategy for a given patient has become controversial and is determined largely by the medical system providing treatment strategies for the patient. Regretably, there are no randomized trials comparing myectomy and ablation and none are anticipated. The comprehensive Hypertrophic Cardiomyopathy Guideline Statements published in 2011 and 2014 differ significantly with the earlier statement favoring surgical myectomy and the more recent statement giving equal class I status to the two septal reduction strategies in adult patients with drug-refractory symptoms. Recently published studies of long-term follow-up of patients after alcohol septal ablation in Europe, where surgical myectomy is rarely performed, confirm long-term safety and effectiveness with survival free of cardiac events exceeding 96% at 15 years. The lesser degree of discomfort and more rapid recovery associated with the minimally invasive catheter-based alcohol ablation procedure coupled with the recently published long-term safety data favor an increased use of this strategy in symptomatic adult patients with hypertrophic obstructive cardiomyopathy (HOCM).

Suicidal right ventricle in children and adults: Trends, triggers, and treatment: A systematic review of a rare but catastrophic event

Background: Suicidal right ventricle (SRV) is defined as a dynamic right ventricular outflow obstruction with a clinical hemodynamic significance. This is a rare and dangerous event in cardiology practice. Objectives: This systematic review is aimed at ascertaining different scenarios that can precipitate SRV in cardiology practice. Methods: Data for the systematic review was retrieved from Cochrane database, Google Scholar, PubMed review, Institute for Scientific Information “Web of Science,” and Medline. The search engine yielded 164 items on SRV. 148 articles were excluded thereafter because they did not meet the criteria for SRV with 16 articles left. The remaining 16 articles fulfilled the inclusion criteria and were further assessed for eligibility and 9 were excluded further, because they did not strictly fulfill the criteria for SRV. Finally, 7 research articles were included in the systematic review and quantitative synthesis. Results: Valvar pulmonary stenosis is the most common diagnosis warranting balloon pulmonary valvotomy (BPV). There is no gender predilection for SRV; 7 males and 6 females. The age range is 5–28 years with a mean of 19.8 ± 6.6 at 95 CI. The most common etiology of SRV was caused by a prior supra systemic right ventricle. In one study, 108 patients had balloon pulmonary valvuloplasty, but only 0.92% (1/108) of the patients who was >5 years developed SRV. Furthermore, out of six patients in another study who had BPV, only one (16.6%) had SRV. The commonest clinical presentation of SRV is cardiovascular collapse, the SRV was relieved in some cases by removing the offending agent (catheter) while some were treated with volume expanders and Beta-blockers. Conclusion: This review has shown that SRV is a rare abnormality in children and adults. It normally occurs during balloon valvotomy or surgical valvotomy.

Echocardiography to Evaluate Pulmonary Stenosis

Congenital pulmonary stenosis (PS) is a common term for lesions causing right ventricular outflow obstruction. It can be further classified as the valvar, supravalvar, and infundibular PS. The PS may often present with other congenital heart diseases. In this article, echo imaging of isolated PS has been discussed. It is imperative to know that the guideline for intervention in isolated PS is totally based on echocardiography. Echocardiographic guidance is required for the selection of procedure, hardwares, evaluation of the outcome of the procedure, and long-term prognosis.

Double Outlet Ventricle: Echocardiographic Evaluation

Double outlet ventricle is a type of conoventricular anomaly. The great arteries arise predominantly (more than 50%) from one of the ventricle. The aortomitral discontinuity varies from minimum discontinuity to complete bilateral conal tissue. Both right and left ventricles can have double outlet though double outlet right ventricle (DORV) is the most common anomaly in this group of abnormalities. Double outlet left ventricle (DOLV) is relatively rare. There are multiple types of DORV based on the site of ventricular septal defect and great artery relationship and presence or absence of ventricular outflow obstruction. The correct anatomical diagnosis requires a detail segmental approach in echocardiography. The echocardiographic features of DORV reviewed in detail followed by a brief discussion on DOLV.

Cardiac Arrest Due to Severe Dynamic Left Ventricular Outflow Obstruction and Hypertrophy Following Anesthesia Induction

Cardiac arrest following induction of general anesthesia is a rare event. A 47-year-old woman with a history of chronic neck pain secondary to spinal stenosis presented for elective cervical laminectomy. Induction of general anesthesia induced cardiac arrest and emergency insertion of the transesophageal echocardiogram probe identified severe, undiagnosed left ventricular hypertrophy with dynamic outflow obstruction. Resuscitative treatment was immediately implemented to include aggressive intravenous fluid resuscitation, intravenous esmolol and phenylephrine to augment preload, afterload, and reflex bradycardia effect. Return of spontaneous circulation was achieved and the patient was admitted to the ICU, where she was extubated with preserved neurocognitive function on the same day. Our case describes the risk presented by undiagnosed cardiac abnormalities in what was accepted as a low-to-intermediate risk patient undergoing an elective procedure. The increasing popularity and use of pocket-sized handheld ultrasound devices may help reduce the risk of occurrences such as this in the future.

P953 When one problem is not enough.

Abstract Background Syncope is a serious complication of significant aortic valve stenosis. Left ventricular outflow obstruction, abnormal arterial and venous vasodilatation and arrhythmic events are usually the most common pathophysiological mechanisms. Structurally abnormal native valves with turbulent abnormal flow are a substrate for infective endocarditis in the elderly population. Clinical Case We report the case of an 74 year-old woman with a past history of hypertension, type II diabetes, dyslipidemia and degenerative severe aortic stenosis waiting valve replacement surgery who presented to the emergency department with syncope. Elevated inflammatory markers, fever and leukocyturia raised the hypothesis of urinary tract infection. Empirical antibiotic was initiated and the patient was admitted to the Internal Medicine ward. Evolution was unsatisfactory with evolution to cardiogenic shock. Urgent transthoracic echocardiogram showed dilated right cavities, mild pericardial effusion and high gradient flow between the left ventricle and right cavities with an unstructured calcified high mobility aortic valve with perivalvular abscess. Patient was transferred to a tertiary center for emergent surgery. A biologic aortic valve and pericardial bovine patch at the proximal membranous septum was implanted. Six-week empirical antibiotic treatment for endocarditis was completed after surgery. Initial blood cultures and native valve culture were negative. Residual restrictive left to right shunt was observed by TTE evaluation. The patient was discharged home and is doing well at follow-up. Conclusion Left-to-right shunt with subsequent cardiogenic shock is a non-common complication of aortic valve endocarditis. Patients presenting with syncope in the context of aortic stenosis must have a careful initial evaluation and mechanical complications excluded. Abstract P953 Figure. EuroEcho2019

2378Blunted stress myocardial oxygenation and not myocardial perfusion reserve is associated with arrhythmic risk in hypertrophic cardiomyopathy

Abstract Background In hypertrophic cardiomyopathy (HCM), myocardial ischaemia is believed to play a role in fatal life-threatening ventricular arrhythmias and caused by microvascular dysfunction manifesting as impaired myocardial perfusion. However, previous studies suggest that myocardial oxygenation during vasodilator stress may also be blunted when perfusion is normal, due to increased metabolic demands conferred by energy-costly sarcomeric mutations, left ventricular hypertrophy and outflow obstruction. Whether or not impaired myocardial perfusion reserve or blunted stress oxygenation on cardiac magnetic resonance (CMR) predict the risk of ventricular arrhythmia in HCM is unknown. Purpose We sought to investigate if impaired myocardial perfusion reserve or stress oxygenation is associated with an increased risk of ventricular arrhythmia in HCM. Methods 103 genotyped HCM patients (mean age 47±15 years) and 32 age- and sex-matched healthy controls underwent adenosine stress blood oxygen level dependent (BOLD) imaging, first pass perfusion and late gadolinium imaging (LGE) on CMR to assess stress oxygenation (BOLD ΔSI), myocardial perfusion reserve index (MPRI), and fibrosis respectively. All HCM patients were monitored for ventricular tachycardia (≥3 beats, ≥120 beats per minute) on a 24-hour Holter. Results As expected, MPRI was significantly reduced in HCM (1.5±0.4 vs 2.0±0.3, p&lt;0.0001) compared to controls. Stress oxygenation response was blunted in HCM versus controls (9.1±4.1% vs 17.0±1.6%, p&lt;0.0001, Figure 1B). Twenty-six (25%) patients developed ventricular tachycardia on Holter monitoring. On univariate analysis, only stress oxygenation and not MPRI associated with ventricular tachycardia. The prevalence of ventricular tachycardia in HCM increased with decreasing quartiles of stress oxygenation (Figure 1D). HCM patients in the lowest quartile of oxygenation (BOLD ΔSI &lt;6.5%) were at a three-fold risk of ventricular tachycardia (OR 3.04, 95% confidence interval 1.02–9.05, p=0.04) on multivariable analysis (after adjusting for sudden cardiac death risk factors and LGE mass) compared to other patients. Sarcomeric mutation status was an independent determinant of stress oxygenation on multivariable analysis. Stress oxygenation was impaired in phenotype-negative sarcomeric mutation carriers (Sarc+P-, n=16) despite normal perfusion (Figure 1C, E). Sarcomeric HCM (Sarc+HCM) had more severe impairment in stress oxygenation than genotype negative HCM (G-HCM) and controls (Figure 1E). Figure 1 Conclusion In HCM, blunted stress-induced oxygenation is associated with an increased risk of ventricular arrhythmia and may represent a novel biomarker of arrhythmic risk. Sarcomeric mutation status is an important determinant of stress oxygenation response. Acknowledgement/Funding National Institute for Health Research Oxford Biomedical Centre and British Heart Foundation.

P1766Clinical impact of atrial fibrillation and heart failure in a cohort of patients with hypertrophic cardiomyopathy

Abstract Background Atrial fibrillation (AF) and heart failure (HF) are common complications in Hypertrophic Cardiomyopathy (HCM) patients, leading to a worsening of their quality of life, need of hospitalization and prognosis. Purpose To analyze clinical variables associated with the presence of AF and HF in HCM patients. Methods HCM patients followed-up in cardiological visits from 2005 to 2017 were included and a descriptive analysis of those with AF and HF was performed. Results Out of 168 patients, 28% had reported AF. They were older than those without arrhythmia (68±15 years (yrs) vs 56±20 yrs, p&lt;0.001) and had more comorbidities such as diabetes (27.7% vs 12.4%, p=0.02) and chronic renal disease (21.3% vs 6.6%, p=0.006). Echocardiographic findings are summarized in Table 1. In our cohort, 27.4% of the patients had HF with a functional class according to the New York Heart Association criteria ≥2. They were older than those without HF (69.3±11.6 yrs vs 55.9±20.6 yrs, p&lt;0.001) and had higher rate of cardiovascular (CV) risk factors such as hypertension (65.2% vs 44.3%, p=0.015). The presence of HF was directly associated with the presence of AF: 52.2% of the patients with HF and 18.9% of the patients without HF developed this arrhythmia (p&lt;0.001). HF patients associated larger left atrial diameter (48±8.1 vs 41.6±7.2mm, p&lt;0.001), myocardial thickness (21.7±3.9 vs 19.2±5.8mm, p=0.002) and higher left ventricular outflow obstruction (LVOO) (55±32 vs 34.3±31.3mmHg, p=0.021), without any differences in the left ventricular ejection fraction. HF patients had a worse prognosis (Picture 1). Multivariate analysis showed that the presence of AF (OR 2.6, CI 95% 1.1–6.3) and LVOO (OR 4.8, CI 95% 1.5–14.8) were independent risk factors of developing HF. Table 1. Echocardiographic findings AF (n=47) Non AF (n=121) p LVOO 27.7 19 0.22 Aortic regurgitation 12.8 3.3 0.02 Mitral regurgitation 27.7 12.4 0.02 Left atrial diameter (mm) 48.8±7.2 40.7±7 &lt;0.001 Myocardial thickness (mm) 20±5.4 19±5.2 0.02 Qualitative variables are expressed as percentages (%) and quantitative variables as mean and standard deviation (M ± SD). Picture 1. Main outcomes of HF patients Conclusions AF and HF were directly associated in our cohort, especially in elderly patients with higher comorbidities, leading to a worse prognosis with a higher hospitalization rate and CV death. This emphasizes the importance of a thorough search of both complications in order to initiate early treatment and improve the prognosis of HCM patients.

Balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction (BATMAN): A novel technique for patients undergoing transcatheter mitral valve replacement.

Transcatheter mitral valve replacement (TMVR) is an option for patients at high risk for mitral valve replacement or repair via sternotomy or left thoracotomy approach. TMVR carries up to 22% risk of left ventricular outflow tract (LVOT) obstruction. Severe LVOT obstruction can have devastating hemodynamic and clinical consequences. We previously presented a novel technique to prevent LVOT obstruction during transapical retrograde mitral valve replacement, by penetrating and ballooning the anterior mitral leaflet (AML), resulting in creation of a "hole" and posterior translocation of AML, then deploying the valve. Three patients underwent TMVR at Saint Louis University for severe mitral regurgitation after being deemed too high risk for surgery, and not candidates for a Mitra-clip procedure. These patients were deemed to be at risk for LVOT obstruction based on the preprocedural evaluation. Via transapical approach, a needle was advanced "through," perforating the AML and wire was placed in the left atrium. Over the wire, an 20-mm valvuloplasty balloon was positioned "within" the anterior leaflet and inflated leading to translocation of the AMVL. Then the valve was deployed. This novel technique has been performed on three patients at our institution. Sapien S3 transcatheter valves were used in all three patients, with 100% procedural success rate. Intraoperative TEE demonstrated no significant LVOT obstruction, cardiopulmonary bypass time was 42-44 min. The balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction technique described here may offer the option of transcatheter mitral valve implantation in patients at high risk of LVOT obstruction. A variation of this technique to allow application in cases with transseptal approach is under investigation.

Percutaneous Intervention for Left Ventricular Assist Device Outflow Obstruction

Left ventricular assist devices (LVADs) are used to support patients with advanced systolic heart failure (HF). These patients might develop LVAD dysfunction and consequent HF symptoms. Occasionally, outflow graft obstruction is responsible for LVAD dysfunction. Here, we describe percutaneous techniques to repair the outflow graft and avoid re-sternotomy.

Alcohol septal ablation in patients with severe septal hypertrophy

ObjectiveThe current guidelines suggest alcohol septal ablation (ASA) is less effective in hypertrophic obstructive cardiomyopathy (HOCM) patients with severe left ventricular hypertrophy, despite acknowledging that systematic data are lacking. Therefore,...