Brian P. O’Neill

Transcatheter caval valve implantation using multimodality imaging: Roles of TEE, CT, and 3D printing

This iPIX illustrates 3-dimensional (3D) printing guided periprocedural, multimodality pictorial planning performed for a successful transcatheter caval valve implantation (CAVI). A 57-year-old patient with severe mitral valve regurgitation status post–mitral ring placement in 2001 (28-mm Cosgrove

Transcatheter Tricuspid Valve Intervention: The Next Frontier

The pioneering work of Dr. Alan Cribier [(1)][1] in 2002 ushered in a new era for the treatment of valvular heart disease. In the past decade, transcatheter aortic valve replacement (TAVR) has gone from a difficult, moderately successful procedure [(2,3)][2] to a widely adopted intervention that

Caval Valve Implantation: Are 2 Valves Better Than 1?

The management of patients with severe symptomatic tricuspid regurgitation (TR) remains extremely challenging for cardiologists and cardiovascular surgeons alike. Medical therapy, consisting primarily of escalating doses of diuretics, becomes ineffective in the long term as patients develop increasing diuretic resistance because of worsening renal function. Although in the United States the use of surgery for TR has shown a slight increase during the past decade, only a small portion of eligible patients undergo surgery.1 This is for several reasons. As patients usually are only referred for surgery late in the disease process when they have severe end-organ compromise, the procedure can be more high risk. In addition, there can be a significant rate of late recurrence of TR post-surgery.2 It is in this setting that the field of transcatheter tricuspid valve intervention has blossomed during the past 5 years, with multiple devices in early stages of development. In this issue of Circulation: Cardiovascular Interventions , Lauten et al3 describe their experience with one of these techniques: caval valve implantation (CAVI).3 See Article by Lauten et al The concept of CAVI centers around the heterotopic placement of a valve in the inferior vena cava (IVC) alone or in combination with a second valve in the superior vena cava (SVC) to redirect the regurgitant jet from the failing tricuspid valve. Protection of the hepatic and renal veins from the effects of this chronic volume overload may help …

Case of Percutaneous Extracorporeal Femoro-Femoral Bypass for Acute Limb Ischemia From Large Bore Access

An 80-year-old man presented with acute inferior ST-segment elevation myocardial infarction and cardiogenic shock. Cardiac catheterization revealed 99% stenosis in the mid-right coronary artery, a 95% focal severe stenosis in mid-left anterior descending coronary artery and a 60% to 70% stenosis in

Tricuspid Valve Intervention : New Direction and New Hope∗

Increasingly, attention has turned toward therapies that correct severe tricuspid regurgitation (TR), stimulated in part by the success of transcatheter therapies for aortic stenosis and mitral regurgitation. In addition, recent evidence suggesting worse survival for patients with untreated isolated

Transcarotid Transcatheter Aortic Valve Replacement: Not Just a Pain in the Neck.

SEE PAGE 2113 V ascular complications were a factor that tempered the enthusiasm of widespread adoption of transcatheter aortic valve replacement (TAVR) after the completion of the original PARTNER IB (The Placement of Aortic Transcatheter Valves IB) trial (1). In that trial, the rate of major vascular complications was 16.2%. This was not surprising given the need for a 22or 24-F delivery sheath via a transfemoral approach only. This rate later decreased in a high risk cohort of patients (2). This was not only as a result of increased operator experience, but also because of the availability of an alternative access for patients with peripheral arterial disease. The transapical approach involved direct left ventricular puncture with placement of a 26-F delivery sheath, which allowed delivery of the valve. As TAVR became available commercially, additional access approaches were developed. The first of these, the transaortic approach, showed lower rates of combined bleeding and vascular events compared to a transapical approach (3). Since these initial studies, valve technology has improved, with commercial valves now being able to be delivered through as small as a 14-F sheath. This has led to many more patients now being able to be treated transfemorally. However, despite these improvements, the need for development of alternative access techniques for patients who are not transfemoral candidates remains. The largest published experience to date, in this issue of JACC: Cardiovascular Interventions

TMVR: Continuing the Paradigm Shift in Valvular Heart Disease Therapy : Hype or Hope?∗

Transcatheter treatment of valvular disease has been performed for more than 3 decades [(1)][1]. Transcatheter mitral valvuloplasty has achieved widespread acceptance for patients with symptomatic mitral stenosis and favorable anatomy [(2)][2]. Most recently, transcatheter aortic valve replacement (

Multimodality Imaging of the Tricuspid Valve for Assessment and Guidance of Transcatheter Repair

The tricuspid valve is a highly complex structure, with variability in the number of leaflets and scallops. The mechanism of regurgitation is multifactorial in etiology, a mix of functional and degenerative tricuspid regurgitation. Iatrogenic tricuspid regurgitation is becoming more common secondary to pacemaker wire impingement of leaflet function and coaptation. Echocardiographic imaging of the tricuspid valve is particularly challenging given its anatomic location and other interfering structures, including pacemaker wires. Preprocedural planning and intraprocedural guidance for transcatheter intervention relies on a comprehensive understanding of tricuspid anatomy and the use of 3-dimensional transesophageal echocardiography. The incorporation of computed tomography and cardiac magnetic resonance imaging likely will provide increasing accuracy and optimization of procedural success.

SEVERE LIMA-LAD ANASTOMOTIC IN-STENT RESTENOSIS AND A LARGE LIMA SIDE BRANCH: WHAT WOULD YOU DO NEXT?

A large, unligated branch of the left internal mammary artery (LIMA) is occasionally encountered on angiography following coronary artery bypass grafting (CABG). The clinical significance of a large LIMA branch is unclear. 66 year old diabetic man presented with angina. Angiography revealed severe