Clifford J. Kavinsky

Preload-independent mechanisms contribute to increased stroke volume following large volume saline infusion in normal volunteers: a prospective interventional study

IntroductionResuscitation with saline is a standard initial response to hypotension or shock of almost any cause. Saline resuscitation is thought to generate an increase in cardiac output through a preload-dependent (increased end-diastolic volume) augmentation of stroke volume. We sought to confirm this to be the mechanism by which high-volume saline administration (comparable to that used in resuscitation of shock) results in improved cardiac output in normal healthy volunteers.MethodsUsing a standardized protocol, 24 healthy male (group 1) and 12 healthy mixed sex (group 2) volunteers were infused with 3 l normal (0.9%) saline over 3 hours in a prospective interventional study. Individuals were studied at baseline and following volume infusion using volumetric echocardiography (group 1) or a combination of pulmonary artery catheterization and radionuclide cineangiography (group 2).ResultsSaline infusion resulted in minor effects on heart rate and arterial pressures. Stroke volume index increased significantly (by approximately 15–25%; P < 0.0001). Biventricular end-diastolic volumes were only inconsistently increased, whereas end-systolic volumes decreased almost uniformly. Decreased end-systolic volume contributed as much as 40–90% to the stroke volume index response. Indices of ventricular contractility including ejection fraction, ventricular stroke work and peak systolic pressure/end-systolic volume index ratio all increased significantly (minimum P < 0.01).ConclusionThe increase in stroke volume associated with high-volume saline infusion into normal individuals is not only mediated by an increase in end-diastolic volume, as standard teaching suggests, but also involves a consistent and substantial decrease in end-systolic volumes and increases in basic indices of cardiac contractility. This phenomenon may be consistent with either an increase in biventricular contractility or a decrease in afterload.

2015 ACC/HRS/SCAI Left Atrial Appendage Occlusion Device Societal Overview

Left atrial appendage (LAA) occlusion devices have the potential to influence the clinical approach to stroke prevention in patients with atrial fibrillation (AF). A number of percutaneous techniques have been proposed, including intracardiac plugs and external ligation. Several devices have been

Single-center comparative outcomes of the Edwards SAPIEN and Medtronic Melody transcatheter heart valves in the pulmonary position.

Two transcatheter pulmonary valve replacement (tPVR) systems (Edwards SAPIEN and Medtronic Melody) are available; however, comparative studies evaluating outcome data are lacking. The aim of this study was to compare short‐ with medium‐term outcome data of these valves in the pulmonary position from a single institution.

Percutaneous device closure of congenital and iatrogenic ventricular septal defects in adult patients

Objectives: We report our 10‐year experience with percutaneous closure of adult congenital and acquired (non‐post‐infarct) ventricular septal defects (VSDs) using different types of Amplatzer occluder devices. Background: Adult congenital and acquired VSDs may produce significant morbidity and mortality. Furthermore, such VSDs pose a significant surgical challenge. Methods: Between February 2000 and August 2009, data were retrospectively reviewed from 28 patients who underwent 29 procedures for percutaneous device closure of hemodynamically significant VSDs. Seventeen had unrepaired congenital VSDs, 10 had post‐operative VSDs (5 with residual patch‐margin defects, 4 post‐aortic valve replacement, 1 post‐myomectomy), and one had an acquired traumatic VSD. Indications for closure included: symptoms related to significant shunt (dyspnea on exertion); unexplained deterioration of LV function, and/or LV dilation; recurrent endocarditis, and pulmonary hypertension. Outcome parameters were procedural success, procedure‐related complications, evidence of residual shunt by echocardiography, and improvement in the signs/symptoms for which the procedure was performed. The mean follow‐up interval was 68 months. Results: Of the 28 patients studied, a single VSD was present in 26 patients, while one patient had two defects, and one patient had one defect on the LV side with three openings at the RV side. The median size of the defects by echocardiography was 6 mm. A device was successfully implanted in 28 of 29 (97%) procedures and 28 of 28 (100%) patients. Procedure‐related complications occurred in two cases: one involving an access site hematoma not requiring transfusion as well as nonsustained ventricular tachycardia that resolved spontaneously and the other involving acute mitral regurgitation due to inadvertent trapping of the anterior mitral valve leaflet between the left ventricular disk and the septum that was resolved by recapturing of the disk. There was immediate complete closure in 20 patients (71%). In six cases there was trivial residual shunt and in two patients the residual shunt was mild. At the latest follow‐up, four of the eight with a residual shunt had no shunt and in the remaining four the residual shunt was trivial. Among symptomatic patients 18 (64%), there was marked improvement in symptoms and for those patients 17 (61%) for whom the procedure was performed to address left ventricular enlargement, there was reduction or stabilization in LV size on serial echoes. Conclusions: Percutaneous closure of VSDs in the adult patient appears to be safe and effective.

Innovative resource utilization to fashion individualized covered stents in the setting of aortic coarctation

Objectives: We describe our experience with self‐fabricated covered stents in the setting of coarctation of the aorta (CoA). Background: Balloon‐expandable covered stents are increasingly being utilized to treat CoA in older children and adults. These stents however, are not available in the United States limiting the interventionalists ability to treat this condition safely and effectively. Methods: Retrospective analysis and follow‐up data review of our complete experience with self‐fabricated covered stents for CoA. Stents were fashioned by suturing an appropriate length of tubular polytetraflouroethylene to a bare metal stent and deploying this stent across the coarctation in a standardized fashion. Results: Over a 9‐year period we implanted 53 balloon‐expandable stents in 49 patients with CoA. Of these 13 were self‐fabricated covered stents deployed in 13 patients (7 male). Median age at implantation was 25.4 years (range, 8.7–49.5 years) with median weight of 65.5 kg (range, 28–168 kg). Indications for stent placement were native coarctation/aortic atresia (n = 9), aneurysm formation (n = 3), and re‐coarctation (n = 1). The median systolic pressure gradient across the coarctation of 33 mm Hg (range, 12–69 mm Hg) was reduced to 3 mm Hg (range, 0–19 mm Hg) post procedure (P < 0.001). There were no deaths on median follow‐up of 44 months (range, 1–83 months). One patient developed acute contained extravasation at implantation, treated with a self‐expanding stent graft. Another patient required thrombectomy for femoral arterial thrombosis. Conclusions: Innovative application of available materials adds to the armamentarium of the interventionalist. Our self‐fabricated covered stent provides effective gradient reduction with no compromise in stent delivery or durability on follow‐up.

Hybrid pulmonary artery plication followed by transcatheter pulmonary valve replacement: Comparison with surgical PVR

Objective/Background

2015 ACC/HRS/SCAI Left Atrial Appendage Occlusion Device Societal Overview A Professional Societal Overview from the American College of Cardiology, Heart Rhythm Society, and Society for Cardiovascular Angiography and Interventions

TABLE OF CONTENTS Preamble2 1. Introduction2 1.1. Key Questions3 2. Stroke Prevention in AF: Current Evidence and Guidelines3 3. Literature Review4 3.1. Background4 3.2. WATCHMAN4 3.3. Amplatzer Cardiac Plug7 3.4. LARIAT7 3.5. Other Percutaneous Devices and Surgical Approaches8 4. Care Team and Facilities8 4.1. Multidisciplinary Heart Team8 4.2. General Requirements9 4.3. Facilities9 5. Operator Training10 6. Protocols for Care10 7. Assessment of Patient Selection and Outcomes10 Appendix 1. Relevant Author Relationships With Industry and Other Entities–ACC/HRS/SCAI Left Atrial Appendage Occlusion Device Societal Overview14 Appendix 2. Reviewer Relationships With Industry And Other Entities–2015 ACC/HRS/SCAI Left Atrial Appendage Occlusion Device Societal Overview15

Percutaneous mechanical thrombectomy for massive pulmonary embolism using a conservative treatment strategy.

INTRODUCTION Percutaneous mechanical thrombectomy (PMT) for treatment of massive pulmonary embolism (PE) has been shown to be technically feasible, although the complication rate of the procedure appears relatively high. Whether a conservative treatment approach defined by an early termination of the PMT procedure once hemodynamic and clinical parameters of the patient have improved is associated with lower complication rates is unknown. We report our experience of PMT in patients with massive PE using the Angiojet system following a conservative treatment strategy. METHODS From April 2003 until November 2007, 13 patients underwent PMT with the Angiojet system. Indications for PMT were massive PE and either failed thrombolysis or contraindications to thrombolytic therapy. All patients were deemed high risk for surgical thrombectomy. RESULTS Technical success was achieved in 12 patients (92%). Mean systemic arterial pressure increased from 87 to 106 mmHg following PMT (P = 0.011), while the heart rate decreased from 119 to 97 beats per minute (P = 0.041). In-hospital mortality was 15% (2 of 13 patients). No complications occurred which were attributable to the PMT procedure. Right ventricular size and function improved in the majority of patients following the PMT procedure. CONCLUSION Using a conservative treatment approach of PMT for the treatment of massive PE carries a low periprocedural complication rate. The low morbidity was achieved without compromising clinical outcome, documented by an in-hospital mortality of 15%. PMT using a conservative treatment approach may result in comparable mortality, but lower morbidity than PMT using more aggressive, angiographically guided treatment strategies.

Predictors of late cardiac events following treatment with Sr-90 β-irradiation for instent restenosis

BACKGROUND Intracoronary radiation therapy (IRT) with Sr-90 using the Novoste Beta-Cath system has been shown to be an effective therapy for instent restenosis (ISR), but the temporal occurrence of cardiac events and the predictors of late complications require further investigation. METHODS We analyzed the demographics, lesion characteristics and clinical outcomes of 138 consecutive patients with ISR treated with IRT from September 1998 to March 2002. Major adverse cardiac events (MACE) were defined as death, myocardial infarction (MI) or target vessel revascularization (TVR). Characteristics of early (< or =8 months) and late (>8 months) failures were analyzed. RESULTS Thirty-two (23.1%) of 138 patients had MACE on follow-up; 25% (8/32) of failures occurred late after treatment with IRT. A comparison of the clinical and angiographic profile of early and late failures using univariate analysis indicates no correlations to late failure following IRT. Duration to failure after IRT was 14.25+/-3.69 months in the late group compared to 4.63+/-2.86 months in the early group (P<.001). CONCLUSIONS Late MACE after IRT with Sr-90 for ISR occur beyond the traditional period for clinical restenosis in 25% of cases and are difficult to predict. Further study is warranted to identify patients at risk for the development of late complications after IRT.

Recurrent events following patent foramen ovale closure in patients above 55 years of age with presumed paradoxical embolism

Objectives: The aim of this article is to summarize our experience of patent foramen ovale (PFO) closure in patients above the age of 55 years. Background: PFO is associated with cryptogenic thromboembolic events (TEs) in patients younger than 55 years. Little is known about the recurrence rate of TE in patients above the age of 55 years undergoing PFO closure for presumed paradoxical embolism. Methods: PFO closure was performed in 1,055 patients, 423 of whom were above 55 years of age. Implantation of the device was guided by fluoroscopy and transesophageal or intracardiac echocardiography. Results: A PFO occluding device was implanted successfully in all patients. Residual shunt was documented in 10% of patients above 55 years of age and in 8.4% of patients aged 55 years or younger (P = 0.325). During a median follow‐up period of 18 months (range, 0–162 months) the annual incidence of recurrent TE in patients above 55 years was 1.8% while patients aged 55 or below had an annual incidence of recurrent TE of 1.3%. TE‐free survival was similar in patients above 55 years of age compared with those aged 55 years and below. Conclusions: PFO closure in older patients is as efficient and seems comparable to those under the age of 55. Although traditional cardiovascular risk factors may be more frequent in the older age group compared with those younger than 55 years, PFO closure should not be withheld as a possible therapeutic option in this age group.