Juan Carlos Rama-Merchan

Percutaneous Closure of Paravalvular Leaks: A Systematic Review.

Paravalvular leak (PVL) is an uncommon yet serious complication associated with the implantation of mechanical or bioprosthetic surgical valves and more recently recognized with transcatheter aortic valves implantation (TAVI). A significant number of patients will present with symptoms of congestive heart failure or haemolytic anaemia due to PVL and need further surgical or percutaneous treatment. Until recently, surgery has been the only available therapy for the treatment of clinically significant PVLs despite the significant morbidity and mortality associated with re-operation. Percutaneous treatment of PVLs has emerged as a safe and less invasive alternative, with low complication rates and high technical and clinical success rates. However, it is a complex procedure, which needs to be performed by an experienced team of interventional cardiologists and echocardiographers. This review discusses the current understanding of PVLs, including the utility of imaging techniques in PVL diagnosis and treatment, and the principles, outcomes and complications of transcatheter therapy of PVLs.

Percutaneous Retrograde Closure of Mitral Paravalvular Leak in Patients With Mechanical Aortic Valve Prostheses

Mechanical aortic valve prostheses are considered a limiting factor when contemplating percutaneous closure of mitral paravalvular leaks using a retrograde approach. However, transfemoral artery access and a retrograde approach have advantages over a trans-septal anterograde approach when the paravalvular defect is large with a significant gradient or when the defect is medial to the mitral valve. We describe a novel technique of mitral paravalvular leak closure in the presence of a mechanical aortic valve prosthesis, which we performed successfully in 3 patients. The technique uses a retrograde approach and arteriovenous wire loop.

Left Atrial Appendage Occlusion With the New AmuletTM Device: Feasibility, Safety and Short-term Efficacy

5. patients and did not change. Regarding LV diastolic function, 28% of patients had normal filling, almost 69% had an impaired relaxation pattern, and 3% had pseudonormal filling. At the end of the study, E wave velocity had increased, E/A ratio had decreased, and deceleration time had shortened. At the end of follow-up, LV diastolic function had significantly improved, with 69% of patients showing normal filling.

Optical coherence tomography characteristics of in-stent restenosis are different between first and second generation drug eluting stents

Aims Characterization of neointimal tissue is essential to understand the pathophysiology of in-stent restenosis (ISR) after drug eluting stent (DES) implantation. Using optical coherence tomography (OCT), we compared the morphologic characteristics of ISR between first and second generation DES. Methods and Results OCT was performed in 66 DES-ISR, defined as > 50% angiographic diameter stenosis within the stented segment. Patients with ISR of first generation sirolimus-eluting stents (SES), paclitaxel eluting stents (PES) and second generation zotarolimus-eluting stents (ZES), everolimus-eluting stents (EES) and biolimus-eluting stents (BES) were enrolled. Quantitative and qualitative ISR tissue analysis was performed at 1-mm intervals along the entire stent, and categorised as homogeneous, heterogeneous and neo-atherosclerosis. The presence of microvessels and peri-strut low intensity area (PSLIA) was determined in all ISR. Neoatherosclerosis was identified by lipid, calcium and thin-cap fibro-atheroma (TCFA) like lesions. We compared the two DES generations at both early (< 1 year) and late (> 1 year) follow-ups. In second generation DES a heterogeneous pattern was prevalent both before and after 1 year (57.1% and 58.6% respectively). Neo-atherosclerosis was more common in the early period in first generation DES (19.4% vs 11.7%, p < 0.01), but after one year was more prevalent in second generation DES (7.0% vs 19.3%, p < 0.01). Similar prevalence of TCFAs was observed in both groups in all comparisons. Conclusions When ISR restenosis occurs in second generation DES, the current data suggest a different time course and different morphological characteristics from first generation. Future prospective studies should evaluate the relationship between ISR morphology, time course and clinical events.

Severe Renal Artery Stenosis After Renal Sympathetic Denervation.

We present the case of a 73-year-old woman scheduled for renal angiography for severe recurrent refractory arterial hypertension 2 months after sympathetic renal denervation with the EnligHTN multielectrode catheter system (St Jude Medical, Saint Paul, Minnesota). The angiogram confirmed right

Chronic total occlusion successfully treated with a bioresorbable everolimus-eluting vascular scaffold

Fully bioresorbable vascular scaffolds (BVS) are a new approach to the percutaneous treatment of coronary artery disease. The BVS have not yet been fully tested in complex lesions, including chronic total occlusion (CTO). We report a CTO case successfully treated with a second-generation bioabsorbable drug-eluting scaffold.

Percutaneous closure of iatrogenic femoral arteriovenous fistula using a covered coronary stent

We present the case of a patient with a high-output fistula between the right superficial femoral artery and femoral vein after left atrial appendage closure successfully treated with a PK-Papyrus covered coronary stent using a 6F guiding catheter. To the best of our knowledge this is the first time a PK-Papyrus coronary stent has been used in this setting.

Pacemaker lead-related tricuspid stenosis successfully treated with percutaneous balloon valvuloplasty guided by 3D echocardiography

The most common etiology of tricuspid stenosis is rheumatic, and in most cases it is associated with valvular regurgitation. Interestingly, there have been reports of tricuspid stenosis without associated valvular regurgitation, mostly related to pacemaker leads. Percutaneous tricuspid valvuloplasty may be a therapeutic alternative to surgery in cases of pure tricuspid stenosis without other concomitant valvulopathies. We report the case of a 52-year-old woman with pacemaker lead-related tricuspid stenosis successfully treated with percutaneous valvuloplasty guided by 3D echocardiography.

Long-term Event Reduction After Left Atrial Appendage Closure. Results of the Iberian Registry II

INTRODUCTION AND OBJECTIVES Many patients with nonvalvular atrial fibrillation are still left without protection due to a contraindication for anticoagulants. This study aimed to establish the occurrence of stroke and major bleeding events in patients with nonvalvular atrial fibrillation and left atrial appendage closure with long-term follow-up and to explore the factors associated with higher long-term mortality. METHODS Analysis of a multicenter single cohort prospectively recruited from 2009 to 2015. Thromboembolic and bleeding events were compared with those expected from CHA2DS2-VASc and HAS-BLED scores. Multivariate analysis examined variables associated with mortality during follow-up. RESULTS A total of 598 patients (1093 patient-years) with a contraindication for anticoagulants were recruited (median 75.4 years). The success rate of left atrial appendage closure device implantation was 95.8%. Thirty patients (5%) experienced periprocedural complications. The rate of events (per 100 patient-years) during follow-up (mean 22.9 months; median 16.1 months) was as follows: death 7.0%; ischemic stroke 1.6% (vs 8.5% expected according to CHA2DS2-VASc; P < .001); intracranial hemorrhage 0.8%; gastrointestinal bleeding 3.2%; severe bleeding 3.9% (vs 6.3% expected by HAS-BLED, P = .002). These results were improved in the subgroup of 176 patients with follow-up > 24 months (mean follow-up 46.6 months, 683 patient-years) for severe bleeding 2.6% (vs 6.3% expected by HAS-BLED, P < .033). The factors significantly associated with higher mortality were age (HR, 1.1), intracranial hemorrhage (HR, 6.8), and stroke during follow-up (HR, 2.7). CONCLUSIONS Left atrial appendage closure significantly reduced the incidence of stroke and bleeding events and the benefit was maintained. Intracranial hemorrhage, age and stroke were associated with higher mortality.

Safety and Effectiveness of Percutaneous Closure of Left Atrial Appendage in Patients With Intracranial Hemorrhage.

Oral anticoagulants (OAC) are the treatment of choice for preventing ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, these drugs (including the new OACs) are associated with an increased risk of serious complications such as intracranial hemorrhage (ICH). Restarting OACs after an ICH triples the risk of hemorrhagic events, therefore their use in this context is controversial and can even be contraindicated. In addition, there is little evidence on the safety of new OACs following ICH. Percutaneous closure of the left atrial appendage (LAA) is an effective therapeutic alternative to OACs. However, there are insufficient data on the safety and effectiveness of this procedure in patients with ICH. Our objective was to evaluate the safety and effectiveness of LAA closure in patients with an indication for OACs due to NVAF with a history of ICH. The study included all patients with an indication for OACs for NVAF and a history of ICH referred to our unit between June 2009 and June 2016 for LAA closure. We analyzed clinical, echocardiographic, and procedure-related variables. The devices used for LAA closure were the Amplatzer Cardiac Plug, the Amplatzer Amulet (both St. Jude Medical), and the Watchman Implant (Boston Scientific). After the procedure, patients were treated with antiplatelet therapy or anticoagulation (low-molecular weight heparin) for at least 45 days. The decision on antiplatelet therapy vs anticoagulation was made at the discretion of the surgeon in consensus with neurology. At follow-up (at 45 days, 6 months, 12 months, and annually thereafter) we analyzed the following variables: death, ischemic stroke, and hemorrhagic events. A follow-up transesophageal echocardiogram was performed at 45 days postprocedure. Continuous variables are presented as median [interquartile range] or mean standard deviation. Categorical variables are presented as frequency and percentage. A P-value < .05 was considered statistically significant. Until June 2016, 174 patients underwent percutaneous LAA closure in our hospital. The indication for closure was ICH in 47 patients (27%; 25 men and 22 women). Table 1 shows the patient and procedural characteristics. The mean age was 80 6 years. The mean CHA2DS2-VASc and HAS-BLED scores were 5 1 and 4 1, respectively. Most patients (63.9%) were on treatment with acenocoumarol (Table 1) when the ICH occurred. Closure of LAA was successful in 95.7% of patients (45/47). Two patients developed complications during the procedure or during their hospital stay (Table 1). The most-used device was the Watchman implant (51.1%). Table 1 Baseline Characteristics