Luca Giugno

Ten‐years, single‐center experience with arterial duct stenting in duct‐dependent pulmonary circulation: Early results, learning‐curve changes, and mid‐term outcome

To evaluate early results, learning‐curve changes, and mid‐term outcome of arterial duct (AD) stenting in congenital heart disease with duct‐dependent pulmonary circulation (CHD‐DPC) in a high‐volume, tertiary referral center.

Transcatheter treatment of Starr-Edwards paravalvular leaks.

: A 56-year-old patient was referred because of refractory heart failure and mild haemolysis caused by multiple, severe paravalvular leaks of a Starr-Edwards valve implanted in mitral position 23 years before. Owing to perceived high risk of surgical re-valving, percutaneous paravalvular leak occlusion was performed by implantation of multiple, simultaneously deployed Amplatzer Vascular Plugs.

Prediction of stenting related adverse events through patient-specific finite element modelling

Right ventricular outflow tract (RVOT) calcific obstruction is frequent after homograft conduit implantation to treat congenital heart disease. Stenting and percutaneous pulmonary valve implantation (PPVI) can relieve the obstruction and prolong the conduit lifespan, but require accurate pre-procedural evaluation to minimize the risk of coronary artery (CA) compression, stent fracture, conduit injury or arterial distortion. Herein, we test patient-specific finite element (FE) modeling as a tool to assess stenting feasibility and investigate clinically relevant risks associated to the percutaneous intervention. Three patients undergoing attempted PPVI due to calcific RVOT conduit failure were enrolled; the calcific RVOT, the aortic root and the proximal CA were segmented on CT scans for each patient. We numerically reproduced RVOT balloon angioplasty to test procedure feasibility and the subsequent RVOT pre-stenting expanding the stent through a balloon-in-balloon delivery system. Our FE framework predicted the occurrence of CA compression in the patient excluded from the real procedure. In the two patients undergoing RVOT stenting, numerical results were consistent with intraprocedural in-vivo fluoroscopic evidences. Furthermore, it quantified the stresses on the stent and on the relevant native structures, highlighting their marked dependence on the extent, shape and location of the calcific deposits. Stent deployment induced displacement and mechanical loading of the calcific deposits, also impacting on the adjacent anatomical structures. This novel workflow has the potential to tackle the analysis of complex RVOT clinical scenarios, pinpointing the procedure impact on the dysfunctional anatomy and elucidating potential periprocedural complications.

Percutaneous Pulmonary Valve Implantation Contraindicated by Severe Aortic Regurgitation Due to Left Coronary Sinus Deformation

1. Morray BH, McElhinney DB, Cheatham JP, Zahn EM, Berman DP, Sullivan PM, et al. Risk of coronary artery compression among patients referred for transcatheter pulmonary valve implantation: A multicenter experience. Circ Cardiovasc Interv 2013; 6: 535 – 542. 2. Lindsay I, Aboulhosn J, Salem M, Levi D. Aortic root compression during transcatheter pulmonary valve replacement. Catheter Cardiovasc Interv 2016; 88: 814 – 821. A 32-year-old man had undergone a Ross procedure involving implantation of a 26-mm pulmonary homograft at the age of 20 due to severe aortic regurgitation (AR) caused by rheumatic disease. He came to our attention due to progressive calcification of the graft causing a systolic maximum gradient of 67 mmHg with a hypertrophic right ventricle (RV) on echocardiography. Percutaneous pulmonary valve implantation (PPVI) was proposed. Basal RV outflow tract angiography confirmed the known graft stenosis, and aortic basal and 3-D rotational angiography showed no significant AR (Figure A,C). Aortography was then repeated with a Cristal balloon 23×45 mm (Balt Extrusion, Montmorency, France) inflated inside the homograft. Severe AR (Figure B) was seen on aortography due to compression and deformation of the left coronary sinus (Figure D; white arrow). PPVI was thus contraindicated and the patient underwent surgery.

Percutaneous management of failed bioprosthetic pulmonary valves in patients with congenital heart defects.

Aims We reviewed our center experience in the field of transcatheter pulmonary valve-in-valve implantation (TPViV), that is emerging as a treatment option for patients with pulmonary bioprosthetic valve (BPV) dysfunction. Methods Between April 2008 and September 2015, a total of six patients with congenital heart disease (four men) underwent TPViV due to stenosis of preexisting BPV. Four patients received a Melody Medtronic Transcatheter Pulmonary Valve and two an Edward Sapien Valve. Results No procedural-related complications occurred. After valve implantation, right ventricular systolic pressure (RVSP, 80.5 ± 25.3–41.2 ± 8.35 mmHg, P < 0.05), right ventricular outflow tract (RVOT) gradient (55.3 ± 23.4–10.6 ± 3.8 mmHg, P < 0.05), and RVSP-to-aortic pressure (0.75 ± 0.21–0.38 ± 0.21, P = 0.01) fell significantly. Echocardiograms at follow-up revealed a significant reduction in estimated RVSP (88.7 ± 22–21.7 ± 4.7 mmHg, P < 0.05), in RVOT (76.2 ± 17.9–25.7 ± 6.1 mmHg, P = 0.005), and in mean RVOT (40.7 ± 9.9–15.5 ± 4.8 mmHg, P < 0.05) gradients. Cardiac magnetic resonance showed no significant change in biventricular dimensions and function. Symptomatic patients reported improvement of symptoms, although cardiopulmonary exercise did not show any significant differences. Conclusion TPViV is an effective and well tolerated treatment for BPV dysfunction, improving freedom from surgical reintervention. Long-term studies will redefine the management of dysfunctional RVOT, either native or surrogate.

ASD Closure in Special Situations: Elderly, PA-IVS

Transcatheter closure is nowadays considered as the first-choice treatment of atrial septal defect (ASD). However, indication, technique, and results of this approach are still challenging and under debate in particular settings, as in elderly or in patients with pulmonary atresia with intact ventricular septum (PA-IVS) submitted to right ventricular decompression.

Transcatheter Treatment of Tricuspid Valve

Tricuspid valve replacement is not a common operation and, in most series, is associated with high postoperative mortality. Although bioprosthetic valves appear to have improved the performance early after surgery, these valves will inevitably experience wear and degeneration, requiring a second implant. Redo valve surgery for bioprosthetic valve failure is challenging. In this context, there has been an understandable interest in percutaneous valve therapy to extend the life span of failing tricuspid valve prostheses.

Alarm!!! A UFO inside the heart.

An 8-year-old asymptomatic child was referred for surgical repair of coronary sinus atrial septal defect resulting in significant left-to-right shunt and right chamber volume overload. The septal fenestration was located near to its drainage site into the right atrium. Due to this seemingly favourable anatomy, transcatheter closure of the septal defect was performed using an Amplatzer Septal Occluder device. The echocardiographic postprocedural evaluation imaged the occluding device almost perpendicular to the atrial septum, seemingly floating above the mitral valve orifice, like an alien spaceship inside the heart.