Marvin H. Eng

The influence of age on health status outcomes after acute myocardial infarction.

BACKGROUND Older age is a risk factor for higher mortality after acute myocardial infarction (AMI), but the association with health status outcomes is largely unexplored. METHODS In a prospective cohort of 2498 patients in the PREMIER study, we compared health-related quality of life (HRQL) and burden of angina symptoms among survivors of AMI by age strata (age groups > or = 75, 65-74, 50-64, and 19-49 years) using the Seattle Angina Questionnaire. Multivariable analyses assessed the relationship between age and 1-year HRQL and angina burden, adjusting for differences in clinical characteristics, treatment, and baseline health status. RESULTS Older patients comprised a majority: 20.1% were > or = 75 years of age, 41.7% were 65 to 74 years of age, 20.7% were 50 to 64 years of age, and 17.4% were < 50 years of age. At 12 months, older patients had higher mortality (17.0% vs 8.7% vs 6.1% vs 3.2% for age groups > or = 75, 65-74, 50-64, 19-49; P < .001). Among survivors of AMI, increasing age was associated with less angina and better HRQL. By 12 months, older patients reported less angina (10.9% vs 12.7% vs 19.3% vs 23.4% for age groups > or = 75, 65-74, 50-64, 19-49; P < .0001) and better HRQL (scores 89.1 vs 88.1 vs 82.5 vs 80.0, respectively; P < .0001), which persisted after adjustment for baseline angina, HRQL, and other demographic, clinical, disease severity, and treatment differences. CONCLUSIONS Although older patients have higher mortality after AMI, those who survive experience fewer symptoms and better HRQL at 1 year than younger patients. Angina remains present in a number of patients across the spectrum of age, supporting strategies to systematically assess and treat symptoms after AMI.

Predicting LVOT Obstruction After TMVR

Evolution of catheter-based structural interventions has given patients less invasive alternatives to surgery; however, the current generation of transcatheter heart valves (THV) are not specifically designed for mitral position implantation and have intrinsic geometry that may make mitral

Implementation of Real Time Three‐Dimensional Transesophageal Echocardiography in Percutaneous Mitral Balloon Valvuloplasty and Structural Heart Disease Interventions

Percutaneous interventions for structural heart disease are performed in a dynamic and complex environment that necessitates multiple imaging modalities to achieve procedural success. Structural interventions are routinely guided by two‐dimensional (2D) modalities such as x‐ray fluoroscopy, transesophageal echocardiography (TEE), and intracardiac echocardiography. Real time imaging with three‐dimensional (3D) echocardiography is a novel method of guidance to facilitate complex structural interventions with the promise of greater safety and efficacy. Real time 3D TEE (RT3D‐TEE) affords the capability of imaging catheters and devices, the interventional objective, and adjacent structures simultaneously. We present an overview of RT3D‐TEE and explore its functionality in structural heart interventions by using percutaneous mitral balloon valvuloplasty as a model.

Enhanced stent visualization: A case series demonstrating practical applications during PCI

BACKGROUND Visualization of coronary stents is increasingly challenging due to the reduction in stent strut thickness to improve deliverability. On the other hand stent expansion and precise implantation in the target vessel are important in optimizing short and long-term outcomes of stent-based revascularization. Stentboost Subtract is a novel X-ray technique that improves visualization of deployed stents in the coronary arteries. Using motion compensation and integration of multiple non-contrast projection images from a fixed gantry position, this new technique depicts stent morphology allowing assessment of stent expansion and extent of overlap with adjacent stents. We present a case series in which enhanced stent visualization (ESV) facilitated interventions. METHODS The clinical and angiographic characteristics of 6 cases utilizing ESV were reviewed. All ESV acquisitions in this case series utilized an 8 in. field of view (FOV), 3 ml/sec. for a total of 6 ml of contrast, and placement of balloon markers in the region of interest. RESULTS The cases presented significantly facilitated the identification of bifurcation stenting techniques, precise stent positioning, stent underexpansion and assisted with defining stent-vessel wall relationship that was additive to intravascular ultrasound. CONCLUSIONS ESV is a novel tool used in coronary interventions that facilitates non-invasive assessment of stent positioning, expansion and stent-vessel interactions. This inexpensive ESV technique is complimentary to IVUS and in some cases obviates its need.

Clinical outcomes following predilation with a novel 1.25-mm diameter angioplasty catheter†

Objective: An unmet need is represented in angioplasty catheters that permit the predilation stage of treating complex coronary anatomy oftentimes not amenable to conventional device therapies. Background: Lesion preparation with balloon angioplasty prior to stent placement remains the most common method of percutaneous coronary revascularization. Methods: Clinical and angiographic outcomes were evaluated following a treatment strategy of coronary artery disease that included predilation with a low‐profile, 1.25‐mm angioplasty catheter prior to stent placement. The study primary end point of procedural success was defined as successful device delivery and lesion treatment, including the absence of clinically significant perforation, arrhythmia, flow‐limiting dissection, or reduction in baseline Thrombolysis In Myocardial Infarction (TIMI) grade with final achievement of TIMI 3 flow. Results: Among 51 patients (54 lesions), predilation using a 1.25 mm angioplasty catheter was associated with procedural and device‐related success rates of 100%. In‐hospital target lesion failure occurred in one patient (2.0%) related to postprocedural myocardial infarction. Patient and angiographic characteristics included diabetes, 43.1%; lesion length ≥20 mm, 20.4%; bifurcation lesion, 31.5%; lesion classification B2/C, 74.1%; and baseline TIMI 0/1 flow, 13.0%. No subsequent in‐hospital adverse events occurred. Conclusions: Percutaneous coronary revascularization involving a predilation strategy with a low profile, 1.25‐mm angioplasty catheter is associated with favorable procedural safety and efficacy and may represent an effective initial treatment for complex coronary anatomy.

The use of the AVERT system to limit contrast volume administration during peripheral angiography and intervention

The AVERTTM Contrast Modulation System (AVERT) (Osprey Medical, MN) is designed to reduce contrast volume administration during angiography. The AVERT provides an adjustable resistance circuit which decreases the pressure head delivering contrast towards the patient. The AVERT has not been previously studied in patients undergoing peripheral digital subtraction angiography (DSA). The purpose of this study was (1) to evaluate contrast savings with the AVERT and (2) to evaluate the ability to generate clinically acceptable DSA images in the process. To better define the mechanism of action in the peripheral circulation, we also developed a bench model to study the effects of the AVERT on the hydrodynamics of contrast delivery.

Implementation of real-time three-dimensional transesophageal echocardiography for mitral balloon valvuloplasty

Transthoracic (TTE) and intracardiac echocardiography (ICE) have both been established as modalities for imaging guidance in mitral balloon valvuloplasty (MBV). Real‐time three‐dimensional transesophageal echocardiography (RT3D‐TEE) improves depth resolution, characterization of pathology and visualization of interventional catheters and devices. Three‐dimensional imaging should enhance catheter navigation but improvements in procedural outcomes are not easily quantified. Using time from transseptal puncture to balloon inflation, procedure time and radiation exposure as surrogates for improvements linked to image guidance, we describe our early experience in implementing RT3D‐TEE during MBV, a prototypical left‐sided structural intervention.

Long or redundant leaflet complicating transcatheter mitral valve replacement: Case vignettes that advocate for removal or reduction of the anterior mitral leaflet

Transcatheter mitral valve replacement (TMVR) procedures can be an alternative to surgical valve replacement for high surgical risk patients with bioprosthetic mitral valves, annuloplasty rings, or severe mitral annular calcification (MAC). TMVR can trigger acute left ventricular outflow tract (LVOT) obstruction from permanent displacement of the native anterior mitral leaflet toward the left ventricular septum, more often among patients undergoing valve‐in‐ring and valve‐in‐MAC procedures. Although acute LVOT obstruction is well described in the literature, there are important additional complications of TMVR related to the length and/or redundancy of the anterior mitral valve that have been recognized after mitral valve surgery and have not been previously reported in the setting of TMVR. These additional complications include acute mitral regurgitation secondary to prolapsing native leaflet through the TMVR, frozen TMVR leaflet secondary to overhanging native leaflet and late LVOT obstruction in the neo‐LVOT secondary to long native leaflet. Preprocedural planning with imaging (echocardiography and computed tomography) and measurement of anterior mitral leaflet length is critical important in understanding the risk for these complications. As transcatheter mitral valve technology proliferates, interactions with the anterior mitral leaflet after TMVR may be more frequent than initially anticipated. We believe that there is no advantage to an intact anterior leaflet and advocate removal or reduction of the leaflet prior to TMVR.

Coronary Stent Fracture : Clinical Use of Image Enhancement

Standard angiography and intravascular ultrasound (IVUS) have limited ability to visualize stent struts and their integrity over time. While it is thought that stent fracture is associated with high incidence of restenosis or thrombosis, the true incidence of stent fracture is difficult to ascertain

Thrombotic valvular dysfunction with transcatheter mitral interventions for postsurgical failures

Degenerated surgical mitral valve repairs or surgical prostheses are currently being treated with transcatheter mitral valve replacement (TMVR). We report the procedural and mid‐term assessment of thirteen cases.