Mehmet Cilingiroglu

Percutaneous Leaflet Repair and Annuloplasty for Mitral Regurgitation

Percutaneous therapy for the treatment of mitral regurgitation has emerged rapidly over the past few years. Most of the percutaneous approaches are modifications of existing surgical approaches to mitral annuloplasty or leaflet repair. Catheter-based devices mimic these surgical approaches with less procedural morbidity and mortality as a consequence of their less invasive nature. Percutaneous annuloplasty can be achieved indirectly via the coronary sinus or directly from retrograde left ventricular access. Catheter-based leaflet repair is accomplished using an implantable clip to mimic the surgical edge-to-edge technique. Several of these percutaneous approaches have been successfully used in patients to demonstrate proof of concept, while others have already stopped further development. There is increasing experience in both trials and practice to begin to define the clinical utility of percutanenous leaflet repair, and annuloplasty approaches are undergoing significant development.

Technique of temporary subcutaneous “Figure-of-eight” sutures to achieve hemostasis after removal of large-caliber femoral venous sheaths†

Over the last decade, significant advances have been made in percutaneous treatment of structural heart diseases. Many of these interventions require insertion of large caliber sheaths in the femoral veins. Manual compression, compression devices, and various closure devices have been used for removal of large‐sized venous sheaths. Here, we describe the use of a temporary subcutaneous “Figure‐of‐Eight” suture technique for venous access site closure after removal of large‐caliber sheaths.

The society for cardiovascular angiography and interventions structural heart disease early career task force survey results: Endorsed by the society for cardiovascular angiography and interventions†

Over the last decade, structural heart disease interventions have emerged as a new field in interventional cardiology. Currently, the Accreditation Council for Graduate Medical Education accredited interventional cardiology fellowship programs in the United States provide high‐quality and well established training curriculum in coronary and peripheral interventions, but training in structural interventions remains in its infancy. The current survey seeks to collect relevant information and assess the opinion of interventional cardiology program directors in ACGME‐accredited institutions that are actively involved in structural interventional training. Our study describes the actual number of structural procedures performed by interventional cardiology fellows in ACGME‐accredited programs, the form of the structural training today and the suggestions from program directors who are actively trying to integrate structural training in the interventional cardiology fellowship programs.

The Role of Anxiety and Emotional Stress as a Risk Factor in Treatment-Resistant Hypertension

Depression and anxiety are both known to be co-morbid with coronary heart disease. Given the high prevalence of coronary heart disease today, specifically the aspect of hypertension, it seems more important than ever to investigate whether or not treatment of these co-morbidities can have an effect on reducing hypertension. This article summarizes the limited amount of literature that has been published in this area and highlights what we believe to be a missing key element that will guide our own future research in this area.

Optical coherence tomography imaging in asymptomatic patients with carotid artery stenosis.

Assessment and treatment plan for asymptomatic patients with carotid stenosis are based on angiography at the present time. However, angiography or other imaging modalities are limited with their resolution to detect high-risk plaque features. Intravascular optical coherence tomography (IVOCT) recently emerged as a novel imaging modality with a unique resolution to identify vulnerable plaque characteristics. We report use of IVOCT in two separate asymptomatic patients with carotid stenosis with two different plaque types.

Structural Heart Diseases Interventional Training in Canada

Structural heart disease interventions have evolved into an important component of interventional cardiology fellowship programs worldwide. Given the complexity of such interventions, the breadth of knowledge needed for optimal patient selection and postprocedural management, and the skills to perform them efficiently, advanced training has become mandatory. Postgraduate medical training in Canada has always been on the cutting edge of new technology, and excellent care is provided to the increasing population of adult patients with congenital heart disease. The current survey sought to collect relevant information and assess the opinion of interventional cardiology program directors in Canada regarding training in structural interventions. Our study reports the approximate number of structural procedures performed by interventional cardiology fellows in Canadian interventional cardiology fellowship programs, the form of the structural training, and the suggestions of program directors who are actively trying to integrate structural training into interventional cardiology fellowship programs.

Intracardiac echocardiography-guided percutaneous mitral balloon valvuloplasty

Percutaneous mitral balloon valvuloplasty (PMBV) was initially described by Inoue in 1984 as a novel percutaneous technique for the management of mitral stenosis. Intracardiac echocardiography was initially used in the 1980s but was not universally accepted due to its high-frequency transducers and problems with steerability and manipulation. In the 1990s technical improvements led to more generalized use in various structural interventional procedures. We present the case of a successful PMBV guided exclusively by ICE.

Successful percutaneous revascularization of totally occluded left subclavian artery using orbital atherectomy

Subclavian artery steal (SAS) after coronary artery bypass graft (CABG) has been reported to be as high as 3.4%. These patients with patent left internal mammary artery (LIMA) anastomosis will also have coronary-subclavian steal syndrome (CSSS). Percutaneous intervention (PCI) by balloon angioplasty (BA) and stenting has been done successfully for subclavian artery (SA) stenosis. The visibility of the vertebral artery (VA) and LIMA during BA and stent positioning is extremely important. Debulking total occlusions by orbital atherectomy (OA) and avoiding unnecessary BA, stenting across side branches may decrease the chance of plaque shifting and subsequent loss of flow especially if they have ostial disease. Herein we report successful OA, BA and stenting of chronic total occlusion (CTO) of proximal left subclavian artery in a patient with coronary-subclavian steal syndrome with preservation of LIMA and diseased left vertebral artery (VA).

Right-sided scimitar syndrome in a patient with a single aortic trunk and coronary-cameral venous fistula

Scimitar syndrome (SS) is a rare congenital anomaly characterized by partial or complete anomalous pulmonary venous drainage of the right or left lung into the inferior vena cava. The syndrome is commonly associated with hypoplasia of the right lung, pulmonary sequestration, persistent left superior vena cava, and dextroposition of the heart. We report a rare variant of SS in a 44-year-old man together with a single aortic trunk, as well as a coronary-cameral venous fistula.

A percutaneous scabbard for the scimitar

Scimitar syndrome (SS), also called ‘‘pulmonary venolobar syndrome,’’ is a rare member of a variety of congenital heart disorders known as ‘‘partial anomalous pulmonary venous connections’’ [1–4]. In its most common form, there is anomalous right pulmonary vein drainage into the inferior vena cava (IVC) with anomalous systemic arterial supply (ASAS) from the abdominal aorta toward the affected pulmonary parenchyma, leading to pulmonary hypertension and subsequent volume overload and heart failure. This syndrome can present early in the neonatal period or later in life with a wide spectrum of symptoms, depending mainly on the presence of other associated congenital heart malformations and degree of shunting particularly from a large ASAS. Correction is considered in symptomatic patients or in patients with an increased pulmonary blood flow and signs of right heart dilation. Surgical repair of SS consists of redirecting the pulmonary venous drainage into the left atrium, either baffling the anomalous drainage into the left atrium via a tunnel or transecting the ‘‘scimitar drainage’’ near its entrance into the IVC and then reimplanting it directly into the left atrium [5,6]. If the presence of a large ASAS to the right lung with pulmonary overcirculation is detected preoperatively, occlusion of ASAS is frequently performed to encourage compensatory growth of the remaining normal lung tissue and to reduce both the associated left-to-right shunt and also the risk of chronic and recurrent infection in the abnormal lung in later life. The surgical option does, however, come with a relatively high incidence of interruption failure, reinserted pulmonary vein stenosis, surgical complications, and redo procedures. Successful percutaneous occlusion of ASAS in infants with SS has emerged as acceptable treatment using the AMPLATZER Vascular Plug VI device, (AGA Medical, Golden Valley, MN; Refs. 7 and 8). It has major advantages in being able to deliver the device through several 0.03800 4F catheter without the need to upsize to a dedicated delivery sheath. In a study of 16 infants who underwent percutaneous ASAS interruption, Uthaman et al. [8] reported significant reduction in left-to-right shunt and pulmonary artery pressures in >90% of the patients that translated into improvement symptoms as well as growth of right lung at follow up. Furthermore, such an approach lead to sustained longterm clinical improvement without need for further surgical correction in majority of patients. In this issue of journal, Weems et al. describe a novel sandwich-like technique for the rapid and complete occlusion of ASAS using two AMPLATZER Vascular Plugs (AVP-II) sandwiching multiple Tornado coils. As illustrated in this case of a 5-yearold patient with the symptoms of heart failure and failure to thrive, such an approach yielded normalization of hemodynamics resulting in resolution of the symptoms. Furthermore, at 5 months follow-up, the structural integrity of the ‘‘sandwich’’ remained well preserved. The case brings up several important points. First, percutaneous occlusion of ASAS seems to be effective treatment in selected group of patients with this syndrome. Given the large size of the ASAS in this case, despite using an 8-mm vascular plug that was oversized 30% of the ASAS diameter, there was significant shunting despite the reported 15-min wait time. Subsequent insertion of a larger 10-mm vascular plug by sandwiching five coils with two additional coils on the aortic end of ASAS finally interrupted the flow. A similar sandwich arrangement for effective embolization with additional coils has been described previously by Kessler and Trerotola [9] in the treatment of a large retroperitoneal shunt during creation of a transjugular intrahepatic portosystemic shunt (TIPS) shunt for gastric variceal hemorrhage. It