Mehul Patel

Outcomes and safety of transcatheter pulmonary valve replacement in patients with large patched right ventricular outflow tracts

BACKGROUNDnAlthough globally accepted, the indication for implantation of the Melody(®) (Medtronic Inc., Minneapolis, MN, USA) transcatheter pulmonary valve is limited to the treatment of haemodynamically dysfunctional right ventricular outflow tract (RVOT) with right ventricle to pulmonary artery (PA) obstruction. The use of the Melody valve for haemodynamically significant isolated pulmonary regurgitation has not been evaluated.nnnAIMnWe evaluated the outcomes of Melody valve insertion in patients with a large patched RVOT.nnnMETHODSnWe analysed procedural and short-term outcomes data from 13 patients who underwent Melody valve implantation for a large RVOT with significant pulmonary regurgitation as the primary lesion. RVOT preparation was done in all patients using the Russian dolls technique and/or the PA jailing technique. Melody valve insertion was performed concomitantly in 10 patients and after 1 to 3 months in three patients.nnnRESULTSnAll procedures were successful. The mean follow-up period was 30 ± 4 months after the procedure. There was no incidence of stent fracture, migration or embolization. Only one patient who underwent the jailing technique developed a significant paraprosthetic leak and is scheduled for redilatation of the Melody valve.nnnCONCLUSIONSnCareful patient selection, balloon sizing and RVOT preparation with prestenting using the Russian dolls technique and/or the PA jailing technique are required to modify the RVOT for transcatheter valve implantation. Short-term follow-up showed competent valves with no stent fracture or migration and appears promising. Wider experience with long-term outcomes may be required to standardize the procedure in such a subset of patients.

Maternal and fetal outcomes of pregnancy with Fontan circulation: A multicentric observational study

BACKGROUNDnDespite serious long-term sequel, women with Fontan palliation have reached childbearing age. However there is paucity of data on the pregnancy outcomes and management of this condition. We aimed to determine the maternal and fetal outcomes of pregnancy in women with Fontan palliation.nnnMETHODSnThis multicentric, retrospective study included women with Fontan circulation followed in 13 French specialized centers from January 2000 to June 2014. All pregnancies were reviewed, including miscarriages, abortions, premature and term births. We reviewed maternal and fetal outcomes.nnnRESULTSnThirty-seven patients had 59 pregnancies. Mean age was 27 ± 5 years at first pregnancy. There were 16 miscarriages (27%) and 36 live births with 1 twin pregnancy. Cardiac events occurred in 6 (10%) pregnancies, with no maternal death. The most common cardiac complication was atrial arrhythmia, which occurred in 3 patients. Hematological complications including thromboembolic/hemorrhagic events (n=3/7) occurred in 5 women antepartum (n=2/3), and 4 women postpartum (n=1/4). Two of the 3 thromboembolic events occurred in patients without anticoagulation. There was a high incidence of prematurity (n=25/36, 69%). Anticoagulation was associated with adverse neonatal outcome (OR=10.0, 95% CI [1.5-91.4], p<0.01). After a median follow-up of 24 months, there was no significant worsening of clinical status and thromboembolic disease noted.nnnCONCLUSIONSnPre-selected women can successfully complete pregnancy with Fontan circulation. There is an increase in cardiac and neonatal morbidity during pregnancy. Because thromboembolism could have a severe consequence on Fontan circulation, anticoagulation should be indicated during pregnancy and postpartum period.

Patent Ductus Arteriosus Stenting (Transcatheter Potts Shunt) for Palliation of Suprasystemic Pulmonary Arterial Hypertension A Case Series

Idiopathic pulmonary arterial hypertension (IPAH) continues to be a progressive and fatal disease.1 Patients with congenital heart disease and PAH constitute a separate subset with Eisenmenger syndrome where the life expectancy is significantly better than patients with IPAH. Prior surgical series have reported improved survival after converting severe and refractory IPAH into an Eisenmenger physiology using a Potts shunt with direct side-to-side anastomosis.2–4 We describe a similar approach using a transcatheter technique by stenting residual or probe-patent ductus arteriosus (PDA) to establish a stable communication between descending thoracic aorta and left pulmonary artery in patients with severe suprasystemic PAH.nnDuring the past 5 years, we have performed cardiac catheterization in 28 IPAH patients and found 4 with a small or probe-patent PDA. One of these patients had infrasystemic PA pressures and did not undergo PDA stenting. The other 3 patients, whose data are summarized in the Table, had the PDA stented.nnPatient 1 was diagnosed with idiopathic PAH at the age of 6 months. Transthoracic echocardiography at the time of the diagnosis showed an atrial septal defect with left-to-right shunt and a small PDA. He remained stable on oral medications until 9.7 years of age when he presented with recurrent syncope. Severe right ventricular dilatation and bowing of the interventricular septum to the left were noted on transthoracic echocardiogram. Cardiac catheterization confirmed suprasystemic PAH and the presence of a small PDA shunting right-to-left with significant restriction (Figure 1).nnnnFigure 1. nAngiographic views from the first case. A , Aortography in lateral view, showing …

Branch Pulmonary Artery Jailing With a Bare Metal Stent to Anchor a Transcatheter Pulmonary Valve in Patients With Patched Large Right Ventricular Outflow Tract

Although transcatheter pulmonary valve replacement using the Melody valve (Medtronic Inc, Minneapolis, MN) has become widely adopted, it has only been formally studied in patients with right ventricle–to–pulmonary artery conduits <22 mm in diameter.1,2 Such patients compose only a small proportion of individuals with right ventricular outflow tract (RVOT) dysfunction, and there is interest and potential utility to broadening the indications for Melody valve implantation. We report nonstandard use of Melody valve in 3 noncandidate patients and discuss salient technical points.nn### Patient 1nnA 25-year-old man with early surgical correction of pulmonary atresia intact septum during infancy, presented with severe PR and no gradient across the RVOT and branch pulmonary arteries (PAs). Calibration using a compliant balloon showed RVOT diameter of 25 mm, making the patient unsuitable for the Melody valve, using the conventional technique (Figure 1 and online-only Data Supplement video clips I and II).nnnnFigure 1. nCineangiogram still frames demonstrate the jailing technique in patient 1. A , Angiogram on 4-chamber view shows the anatomy of the right ventricular outflow tract (RVOT) and pulmonary artery (PA) tree. B , RV angiogram after placement of open-cell, bare metal stents shows symmetrical perfusion of the 2 PAs and incomplete apposition of the stents to the RVOT. C , Angiogram shows opening of the cells at the level of the jailed PA before Melody insertion. D , Final angiogram shows reduction of pulmonary regurgitation with a small amount of paraprosthetic leak.nnnn### Patient 2nnAn 18-year-old man with pulmonary atresia and ventricular septal defect underwent palliative Blalock-Taussig shunt in the immediate postnatal period and subsequently, complete repair without pulmonary valved or nonvalved conduit. A false RVOT aneurysm was closed, using an atrial septal defect occluder. The patient presented with native left PA stenosis, severe pulmonary regurgitation (PR), and worsening functional status. There was no gradient …

Longitudinal strain of systemic right ventricle correlates with exercise capacity in adult with transposition of the great arteries after atrial switch

BACKGROUNDnSystemic right ventricle (sRV) dysfunction in d-transposition of the great arteries following atrial switch (d-TGA) is associated with increased mortality. We aimed to characterize maladaptive sRV mechanisms in d-TGA patients, analyzing relation of echocardiographic parameters of sRV systolic function to objective measurements of exercise capacity.nnnMETHODSnForty-seven adult patients with d-TGA and atrial switch (mean age 31.6±4.2years) underwent conventional echocardiography, bidimensional strain (2D-strain), cardiac magnetic resonance (CMR) imaging and cardiopulmonary exercise evaluation on the same day. Those with median peak oxygen uptake (VO2)>64.5% (n=23) constituted group A, those with VO2≤64.5% (n=24) constituted group B and 23 healthy age and gender matched subjects constituted the control group.nnnRESULTSnIn group A, global longitudinal peak systolic 2D-strain (GLS) of sRV was significantly reduced compared to GLS of normal RV and LV in the healthy control group (p<0.01), however peak longitudinal 2D strain was similar at basal and mid-segment of sRV free wall than normal LV. In group B, GLS was significantly reduced compared to group A (-10.9±2.9% vs -13.1±2.3%, p<0.05), mostly due to significant decrease of interventricular septum longitudinal strain. Other echocardiographic systolic parameters were not significantly different between groups A and B. Only sRV GLS showed significant correlation with functional capacity as measured by VO2 (r=0.42, p<0.01), while CMR RVEF did not.nnnCONCLUSIONnGLS of sRV predicts functional capacity and may be more sensitive than CMR RVEF in detecting early myocardial damage of sRV in patients with d-TGA and atrial switch.

Safety and effectiveness of compassionate use of LARIAT® device for epicardial ligation of anatomically complex left atrial appendages

BackgroundPercutaneous left atrial appendage (LAA) ligation using an epicardial suture system (LARIAT®, SentreHEART, Palo Alto, CA) has been used in patients with nonvalvular atrial fibrillation (AF) and contraindication to oral anticoagulation. However, complex LAA anatomy may preclude its use. We report the safety and effectiveness of compassionate use of first-generation LARIAT® device for epicardial ligation of large, complex left atrial appendages.MethodsBetween January 2010 and March 2013, 93 patients with AF, high CHADS2 score, and contraindication(s) for oral anticoagulation therapy were evaluated for LAA ligation. Complex anatomy detected by 3D cardiac computed tomography CT angiography led to preclusion of 25 patients (27%). Of these, nine patients who opted for epicardial LAA ligation on compassionate grounds were studied.ResultsMean age was 68.1u2009±u20098.2xa0years, four females, all with large LAA width (>40xa0mm, 45–58xa0mm) and additional anatomic complexities such as bilobed (two), long C-shaped-like (two), goose neck-like (one), multilobed cauliflower-like (two), cactus-like (one), and chicken wing-like (one) LAA. LAA ligation with LARIAT® was successfully performed with surgical standby in all patients. Seven patients (78%) were safely treated percutaneously and only two patients required minimally invasive thoracotomy (one due to inability to release the epicardial snare from long C-shaped LAA and other due to preexisting adhesions precluding pericardial entry). There were no major complications. Repeat trans-esophageal echocardiography at 3xa0months showed no remnant flow and none had stroke off Coumadin at 19.3u2009±u20098.2xa0months of follow-up.ConclusionsDespite a high preclusion rate, percutaneous LAA ligation may be safely and effectively performed on compassionate grounds using the first-generation LARIAT® device with surgical standby in patients with large and complex LAA.

Feasibility of transcatheter techniques for intracardiac and extracardiac cavocaval connection in principle for Fontan completion in chronic animal models

OBJECTIVESnWe report the safety and feasibility of various transcatheter techniques of cavocaval connection in principle for the completion of Fontan circulation in viable, chronic and ovine heart models. Surgically simulated preparations of both intracardiac and extracardiac cavocaval connections were studied.nnnMETHODSnSixteen sheep were divided into two groups per the type of surgical preparation. All animals underwent standard right thoracotomy with interposition of a 20-mm Gore-tex(®) conduit between the superior vena cava (SVC) and the right atrium (RA). Nitinol rings were placed around the SVC and the inferior vena cava (IVC). In Group I (intracardiac, n = 10), the SVC-RA junction was closed using a polytetrafluoroethylene (PTFE) membrane 1 cm below the SVC-Gore-tex(®) anastomosis. In Group II (extracardiac, n = 6), a 20-mm Gore-tex conduit de-aired and filled with heparinized saline was anastomosed to connect the SVC and the IVC. The IVC end was anastomosed in a termino-lateral fashion and the SVC end in a termino-terminal fashion; both the ends were occluded with a PTFE membrane. Animals were scheduled for transcatheter cavocaval connection after a variable healing period.nnnRESULTSnFour animals in Group I died; three early and one late after surgical preparation. After a median interim period of 1 month (0-9 months), five sheep from Group I and six from Group II underwent successful transcatheter cavocaval connection. Perforation of the PTFE membrane was successful in all animals. Covered stents were deployed precisely and with good stability ensured by the nitinol rings. All animals survived transcatheter completion and were sacrificed after a median follow-up of 4 months (0-8 months) per protocol. No stent migration, thromboembolic events, residual shunts or paraprosthetic leak was noticed on angiographic evaluation or at autopsy in any animal.nnnCONCLUSIONSnTranscatheter techniques for completion of cavocaval connection in surgically simulated, chronic animal models is safe and feasible. Both techniques were equally successful with no failures or short-term complications. Such techniques should work in principle for completion of intracardiac and extracardiac Fontan circulation.

Feasibility of creating a novel animal heart model to test transcatheter techniques for a cavocaval connection that mimics a Fontan completion

OBJECTIVEnThe objective of this study was to create a novel animal model to foster the future development of interventional techniques for a cavocaval connection that mimics a Fontan completion.nnnMETHODSnTen sheep were studied. All had the superior vena cava-right atrium junction closed using a polytetrafluoroethylene membrane. A valveless Gore-Tex conduit connecting the terminal portion of the superior vena cava to the right atrium was used to bypass the polytetrafluoroethylene occlusion and to allow normal venous drainage through the right atrium. Radio-opaque nitinol rings were placed around the inferior vena cava near its entry in the right atrium to allow better fluoroscopic visualization and to enhance stent stability during transcatheter cavocaval connection.nnnRESULTSnThe first 3 animals died during the learning curve as a result of technical issues. The subsequent 7 surviving sheep showed good flow dynamics on cardiac catheterization. Transcatheter cavocaval connection was performed successfully performed in 6 sheep at 0 to 9 months after the initial surgery. Sacrifice was done electively in all animals at 1 to 9 months per protocol. One animal was euthanized early because of an untreatable infection. One sheep was observed as a control without a transcatheter cavocaval connection and was sacrificed at 12 months.nnnCONCLUSIONSnA novel, chronic ovine model to foster development of transcatheter techniques for cavocaval connection to mimic a Fontan completion was created. The successful model is easily reproducible after a short learning curve and shows good survival.

CMR assessment of the left ventricle apical morphology in subjects with unexplainable giant T-wave inversion and without apical wall thickness ≥15 mm

Aims Patients with unexplainable giant T-wave inversion in the precordial leads and apical wall thickness <15 mm have been reported. These patients cannot be diagnosed as apical hypertrophic cardiomyopathy (AHCM) according to the current criteria. The objective of this study was to evaluate the apical morphological features of this type of patients using cardiac magnetic resonance. Methods and results Institutional ethics approval and written informed consent were obtained. A total of 60 subjects with unexplainable giant T-wave inversion and 76 healthy volunteers were prospectively enrolled in the study. The segmented left ventricular (LV) wall thickness was measured according to the American Heart Association 17-segmented model. The apical angle (apA) as well as the regional variations in LV wall thickness was analysed. Considerable variation in LV wall thickness in normals was observed with progressive thinning from the base to apex (male and female, P < 0.01). The apical thickness of subjects with giant T-wave inversion was 8.10 ± 1.67 mm in male, which is thicker than that of controls (4.14 ± 1.17 mm, P < 0.01). In female, the apical thickness was also significantly different from controls (5.85 ± 2.16 vs. 2.99 ± 0.65 mm, P < 0.01). Compared with normals, the apA decreased significantly in male (87.44 ± 13.86 vs.115.03 ± 9.90°, P < 0.01) and female (90.69 ± 8.84 vs. 110.07 ± 13.58°, P < 0.01) subjects, respectively. Conclusion Although the absolute thickness of apical wall was below the current diagnostic criteria of AHCM, the apical morphological features of subjects with unexplainable giant T-wave inversion were significantly different from normals. Whether these subjects should be included into a preclinical scope of AHCM needs further investigations.

CMR Assessment of the Left Ventricle Apical Morphology in Subjects with Giant T-wave Inversions and Without Apical Wall Thickness>15mm

Background Unexplainable giant T-wave inversions in the precordial leads with apical wall thickness 15 mm using cardiac magnetic resonance (CMR).