Philippe Brenot

Infective Endocarditis Risk After Percutaneous Pulmonary Valve Implantation With the Melody and Sapien Valves

OBJECTIVESnThis study compared the risk of infective endocarditis (IE) after percutaneous pulmonary valve implantation (PPVI) with the Sapien and Melody valves.nnnBACKGROUNDnThe incidence of IE after PPVI is estimated at 3% per year with the Melody valve. The Sapien valve is a more recently marketed valve used for PPVI.nnnMETHODSnWe retrospectively included consecutive patients who underwent PPVI at a single center between 2008 and 2016. IE was diagnosed using the modified DUKE criteria.nnnRESULTSnPPVI was performed in 79 patients (Melody valve, 40.5%; Sapien valve, 59.5%). Median age was 24.9 years (range 18.1 to 34.6). IE occurred in 8 patients (10.1%) at a median of 1.8 years (minimum: 1.0; maximum: 5.6) after surgery. Causative organisms were methicillin-sensitive Staphylococcus aureus (nxa0= 3), Staphylococcus epidermidis (nxa0= 1), Streptococcus mitis (nxa0= 1), Aerococcus viridans (nxa0= 1), Corynebacterium striatum (nxa0= 1), and Haemophilus influenzae (nxa0=xa01). All 8 cases occurred after Melody PPVI (25.0% vs. 0.0%). The incidence of IE was 5.7% (95% confidence interval: 2.9% to 11.4%) per person-year after Melody PPVI. The Kaplan-Meier cumulative incidence of IE with Melody PPVI was 24.0% (95% confidence interval: 12.2% to 43.9%) after 4 years and 30.1% (95% confidence interval: 15.8% to 52.5%) after 6 years, compared with 0.0% with the Sapien PPVI after 4 years (pxa0< 0.04 by log-rank test). There was a trend toward a higher incidence of IE in the first 20 patients with Melody PPVI (who received prophylactic antibiotics during the procedure only) and in patients who had percutaneous interventions, dental care, or noncardiac surgery after PPVI.nnnCONCLUSIONSnIE after PPVI may be less common with the Sapien compared with the Melody valve.

Transcarotid Transcatheter Aortic Valve Replacement: General or Local Anesthesia

OBJECTIVESnThe study sought to assess the safety and efficacy of a minimally invasive strategy (MIS) (local anesthesia and conscious sedation) compared to general anesthesia (GA) among the largest published cohort of patients undergoing transcarotid transcatheter aortic valve replacement (TAVR).nnnBACKGROUNDnTranscarotid TAVR has been shown to be feasible and safe. There is, however, no information pertaining to the mode anesthesia in these procedures.nnnMETHODSnBetween 2009 and 2014, 174 patients underwent transcarotid TAVR at 2 French centers. All patients werexa0unsuitable for transfemoral TAVR due to severe peripheral vascular disease. An MIS was undertaken in 29.8% (nxa0=xa052)xa0and GA in 70.1% (nxa0= 122). One-year clinical outcomes were available in all patients and were described according to the Valve Academic Research Consortium-2 consensus.nnnRESULTSnTranscarotid vascular access and transcatheter valve deployment was successful in all cases. Thirty-day mortality was 7.4% (nxa0= 13) and 1-year all-cause and cardiovascular mortality were 12.6% (nxa0= 22) and 8.0% (nxa0= 14), respectively. According to the type of anesthesia, there was no between group difference in 30-day mortality (GA 7.3% vs. MIS 7.6%; pxa0= 0.94), 1-year mortality (GA 13.9% vs. MIS 9.6%; pxa0= 0.43), 1-month clinical efficacy (GA 85.2% vs. MIS 94.2%; pxa0= 0.09), and early safety (GA 77.8% vs. MIS 86.5%; pxa0= 0.18). There were 10 (5.7%) periprocedural cerebrovascular events: 4 strokes (2.2%) and 6 transient ischemic attacks (3.4%) among those treated with GA. There was neither stroke nor transient ischemic attack in the MIS group (pxa0< 0.001).nnnCONCLUSIONSnThe transcarotid approach for TAVR is feasible using general or local anesthesia. A higher rate of perioperative strokes was observed with GA.

Transcatheter Closure of Large Atrial Septal Defects Feasibility and Safety in a Large Adult and Pediatric Population

Background—Data are needed on the safety and efficacy of device closure of large atrial septal defects. Methods and Results—Between 1998 and 2013, 336 patients (161 children <15 years) with large, isolated, secundum atrial septal defects (balloon-stretched diameter ≥34 mm in adults or echocardiographic diameter >15 mm/m2 in children) were managed using the Amplatzer device, at the Marie Lannelongue Hospital. Transthoracic echocardiographic guidance was used starting in 2005 (n=219; 65.2%). Balloon-stretched diameter was >40 mm in 36 adults; mean values were 37.6±3.3 mm in other adults and 26.3±6.3 mm/m2 in children. Amplatzer closure was successful in 311 (92.6%; 95% confidence interval, 89%–95%) patients. Superior and posterior rim deficiencies were more common in failed than in successful procedures (superior, 24.0% versus 4.8%; P=0.002; and posterior, 32.0% versus 4.2%; P<0.001). Device migration occurred in 4 adults (2 cases each of surgical and transcatheter retrieval); in the 21 remaining failures, the device was unreleased and withdrawn. After a median follow-up of 10.0 years (2.5–17 years), all patients were alive with no history of late complications. Conclusions—Closure of large atrial septal defects using the Amplatzer device is safe and effective in both adults and children. Superior and posterior rim deficiencies are associated with procedural failure. Closure can be performed under transthoracic echocardiographic guidance in experienced centers. Early device migration is rare and can be safely managed by device extraction. Long-term follow-up showed no deaths or major late complications in our population of 311 patients.

Type II endoleak prevention with coil embolization during endovascular aneurysm repair in high-risk patients

OBJECTIVEnThis study evaluated endoleak level and size decrease of infrarenal abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) with coil embolization in patients at high risk for type II endoleak.nnnMETHODSnBetween 2009 and 2013, 83 of 187 patients (44.3%) who underwent EVAR for AAA also underwent coil embolization of the aneurysm sac immediately after complete stent graft release because of risk factors for type II endoleak, including absence of a circumferential thrombus, two or more pairs of patent lumbar arteries, or a patent inferior mesenteric artery. Coil embolization was achieved using a 4F catheter with a microcatheter placed between the stent graft and the aneurysm wall. Computed tomography and color duplex ultrasound imaging were performed 1, 6, 12, and 24 months later to look for an endoleak and assess aneurysm sac diameter.nnnRESULTSnMean follow-up was 24 ± 11 months (range, 6-53 months). A mean of 12 coils (range, 4-23) was used. Technical success was achieved in all patients, with no procedurally related complications. Follow-up computed tomography showed type II endoleak in one patient. Aneurysm sac diameter was significantly decreased after 6 months (P = .001), 12 months (P = .001), and 24 months (P = .001). Surgery was required in one patient for common femoral artery occlusion unrelated to the procedure and in another patient for distal type I endoleak.nnnCONCLUSIONSnAneurysm sac coil embolization during EVAR for patients at risk for type II endoleak is technically feasible, safe, and effective in preventing type II endoleak. This procedure leads to rapid AAA shrinkage. Thus, coil embolization could be used routinely to improve EVAR outcomes for patients at risk for type II endoleak.

Catheter-Based Interventions for Modified Blalock–Taussig Shunt Obstruction: A 20-Year Experience

Thrombotic occlusion of a modified Blalock–Taussig (BT) shunt is rare, leading to life-threatening hypoxemia. Rescue percutaneous interventions may allow recanalization of the systemic-to-pulmonary shunt but data on large patients’ scales are lacking. We aimed to describe safety and effectiveness of catheter-based interventions to restore modified BT shunt patency. All patients who attempted transcatheter intervention for thrombotic occlusion of a modified BT shunt at our Institution from 1994 to 2014 were reviewed. Characteristics, management, and outcomes of the 28 identified patients were analyzed. Thirty-three procedures were performed at a median age of 0.6xa0years old (range 0.03–32.1xa0years) and a median weight of 5.8xa0kg (range 2.2–82xa0kg). Percutaneous intervention consisted in 33 balloon angioplasty (100xa0%) and 14 stent implantations (42.4xa0%). Thrombolytic agents were also used in 6.1xa0% cases. No peri-procedural death occurred but complications were observed in five patients (15.2xa0%), including one catheter-induced transient complete atrioventricular block, one cardiac tamponade, and one massive thrombo-embolic stroke. Early procedural success was obtained in 28 patients (84.8xa0%) and remained long-lasting in 26 patients (78.8xa0%). A young age and a low body-weight at the time of the procedure were significantly associated with procedural failure (pxa0=xa00.0364 and pxa0=xa00.0247, respectively). Although technically challenging and carrying potential major complications, transcatheter intervention can be considered as an efficient rescue strategy to restore patency in case of thrombotic obstruction of a modified BT shunt.

Closure of Isolated Congenital Coronary Artery Fistula: Long-Term Outcomes and Rate of Re-intervention

Long-term outcome after closure of isolated congenital coronary artery fistula (ICCAF) is poorly documented. To assess late outcome after ICCAF closure, a 1983–2013 retrospective study included all patients who attempted an ICCAF closure and whose follow-up was ≥1xa0year. ICCAF was diagnosed in 23 patients [median age 6.9xa0years (0.1–70.5xa0years), 13 children]. ICCAF was symptomatic in 12 patients (52.2xa0%). First intervention was either a transcatheter embolization (nxa0=xa019 patients, 82.6xa0%) or a surgical ligation (nxa0=xa04 patients, 17.4xa0%). After a follow-up of 9.0xa0years (2.8–33.5), neither death nor late ischemic event occurred but one patient was transplanted, because of postoperative myocardial infarction. Late ICCAF recanalization occurred in eight patients, leading to successful embolization of the shunt in all patients after a delay of 9.8xa0years (5.7–13.8xa0years) from the first intervention. Re-intervention occurred later in children (pxa0=xa00.0027), with a 50 and 37.5xa0% freedom from re-intervention in adults compared to a 100 and 89.0xa0% in children, respectively, at 1 and 6xa0years of follow-up. At last follow-up, coronary artery diameter had decreased from a mean z score of 12.0xa0±xa07.7 to a mean z score of 6.0xa0±xa06.0 (pxa0=xa00.002). Long-term outcome after ICCAF closure is excellent, with neither death nor late ischemic event, and a significant decrease in coronary artery diameter with time. Late follow-up is of paramount importance, as one-third of patients will require a re-intervention for late shunt recanalization.

Left Anterior Descending Coronary Artery Occlusion During Transcatheter Pulmonary Valve Implantation: Successful Rescue Percutaneous Revascularization

A 34-year-old woman was referred for transcatheter pulmonary valve implantation. She had been exposed to radiotherapy for Hodgkin’s disease and underwent a Ross procedure 16 years before for post-endocarditis aortic regurgitation. Test-balloon angioplasty with a 22xa0× 20-mm Atlas balloon (Bard

Kissing Stents for Superior Vena Cava Syndrome Due to Mediastinal Fibrosis

Purpose: To report the endovascular reconstruction of the superior vena cava (SVC), innominate and internal jugular veins following stenosis due to mediastinal fibrosis. Case Report: A 36-year-old female with mediastinal fibrosis was referred for symptomatic SVC syndrome (SVCS). A covered stent was inserted in the SVC with 2 kissing stents in the innominate and jugular veins via anterograde right femoral vein access with sandwich technique. She exhibited near-immediate relief of debilitating symptoms. Computed tomographic scan demonstrated patent vessels at 1u2009year. Conclusions: Extensive endovascular venous reconstruction is an effective treatment for SVCS due to mediastinal fibrosis.

IMPACT OF INITIATION OF BALLOON PULMONARY ANGIOPLASTY PROGRAM ON REFERRAL OF PATIENTS WITH CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION TO SURGERY

Balloon pulmonary angioplasty (BPA) is a rising technique for inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to assess whether initiation of BPA has modified the referral of patients undergoing pulmonary endarterectomy (PEA).nnThis prospective study

Impact of the initiation of balloon pulmonary angioplasty program on referral of patients with chronic thromboembolic pulmonary hypertension to surgery

BACKGROUNDnBalloon pulmonary angioplasty (BPA) is a technique proposed for inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). In this study we aimed to determine whether initiation of the BPA program has modified the characteristics and outcome of patients undergoing pulmonary endarterectomy (PEA), and compared the characteristics of patients undergoing one or the other procedure.nnnMETHODSnThis prospective registry study included all patients with CTEPH who underwent PEA in the French National Reference Center before (2012 to 2013) and after (2015 to 2016) BPA program initiation (February 2014). Pre-operative clinical and hemodynamics profiles, peri-operative (Jamieson classification, surgery duration, need of assistance) characteristics of both groups, and all-cause mortality were compared using the t-test or chi-square test. Characteristics of patients subjected to surgery or BPA since February 2014 were also compared.nnnRESULTSnThe total number of patients referred to the CTEPH team increased in the BPA era (nu202f=u202f291 vs nu202f=u202f484). The pre-operative characteristics of patients from the pre-BPA era (nu202f=u202f240) were similar to those from the BPA era (nu202f=u202f246). Despite more Jamieson Type 3 cases (29%) in the second period, 30- and 90-day mortality remained stable (both p > 0.30). Patients subjected to BPA (nu202f=u202f177) were older than those subjected to PEA (nu202f=u202f364) (64 ± 14 vs 60 ± 14 years, respe`ctively), and had higher rates of splenectomy (10% vs 1%) or implantable port (9% vs 3%), lower total pulmonary resistance, better cardiac index, and better renal function (all p < 0.01).nnnCONCLUSIONSnThis study shows the influence of the initiation of the BPA program on the profile of patients with CTEPH undergoing PEA.