Vladimir Jelnin

Clinical Outcomes in Patients Undergoing Percutaneous Closure of Periprosthetic Paravalvular Leaks

OBJECTIVES The purpose of this study was to evaluate the feasibility and efficacy of the percutaneous device closure of a consecutive series of patients with periprosthetic paravalvular leaks referred to our structural heart disease center with congestive heart failure and hemolytic anemia. BACKGROUND Clinically significant periprosthetic paravalvular leak is an uncommon but serious complication after surgical valve replacement. Percutaneous closure has been utilized as an alternative to surgical repair of this defect in high-risk surgical patients. METHODS This is a retrospective review of 57 percutaneous paravalvular leak closures that were performed in 43 patients (67% male, mean age 69.4 ± 11.7 years) between April 2006 and September 2010. Integrated imaging modalities were used for the evaluation, planning, and guidance of the interventions. RESULTS Closure was successful in 86% of leaks and in 86% of patients. Twenty-eight of 35 patients improved by at least 1 New York Heart Association functional class. The percentage of patients requiring blood transfusions and/or erythropoietin injections post-procedure decreased from 56% to 5%. Clinical success was achieved in 89% of the patients in whom procedure was successful. The survival rates for patients at 6, 12, and 18 months after paravalvular leak closures were 91.9%, 89.2%, and 86.5%, respectively. Freedom from cardiac-related death at 42 months post-procedure was 91.9%. CONCLUSIONS Percutaneous closure of symptomatic paravalvular leaks, facilitated by integrated imaging modalities has a high rate of acute and long-term success and appears to be effective in managing symptoms of heart failure and hemolytic anemia.

Clinical Experience With Percutaneous Left Ventricular Transapical Access for Interventions in Structural Heart Defects: A Safe Access and Secure Exit

OBJECTIVES This study sought to evaluate the safety of percutaneous direct left ventricular access for interventional procedures. BACKGROUND Experience with percutaneous access of the left ventricle (LV) for interventional procedures has been limited and associated with a high percentage of major complications. We report our clinical experience with percutaneous direct LV access for interventional procedures. METHODS Between March 2008 and December 2010, there were 32 percutaneous transapical punctures in 28 consecutive patients (16 males, mean age 68.2 ± 10.8 years). The delivery sheath sizes ranged from 5- to 12-F. RESULTS All transapical punctures were successfully performed, and safe closure of the access sites was achieved. Total procedural time was 153.6 ± 49.4 min for procedures converted from conventional approaches to a transapical approach, 129.5 ± 29.6 min for the transapical approach with trans-septal rail support, and 109.3 ± 41.4 min for the planned transapical approach. Fluoroscopy time was 61.3 ± 26.1 min, 29.7 ± 20.8 min, and 27.4 ± 21.4 min, respectively. Fluoroscopy time for closure of mitral paravalvular leaks was reduced by 35%, from 42.6 ± 29.9 min to 27.4 ± 15.6 min. Complications were observed in 2 patients (7.1%). CONCLUSIONS With meticulous planning, transapical puncture is safe. The transapical access provides a more direct approach to the LV targets for intervention and leads to a significant decrease in the procedural and fluoroscopy times. Device closure of the direct LV access site is a reliable and safe method of hemostasis. Placement of a closure device should be considered if sheaths larger than 5-F are used. Although we used this technique only for paravalvular leak and LV pseudoaneurysm closure, it may have application for other percutaneous structural heart interventions.

Percutaneous Closure of Left Ventricular Pseudoaneurysm

Background—Left ventricular pseudoaneurysm is a rare but serious complication from myocardial infarction and cardiac surgery. Although standard treatment is surgical intervention, percutaneous closure of left ventricular pseudoaneurysm has become an option for high-risk surgical candidates. Experience with percutaneous treatment is limited to a few single case reports. This is the first series of percutaneous treatment of the left ventricular pseudoaneurysms. Methods and Results—This is a retrospective analysis of 9 procedures of percutaneous repair of left ventricular pseudoaneurysm in 7 consecutive patients (ages 51 to 83 years, 6 men) completed in our Structural Heart Disease center from June 2008 to December 2010. All patients were considered as a high risk for surgery because of multiple comorbidities. Multiple imaging modalities were used before, during, and after the procedures to improve success and efficacy. The left ventricular pseudoaneurysms of all 7 patients were successfully repaired. Fluoroscopy time on average was 36.5±24.0 minutes (range, 12.4 to 75.7 minutes). All patients were followed up for a period ranging from 3 to 32 months after the procedure. Each patient improved by at least 1 New York Heart Association functional class, and 4 patients improved by 2 classes. Conclusions—Transcatheter closure of the left ventricular pseudoaneurysm is a feasible alternative for high-risk surgical candidates. The use of multiple imaging modalities is required for a detail planning and execution of the procedure.

Stent Gap by 64-Detector Computed Tomographic Angiography: Relationship to In-Stent Restenosis, Fracture, and Overlap Failure

OBJECTIVES The goal of this study was to define the frequency of stent gaps by 64-detector computed tomographic angiography (CTA) and their relation to in-stent restenosis (ISR), stent fracture (SF), and overlap failure (OF). BACKGROUND SF defined by catheter angiography or intravascular ultrasound has been implicated in ISR. METHODS A total of 292 consecutive patients, with 613 stents, who underwent CTA were evaluated for stent gaps associated with decreased Hounsfield units. Correlations with catheter coronary angiography (CCA) were available in 143 patients with 384 stents. RESULTS Stent gaps were noted in 16.9% by CTA and 1.0% by CCA. ISR by CCA was noted in 46.1% of the stent gaps (p < 0.001) as determined by CCA, and stent gaps by CTA accounted for 27.8% of the total ISR (p < 0.001). In univariate analysis, stent diameter > or =3 mm was the only CCA characteristic significantly associated with stent gaps (p = 0.002), but was not a significant predictor by multivariate analysis. Bifurcation stents, underlying calcification, stent type, location, post-dilation, and overlapping stents were not observed to be predisposing factors. Excessive tortuosity and lack of conformability were not associated with stent gaps; however, their frequency was insufficient to permit meaningful analysis. CONCLUSIONS Stent gap by CTA: 1) is associated with 28% of ISR, and ISR is found in 46% of stent gaps; 2) is associated with > or =3-mm stents by univariate (p = 0.002) but not by multivariate analysis; 3) is infrequently noted on catheter angiography; and 4) most likely represents SF in the setting of a single stent, and may represent SF or OF in overlapping stents.

Three dimensional CT angiography for patients with congenital heart disease: Scanning protocol for pediatric patients

The objective of our study was to determine the contrast attenuation level that yields high quality cardiac three‐dimensional (3‐D) images and to predict the contrast injection rate (IR), from body weight, to reach this attenuation level. Enhanced electron beam computerized tomography (EBCT) with 3‐D reconstruction is useful in delineating cardiac anatomy in complex congenital heart disease (CHD). The current experience of using electron beam angiography (EBA) in pediatric CHD is limited. Well‐defined contrast injection protocols, specifically the contrast IR, have not been standardized when compared to those for adults. Establishing the contrast IR is essential in obtaining high quality 3‐D images. We retrospectively analyzed the studies of 115 pediatric patients with CHD. EBA images were divided into group 1 with good quality 3‐D images and group 2 with poor quality. The mean of measured enhancement level, expressed in Hounsfield units (HU), and contrast IR were analyzed in both groups. Spearman correlation was used to examine the relationship between weight and IR. The IR was predicted from weight using simple linear regression analysis. The mean level of enhancement was 344 ± 91 and 174 ± 31 HU for group 1 and group 2, respectively. Group 1 consisted of 103 patients (90%) and the IR strongly correlated with weight (ρ = 0.861, P < 0.01). The IR was estimated from the linear regression equation IR = 0.59 + 0.056 × weight. Necessary contrast enhancement level for quality 3‐D reconstruction should be greater than 250 HU, and the IR can be estimated from patients weight.

Optimal imaging for guiding TAVR: transesophageal or transthoracic echocardiography, or just fluoroscopy?

THE FOLLOWING iFORUM DEBATE FEATURES 3 VIEWPOINTS related to the most practical and effective imaging strategy for guiding transcatheter aortic valve replacement (TAVR). Kronzon, et al. provide evidence that enhanced analysis of abrtic valve anatomy and improved appreciation of complications mandate the use of transesophageal echocardiography as front-Line imaging modality for ALL patients undergoing TAVR. On the other hand, Saric and colleagues compare and contrast the approach of performing TAVR under transthoracic guidance. Lastly, Kasel and co-workers provide preliminary evidence that TAVR could be performed under fluoroscopic guidance without the need for additional imaging technique. Although the use of Less-intensive sedation or anesthesia might reduce the procedural time, we need more randomized data to establish the most cost-effective approach in guiding TAVR.

Cardiac computed tomography compared to transthoracic echocardiography in the management of congenital heart disease.

Objectives: To compare cardiac CT and transthoracic echocardiography (TTE) as diagnostic utilities in congenital heart disease (CHD) and to determine their advantages and limitations. Background:TTE is widely used in the evaluation of CHD. Recent reports suggested an increasing role of CT. However, there are few quantitative data on its diagnostic accuracy. Methods:We investigated a total of 162 patients (51.24% male; mean age: 16.06 ±± 17.92) with congenital heart defects, who underwent electron beam CT (EBCT) and TTE between March 2002 and June 2005. We retrospectively analyzed a total of 667 findings, stratified for age and anatomic categories. Results: EBCT and TTE findings are concordant in patients below 1 year of age (85.43% agreement). EBCT had poor sensitivity and specificity in detecting anomalies of cardiac chambers (0.68, 0.58), but was useful for great arteries (0.91, 0.85). Furthermore, sensitivity and specificity were remarkably different in systemic venous return (0.93, 0.3) and coronary vessels (0.8, 0.33) because of “false positive” findings, which were later found to be most likely real findings not detectable by reference standard. The opposite was true for cardiac valves (0.66, 0.89) and septa (0.76, 0.91). Conclusions: EBCT delineates findings related to systemic venous return and coronary vessels well due to simultaneous visualization of complex anatomy. This advantage does not seem to apply in patients below 1 year of age with better acoustic windows. TTE was found more suitable for cardiac valves and septal defects because of the availability of flow imaging.

Identifying the course of an anomalous left coronary artery using contrast-enhanced electron beam tomography and three-dimensional reconstruction.

Coronary anomalies are a rare but recognized cause of myocardial ischemia and sudden death. Until recently, invasive coronary arteriography was the diagnostic method of choice. However, contrast‐enhanced electron beam tomography has the advantage of three‐dimensional visualization of anomalous coronary arteries. We describe a case of anomalous origin of the left coronary artery. Cathet Cardiovasc Intervent 2002;57:532–536.

Insight Into the Dynamics of the Coronary Sinus/Great Cardiac Vein and the Mitral Annulus Implications for Percutaneous Mitral Annuloplasty Techniques

Background—Implantation of devices into the coronary sinus (CS)/great cardiac vein (GCV) to reshape the mitral annulus (MA) is being investigated, despite these structures not being within the same plane and coronary arteries frequently traversing between them. Furthermore, dynamic changes in their relationship have never been studied. We analyzed the CS/GCV dimensions and its relationship with the MA and the coronary arteries. Methods and Results—Of 390 consecutive computed tomography angiographies reviewed, 56 met the inclusion criteria. Mean age of the patients was 68.9±13.1 years (26.8% men). The dimensions of the CS/GCV and the distance between this structure and the MA were measured at 10 different spatial points along the CS/GCV trajectory and at 3 different time points along the cardiac cycle (phases 0%, 40%, and 75% of the RR interval) by using curved multiplanar reconstruction technique. The CS/GCV was larger in phase 40% than in phase 75% and was smallest in phase 0% (P<0.001). The distance between the CS/GCV and the MA was longest in phase 40% and shortest in phase 0% (P=0.013). The diameter of the MA was measured in oblique 2- and 4-chamber reconstructions, being largest in phase 0% and smallest in phase 40% (P=0.019). A coronary artery traversed between the CS/GCV and the MA in 85.7% of the patients. Conclusions—This study demonstrated dynamic changes in the relationship between the CS/GCV and the MA and also that coronary arteries frequently traverse between both structures. Whether these findings are of clinical relevance for patients undergoing percutaneous mitral annuloplasty needs to be prospectively evaluated.Background— Implantation of devices into the coronary sinus (CS)/great cardiac vein (GCV) to reshape the mitral annulus (MA) is being investigated, despite these structures not being within the same plane and coronary arteries frequently traversing between them. Furthermore, dynamic changes in their relationship have never been studied. We analyzed the CS/GCV dimensions and its relationship with the MA and the coronary arteries. Methods and Results— Of 390 consecutive computed tomography angiographies reviewed, 56 met the inclusion criteria. Mean age of the patients was 68.9±13.1 years (26.8% men). The dimensions of the CS/GCV and the distance between this structure and the MA were measured at 10 different spatial points along the CS/GCV trajectory and at 3 different time points along the cardiac cycle (phases 0%, 40%, and 75% of the RR interval) by using curved multiplanar reconstruction technique. The CS/GCV was larger in phase 40% than in phase 75% and was smallest in phase 0% ( P <0.001). The distance between the CS/GCV and the MA was longest in phase 40% and shortest in phase 0% ( P =0.013). The diameter of the MA was measured in oblique 2- and 4-chamber reconstructions, being largest in phase 0% and smallest in phase 40% ( P =0.019). A coronary artery traversed between the CS/GCV and the MA in 85.7% of the patients. Conclusions— This study demonstrated dynamic changes in the relationship between the CS/GCV and the MA and also that coronary arteries frequently traverse between both structures. Whether these findings are of clinical relevance for patients undergoing percutaneous mitral annuloplasty needs to be prospectively evaluated. Received April 15, 2009; accepted October 15, 2009. # CLINICAL PERSPECTIVE {#article-title-2}

Insight Into the Dynamics of the Coronary Sinus/Great Cardiac Vein and the Mitral Annulus

Background—Implantation of devices into the coronary sinus (CS)/great cardiac vein (GCV) to reshape the mitral annulus (MA) is being investigated, despite these structures not being within the same plane and coronary arteries frequently traversing between them. Furthermore, dynamic changes in their relationship have never been studied. We analyzed the CS/GCV dimensions and its relationship with the MA and the coronary arteries. Methods and Results—Of 390 consecutive computed tomography angiographies reviewed, 56 met the inclusion criteria. Mean age of the patients was 68.9±13.1 years (26.8% men). The dimensions of the CS/GCV and the distance between this structure and the MA were measured at 10 different spatial points along the CS/GCV trajectory and at 3 different time points along the cardiac cycle (phases 0%, 40%, and 75% of the RR interval) by using curved multiplanar reconstruction technique. The CS/GCV was larger in phase 40% than in phase 75% and was smallest in phase 0% (P<0.001). The distance between the CS/GCV and the MA was longest in phase 40% and shortest in phase 0% (P=0.013). The diameter of the MA was measured in oblique 2- and 4-chamber reconstructions, being largest in phase 0% and smallest in phase 40% (P=0.019). A coronary artery traversed between the CS/GCV and the MA in 85.7% of the patients. Conclusions—This study demonstrated dynamic changes in the relationship between the CS/GCV and the MA and also that coronary arteries frequently traverse between both structures. Whether these findings are of clinical relevance for patients undergoing percutaneous mitral annuloplasty needs to be prospectively evaluated.Background— Implantation of devices into the coronary sinus (CS)/great cardiac vein (GCV) to reshape the mitral annulus (MA) is being investigated, despite these structures not being within the same plane and coronary arteries frequently traversing between them. Furthermore, dynamic changes in their relationship have never been studied. We analyzed the CS/GCV dimensions and its relationship with the MA and the coronary arteries. Methods and Results— Of 390 consecutive computed tomography angiographies reviewed, 56 met the inclusion criteria. Mean age of the patients was 68.9±13.1 years (26.8% men). The dimensions of the CS/GCV and the distance between this structure and the MA were measured at 10 different spatial points along the CS/GCV trajectory and at 3 different time points along the cardiac cycle (phases 0%, 40%, and 75% of the RR interval) by using curved multiplanar reconstruction technique. The CS/GCV was larger in phase 40% than in phase 75% and was smallest in phase 0% ( P <0.001). The distance between the CS/GCV and the MA was longest in phase 40% and shortest in phase 0% ( P =0.013). The diameter of the MA was measured in oblique 2- and 4-chamber reconstructions, being largest in phase 0% and smallest in phase 40% ( P =0.019). A coronary artery traversed between the CS/GCV and the MA in 85.7% of the patients. Conclusions— This study demonstrated dynamic changes in the relationship between the CS/GCV and the MA and also that coronary arteries frequently traverse between both structures. Whether these findings are of clinical relevance for patients undergoing percutaneous mitral annuloplasty needs to be prospectively evaluated. Received April 15, 2009; accepted October 15, 2009. # CLINICAL PERSPECTIVE {#article-title-2}