Wesley Pedersen

Percutaneous Balloon Aortic Valvuloplasty Revisited Time for a Renaissance

Case Presentation: A 92-year-old woman presented with progressive heart failure in the setting of known aortic valve stenosis. Despite aggressive medical therapy, she remained in New York Heart Association functional class IV. She lived in an assisted-care facility and wanted to engage in more vigorous daily activities. She did not wish to undergo surgical aortic valve replacement. An echocardiogram showed a left ventricular ejection fraction of 50%. The aortic valve was heavily calcified and severely stenotic, with a mean gradient of 64 mm Hg and an aortic valve area of 0.46 cm2. The patient was offered balloon aortic valvuloplasty, to which she and her family consented. A retrograde approach with a 23-mm balloon was used. A total of 3 inflations were carried out across the aortic valve during simultaneous rapid ventricular pacing at 220 bpm. The postvalvuloplasty mean gradient was reduced to 28 mm Hg, and the aortic valve area increased to 0.98 cm2. She was seen in the clinic 6 months later with stable functional class II symptoms and remained quite satisfied with her improved lifestyle. Calcific aortic stenosis (AS) is the most frequent expression of valvular heart disease in the Western world, with increasing prevalence expected as the population ages. Three percent of all adults ≥75 years of age have moderate or severe AS, and it is the leading indication for valve replacement in Europe and the United States. Surgical aortic valve replacement is the preferred treatment strategy for patients of all age groups, although it has limitations in the octogenarian and nonagenarian populations. Open heart approaches are limited by higher perioperative risk, prolonged recovery, and poor quality of life after surgery.1 The surgical 30-day mortality rate for the nonagenarian population is ≈17% in 1 contemporary series, with 40% mortality by 13 months. …

Clinical, Angiographic, and Interventional Follow-Up of Patients With Aortic-Saphenous Vein Graft Connectors

Background—The use of aortic connectors for proximal saphenous vein bypass graft anastomoses eliminates the need for aortic clamping during coronary artery bypass grafting (CABG) and may reduce the incidence of stroke in the elderly and in patients with severe aortic atherosclerosis. Methods and Results—We studied 74 consecutive patients who received the Symmetry Bypass System aortic connector at the time of CABG. A total of 131 of 144 proximal vein graft anastomoses were performed with this device. The left internal mammary artery was used in 62 patients, and 61 patients had “off-pump” coronary revascularization. A total of 11 patients were readmitted with chest pain consistent with unstable angina 173±39 days after CABG. Five of the 11 patients had previous in-stent restenosis before CABG. At angiography, 20 saphenous vein bypass grafts containing 19 connectors were found to have severe stenosis (n=12) or occlusion (n=6) and were treated with angioplasty and stenting or medical therapy. Seven of 11 patients were readmitted 76±11 days later with recurrent chest pain and were found to have severe stenosis at the previously stented connector site. Six patients underwent angioplasty followed by brachytherapy. Three of these patients redeveloped chest pain and were readmitted 151±71 days later. Two patients were started on oral Rapamune, and one patient underwent redo-CABG. Conclusion—Eleven of 74 patients who received aortic connectors at the time of CABG developed symptomatically significant stenosis or occlusion at the connector site shortly after CABG, requiring multiple repeat interventions, including brachytherapy.

The prognostic role of mitral regurgitation after primary percutaneous coronary intervention for acute ST-Elevation myocardial infarction†

Objectives: The aim of this study was to elucidate the prognostic significance of mitral regurgitation (MR) after primary percutaneous coronary intervention (PCI) for acute ST‐elevation myocardial infarction (STEMI). Background: MR has prognostic implications after myocardial infarction (MI). However, for STEMI patients receiving primary PCI, the influence of MR on long‐term (3–5 years) outcome is unknown. Methods: We examined 888 STEMI patients receiving primary PCI enrolled in a prospective database at a regional STEMI center, who had an echocardiogram within 72 hr following successful primary PCI. MR was graded by color Doppler as none/trace vs. mild vs. moderate/severe. Mean ± SD follow‐up was 3.1 ± 1.4 years. Results: For patients with none/trace (n = 469), mild (n = 325), and moderate/severe (n = 94) MR, mortality at 3 years was 8.1%, 13.6%, and 25.7% and at 5 years was 12.7%, 18.3%, and 33.5%, respectively (P < 0.0001, log‐rank test). Patients with moderate/severe MR tended to be older (P < 0.0001) with lower ejection fraction (P < 0.0001) and were less likely to have had an anterior MI (P < 0.001). Independent predictors of mortality included age, creatinine, and heart rate. Conclusions: Following primary PCI for STEMI, echocardiographic detected MR in the first 72 hr following PCI stratifies mortality risk. However, when accounting for age, MR is not an independent predictor of mortality.

Use of cardiac CT angiography to assist in the diagnosis and treatment of aortic prosthetic paravalvular leak: a practical guide.

Percutaneous repair of aortic paravalvular regurgitation can help avoid the need for repeat valve surgery. Although the initial diagnosis of paravalvular regurgitation is usually made with echocardiography, cardiac CT angiography helps to determine the site and morphology of these leaks. The utility of CT is highly dependent on the quality of the data. Herein, we describe a systematic approach to image acquisition and interpretation of cardiac CT angiography in patients with aortic paravalvular regurgitation, which integrates findings from echocardiography. This approach can be used to minimize inaccuracies in the diagnosis and enhance the procedural success for percutaneous repair of aortic paravalvular regurgitation.

Successful rotational atherectomy in the setting of extensive coronary dissection: A case of failed balloon angioplasty in a nondilatable calcified lesion complicated by balloon rupture and extensive dissection

We describe a case of rotational atherectomy (RA) used in the setting of extensive coronary dissection. Unsuccessful predilitation of a heavily calcified proximal LAD stenosis resulted in balloon rupture, which produced occlusive dissection extending into the mid LAD. Limited options for this patient required that we perform RA to permit stent delivery and deployment and avoid anterior myocardial infarction. A brief discussion of reasons for balloon angioplasty failure and the potential role for subsequent RA is given. Predictors for coronary perforation when performing RA are reviewed. Our rationale and strategy to avoid the increased risk of perforation with RA in this contraindicated setting of extensive dissection is given. Cathet Cardiovasc Intervent 2003;59:329–332.

Initial findings using the V8 hourglass‐shaped valvuloplasty balloon for postdilatation in treating paravalvular leaks associated with transcatheter self‐expanding aortic valve prosthesis

The aim of this study was to assess the effect of a novel hourglass‐shaped balloon on reduction of paravalvular leak (PVL) in patients undergoing transcatheter aortic valve replacement (TAVR) with self‐expanding prostheses.

IMPACT OF THE COMMERCIAL INTRODUCTION OF TRANSCATHETER MITRAL VALVE REPAIR ON MITRAL SURGICAL PRACTICE

With the commercial introduction of transcatheter mitral valve repair with MitraClip into the U.S. in 2013, there has been uncertainty regarding the effect of this therapy on cardiac surgical practice. The present investigation was undertaken to examine the impact of this introduction in the context

Five-year outcomes of transcatheter reduction of significant mitral regurgitation in high-surgical-risk patients

Objectives This study evaluates the 5-year clinical outcomes of transcatheter mitral valve (MV) repair with the MitraClip device in patients at high risk for MV surgery treated in the Endovascular Valve Edge-to-Edge Repair (EVEREST) II High Risk Study (HRS). Methods Patients with mitral regurgitation (MR) 3+ or 4+ and predicted surgical mortality risk ≥12% or surgeon assessment based on prespecified high-risk factors were enrolled. Patients prospectively consented to 5 years of follow-up. Results At 5 years, clinical follow-up was achieved in 90% of 78 enrolled patients. The rate of postprocedural adverse events declined from 30 days to 1 year follow-up and was stable thereafter through 5 years. Two patients (2.6%) developed mitral stenosis (MS). Two patients underwent MV surgery, including one due to MS. A total of 42 deaths were reported through 5 years. Effectiveness measures at 5 years showed reductions in MR severity to ≤2+ in 75% of patients (p=0.0107), left ventricular (LV) end-diastolic volume (−38.2 mL; 95% CI −55.0 to –21.4; p<0.0001) and LV end-systolic volume (−14.6 mL; 95% CI −27.7 to −1.5; p=0.0303) compared with baseline. The New York Heart Association (NYHA) functional class improved from baseline to 5 years (p<0.005), and septal-lateral annular dimensions remained stable with no indication of mitral annular dilation through 5 years. Conclusions The EVEREST II HRS demonstrated long-term safety and efficacy of MitraClip in high-surgical-risk patients through 5 years. The observed mortality was most likely a consequence of the advanced age and comorbidity profile of the enrolled patients, while improvements in NYHA class in surviving patients were durable through long-term follow-up. Trial registration number NCT01940120.

CRT-800.32 Improvement in Aortic Valve Area in Aortic Stenosis Patients Using a New “Hourglass” Shaped Valvuloplasty Compared with Cylindrical Balloons

Balloon (bal) aortic valvulopasty (BAV) has reemerged with transcatheter therapy. Cylindrical bal have been the device of choice despite limitations. The V8 (InterValve Inc) bal with broader segments separated by a narrowed waist is designed to permit enhanced fix and better leaflet opening without

EFFECTIVENESS OF TRANSCATHETER REDUCTION OF SIGNIFICANT MITRAL REGURGITATION IN HIGH SURGICAL RISK PATIENTS WITH MITRACLIP: FINAL 5 YEAR RESULTS OF THE EVEREST II HIGH RISK REGISTRY

The EVEREST II High Risk Registry (HRR) enrolled 78 patients with severe mitral regurgitation (MR) who were too high risk for mitral valve (MV) surgery. As of November 2013, all patients completed 5 year follow-up. Results through 1 year have been published, and final outcomes through 5 years will