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Despite maturing experience, transseptal puncture (TSP) remains a challenging part of percutaneous left atrial appendage closure (LAAC) and has inherent risks and safety concerns in accessing the left atrium (LA). The VersaCross radiofrequency (RF) system (Baylis Medical), a new RF-tipped pigtail wire-based TSP system, may facilitate LA access by serving as an exchange support wire once access is achieved. We retrospectively compared TSP safety and procedural efficiency in 10 consecutive LAAC cases using the VersaCross RF system to 10 cases using the conventional BRK1-XS mechanical needle (Abbott Vascular). The safety and time from femoral access to delivery of the device sheath were compared to the conventional workflow using BRK1-XS/SL1. We included consecutive 20 cases between July 2019 and November 2019 (12 with WATCHMAN (Boston Scientific, Natick, MA) and 8 with Amulet (St. Jude Medical, St Paul, MN)). Baseline patient characteristics and procedural details were similar in both groups (VersaCross RF system vs. conventional BRK1-XS mechanical needle). All cases were completed successfully with no procedural or in-hospital complications. VersaCross reduced time from femoral access to TSP [4.1 ± 2.5 min vs. 8.4 ± 4.0 min (p = 0.009)] and time from femoral access to delivery sheath access into LA [6.7 ± 2.4 min vs. 13.4 ± 5.4 min (p = 0.002)] compared to BRK1-XS. Combining a starter wire, transseptal needle and exchange guidewire in the VersaCross RF system enabled faster LA access, which potentially leads to efficient workflow. Further investigation with larger sample size is warranted to corroborate our findings.

Percutaneous left atrial appendage closure is increasingly performed for stroke prevention for patients with nonvalvular atrial fibrillation with contraindications to oral anticoagulation. The success and complication rates with left atrial appendage closure have dramatically improved with maturing experience, growing procedural familiarity, and preprocedural planning. Multimodality imaging involving cardiac computer tomography angiography, transesophageal echocardiography, or intracardiac echocardiography in conjunction with fluoroscopy has improved the efficacy, procedural success, and safety of left atrial appendage closure in recent years. Proceduralists need to familiarize themselves with the various modalities and understand their complimentary roles and their limitations.

PURPOSE: Cardiac computed tomography angiography (CCTA) is increasingly used for device surveillance after left atrial appendage closure (LAAC). While CT protocols with delayed scans are useful to diagnose thrombus in the LAA, an optimal protocol for post-procedural CCTA has not been established. Therefore, we assessed the role of delayed versus early scans for device surveillance. METHODS: We retrospectively reviewed patients who underwent LAAC at Vancouver General Hospital who had follow-up CCTAs using standard (early) and delayed scans. Scans were performed on Toshiba 320-detector (Aquilion ONE). Image quality was interpreted by 2 independent observers for anatomy, LAA contrast patency, and device-related thrombus (DRT) using VitreaWorkstation(TM). A Likert scale of 1–5 was used (1= poor quality, 5= excellent) for assessment. RESULTS: We included 27 consecutive LAAC patients (9 Amplatzer, 18 WATCHMAN) with mean age 76.0±7.7 years, mean CHADS(2) score 2.8±1.3, CHA(2)DS(2)-VASc score 4.4±1.6 and HAS-BLED score 3.4±1.0. Subjective quality assessments by both reviewers favored early scans for assessment of anatomy (reviewer 1: 4.63±0.63 [early] vs. 1.74±0.71 [delayed]; reviewer 2: 4.63±0.63 [early] vs. 1.89±0.64 [delayed]) and DRT (reviewer 1: 4.78±0.42 [early] vs. 3.11±1.16 [delayed]; reviewer 2: 4.70±0.47 [early] vs. 3.04±1.29 [delayed]). Inter-rater variability showed good correlation between reviewers (intraclass correlation 0.61–0.95). Mean LAA/LA attenuation ratios were significantly different between scans, with larger mean percent reduction of contrast opacification from LA to LAA in the early scans (57.0±36.6% reduction for early vs. 29.1±30.8% for delayed; p < 0.001). CONCLUSION: For CT device surveillance post-LAAC early phase imaging provides superior image quality objectively and subjectively compared with delayed scanning.

Subacute or late complications > 24 hours after left atrial appendage closure (LAAC) are infrequent. We therefore created a clinical pathway to enable safe same-day discharge (SDD) after LAAC. Patients were assessed for overall physical conditioning, lack of significant frailty and comorbidities limiting physical abilities, good home support, and patient preference. Of 78 LAACs performed, 24 patients (30.8%) were discharged the same day: 21 were transesophageal echocardiography guided and 3 intracardiac echocardiography guided. SDD clinical pathway patients were discharged 395.4 ± 56.6 minutes after leaving the procedural room. There were no clinical complications at 1 month or in long-term follow-up. SDD is safe and feasible after LAAC, following a dedicated clinical pathway and surveillance in carefully selected patients.

Spontaneous coronary artery dissection (SCAD) accounts for up to 4% of acute coronary syndromes (ACS) on coronary angiography and predominantly affects women (90%). SCAD most often occurs in patients with few or no conventional cardiovascular risk factors. This condition remains underdiagnosed due to a lack of awareness among health-care providers and misdiagnosis on coronary angiography. Areas covered: In this review, authors aim to summarize contemporary data on the etiology, morbidity and mortality risks, as well as management strategies in order to raise awareness. Expert opinion: The last decade of extensive research revealed that SCAD is not as rare as previously thought and needs to be in the differential diagnosis of all MI patients, especially in young to middle-aged women. Predisposing factors, such as fibromuscular dysplasia, and potential triggers like physical or emotional stresses, are frequently linked. Coronary angiography is the first-line diagnostic tool and should be performed meticulously because of more fragile vessel architecture to avoid iatrogenic dissections. If angiographic findings are uncertain, the use of intravascular imaging may be required. Conservative therapy is favored over revascularization unless patients have high-risk features. Recurrent cardiovascular events post-SCAD are frequent, and patients should be closely monitored after a SCAD event.

OBJECTIVES: To describe imaging assessment, procedural and follow-up outcome of patients undergoing left atrial appendage (LAA) occlusion (LAAO) using a "sandwich" technique.BACKGROUND: The presence of a LAA with chicken wing morphology constitutes a challenge that sometimes requires specific occlusion strategies like the "sandwich" technique. However, procedural and follow-up data focusing on this implanting strategy is scarce.METHODS: This multicenter study collected individual data from eight centers between 2012 and 2019. Consecutive patients with chicken-wing LAAs defined as an early (90°) who underwent LAAO with Amplatzer devices and using the "sandwich" technique were included in the analysis.RESULTS: Overall, 190 subjects were enrolled in the study. Procedures were done with the Amulet device (85%) and the Amplatzer Cardiac Plug (15%). Successful implantation was achieved in 99.5% with ≤1 partial recapture in 80% of cases. Single (46.2%) and dual antiplatelet therapy (39.4%) were the most used antithrombotic therapies after LAAO. In-hospital major adverse events rate was 1.5% with no deaths. One patient (0.5%) had cardiac tamponade requiring percutaneous drainage. With a mean follow-up of 19.6 ± 14.8 months, the mortality and stroke rates were 7.7%/year and 2.5%/year, respectively. Follow-up transesophageal echocardiography (TEE) at 2-3 months showed device-related thrombosis in 2.8% and peri-device leak ≥3 mm in 1.2% of patients.CONCLUSIONS: In a large series of patients with chicken wing LAA anatomies undergoing LAAO, the use of the "sandwich" technique was feasible and safe. Preprocedural imaging was a key-factor to determine specific measurements.

BACKGROUND Transseptal access for large sheaths may be encumbered by tissue resistance against the sheath-dilator stepped interface. The ExpanSure Large Access Transseptal Dilator (Baylis Medical) is designed as a single introducer and dilation device with a smooth sheath-dilator transition to support transseptal puncture. It may facilitate ease and efficiency of interatrial crossing. METHODS This study experimentally evaluated the crossing force of ExpanSure relative to a conventional 8.5 F Swartz SL1 transseptal sheath and dilator in a benchtop septum model. Its ability to reduce the subsequent crossing force of a 14 F WATCHMAN delivery sheath was also tested. The clinical use of ExpanSure, including procedure time, was then validated in a series of left atrial appendage closure (LAAC) procedures. RESULTS In a benchtop septum model (N = 12), less peak force (1.90 ± 0.08 N vs. 2.36 ± 0.09 N; p

Background: Patients with atrial fibrillation undergoing transcatheter aortic valve implantation (TAVI) have a worse prognosis than those in sinus rhythm. The bleeding risk associated with oral ant...

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in women with few or no conventional cardiovascular risk factors. Lack of awareness about this condition among healthcare providers had led to significant underdiagnosis and misdiagnosis in this relatively young patient population.The current review summarizes the contemporary data on cause, management strategies and outcomes of SCAD.SCAD is not as rare as previously thought, accounting for up to 4% of all acute coronary syndromes. It is frequently linked with predisposing factors, such as fibromuscular dysplasia or other vasculopathies, and is often triggered by physical or emotional stress. Due to more fragile vessel architecture, coronary angiography as the first-line diagnostic tool should be performed meticulously to avoid iatrogenic dissection. Intravascular imaging may be required if angiographic findings are uncertain. Unless patients have high-risk features such as ongoing ischemia, recurrent chest pains, left main artery dissection, ventricular arrhythmias, or hemodynamic instability, a conservative treatment strategy is favored over revascularization. Close monitoring is essential after a SCAD-event as recurrent cardiovascular events post-SCAD are frequent.

AIMS Device surveillance after left atrial appendage (LAA) closure (LAAC) is important to assess device positioning, peri-device leak (PDL) and device-related thrombus (DRT). There are limited data on the role of cardiac CT angiography (CCTA) after LAAC. We therefore sought to compare CCTA to transoesophageal echocardiography (TEE) in patients who successfully underwent LAAC. METHODS AND RESULTS We report our consecutive series of non-valvular atrial fibrillation patients who underwent LAAC and had CCTA and TEE post LAAC. Prospective cardiac-gated CCTA was performed with the Toshiba 320-detector or Siemens second-generation 128-slice dual-source scanner, and post-processing was performed with IMPAX 3D reformats. Glomerular filtration rate

Aims. To assess the incremental prognostic value of SYNTAX score II (SxSII) as compared to anatomical SYNTAX Score (SxS) and GRACE risk score in patients with acute coronary syndromes who underwent percutaneous coronary intervention. Methods and results. SxSII and SxS were determined in 734 ACS patients. Patients were enrolled in the prospective Special Program University Medicine ACS and the COMFORTABLE AMI cohorts and later on stratified according to tertiles of SxSII (SxSIILow ≤21.5 (n=245), SxSIIMid 21.5–30.6 (n=245), and SxSIIHigh ≥30.6 (n=244). The primary endpoint of adjudicated all-cause mortality and secondary endpoints of MACE (cardiac death, repeat revascularization, and myocardial infarction) and MACCE (all-cause mortality, cerebrovascular events, MI, and repeat revascularization) were determined at 1-year follow-up. SxSII provided incremental predictive information for risk stratification when compared to SxS and GRACE risk score (AUC 0.804, 95% CI 0.77–0.84, p<0.001 versus 0.67, 95% CI 0.63–0.72, p=0.007 versus 0.69, 95% CI 0.6–0.8, p=0.002), respectively. In a multivariable Cox regression analysis, we found that unlike SxS (adjusted HR 1.013, 95% CI (0.96–1.07), p=0.654), SxSII was significantly associated with all-cause mortality (HR = 1.095, 95% CI (1.06–1.11), p<0.001). This was also true for the prediction of both secondary outcomes MACE (n=60) and MACCE (n=70) with an adjusted HR = 1.055, 95% CI (1.03–1.08), p<0.001, and HR = 1.065, 95% CI (1.04–1.09), p<0.001. Conclusion. In patients with ACS who underwent PCI, SxSII is an independent predictor of mortality during 1-year follow-up. SxSII shows superiority in discriminating risk compared to conventional SxS and GRACE for all-cause mortality.

Although rates of atrial septal defect (ASD) closure are stable, dramatic increases in the rates of patent foramen ovale (PFO) closure have placed greater demands on existing catheterization laboratory resources. The Vancouver PFO/ASD Clinical Pathway (Figure 1) was designed to facilitate same-day