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Background The risk of nosocomial COVID-19 infection for vulnerable aortic stenosis patients and intensive care resource utilization has led to cardiac surgery deferral. Untreated severe symptomatic aortic stenosis has a dismal prognosis. TAVR offers an attractive alternative to surgery as it is not reliant on intensive care resources. We set out to explore the safety and operational efficiency of restructuring a TAVR service and redeploying it to a new non-surgical site during the COVID-19 pandemic. Methods The institutional prospective service database was retrospectively interrogated for the first 50 consecutive elective TAVR cases prior to and after our institution's operational adaptations for the COVID-19 pandemic. Our endpoints were VARC-2 defined procedural complications, 30-day mortality or re-admission and service efficiency metrics. Results The profile of patients undergoing TAVR during the pandemic was similar to patients undergoing TAVR prior to the pandemic with the exception of a lower mean age (79 vs 82 years, p, Highlights • Rapidly redeploying an experienced TAVR team to a non-surgical site is feasible and safe. • Restructuring and streamlining a TAVI service aligns with pandemic-mandated operational efficiency. • Minimalist TAVR can be undertaken safely in selected cases on an elective basis during the COVID-19 pandemic.

Background Left atrial appendage occlusion (LAAO) has been widely adopted as a strategy for stroke prevention in patients with atrial fibrillation ineligible for oral anticoagulation. Objective The purpose of this study was to explore longer-term “real-world” safety and efficacy outcomes in patients undergoing LAAO given varied practices in antithrombotic regimens and adoption of same-day discharge. Methods Analysis of acute procedural and long-term outcome data was performed for all patients undergoing LAAO implant in a United Kingdom tertiary center over an 11-year period. Rates of adverse events were calculated and compared to predicted rates in historical cohorts according to CHA2DS2-VASc and HAS-BLED scores. Results Device implantation was attempted in 229 patients, with an acute procedural success rate of 98.2% and low rate of major procedural complications of 2.6% at 30 days, including 1.3% procedure-related mortality. In the last year of enrollment, 75% of patients were discharged on the same day of the procedure. A strategy of early cessation of antithrombotic therapy was adopted, with a low rate of device-related thrombus. Over total follow-up of 889 patient-years, there were low rates of thromboembolic events (2.2/100 patient-years) and of significant bleeding events (intracranial bleed 0.6/100 patient-years; nonprocedural major bleeding 2.3/100 patient-years). Conclusion LAAO with a same-day discharge strategy and early cessation of antiplatelet therapy seems to be safe and effective in reducing the risk of stroke and major bleeding over mean follow-up approaching 4 years. Although these data are reassuring, results from randomized trials with strict shorter periods of postprocedural antithrombotic therapy are eagerly awaited.

Background Older patients with severe aortic stenosis (AS) are increasingly identified as having cardiac amyloidosis (CA). It is unknown whether concomitant AS-CA has worse outcomes or results in futility of transcatheter aortic valve replacement (TAVR). Objectives This study identified clinical characteristics and outcomes of AS-CA compared with lone AS. Methods Patients who were referred for TAVR at 3 international sites underwent blinded research core laboratory 99mtechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy (Perugini grade 0: negative; grades 1 to 3: increasingly positive) before intervention. Transthyretin-CA (ATTR) was diagnosed by DPD and absence of a clonal immunoglobulin, and light-chain CA (AL) was diagnosed via tissue biopsy. National registries captured all-cause mortality. Results A total of 407 patients (age 83.4 ± 6.5 years; 49.8% men) were recruited. DPD was positive in 48 patients (11.8%; grade 1: 3.9% [n = 16]; grade 2/3: 7.9% [n = 32]). AL was diagnosed in 1 patient with grade 1. Patients with grade 2/3 had worse functional capacity, biomarkers (N-terminal pro-brain natriuretic peptide and/or high-sensitivity troponin T), and biventricular remodeling. A clinical score (RAISE) that used left ventricular remodeling (hypertrophy/diastolic dysfunction), age, injury (high-sensitivity troponin T), systemic involvement, and electrical abnormalities (right bundle branch block/low voltages) was developed to predict the presence of AS-CA (area under the curve: 0.86; 95% confidence interval: 0.78 to 0.94; p Conclusions Concomitant pathology of AS-CA is common in older patients with AS and can be predicted clinically. AS-CA has worse clinical presentation and a trend toward worse prognosis, unless treated. Therefore, TAVR should not be withheld in AS-CA.

Objectives The purpose of this study was to validate computed tomography measured ECV (ECVCT) as part of routine evaluation for the detection of cardiac amyloid in patients with aortic stenosis (AS)-amyloid. Background AS-amyloid affects 1 in 7 elderly patients referred for transcatheter aortic valve replacement (TAVR). Bone scintigraphy with exclusion of a plasma cell dyscrasia can diagnose transthyretin-related cardiac amyloid noninvasively, for which novel treatments are emerging. Amyloid interstitial expansion increases the myocardial extracellular volume (ECV). Methods Patients with severe AS underwent bone scintigraphy (Perugini grade 0, negative; Perugini grades 1 to 3, increasingly positive) and routine TAVR evaluation CT imaging with ECVCT using 3- and 5-min post-contrast acquisitions. Twenty non-AS control patients also had ECVCT performed using the 5-min post-contrast acquisition. Results A total of 109 patients (43% male; mean age 86 ± 5 years) with severe AS and 20 control subjects were recruited. Sixteen (15%) had AS-amyloid on bone scintigraphy (grade 1, n = 5; grade 2, n = 11). ECVCT was 32 ± 3%, 34 ± 4%, and 43 ± 6% in Perugini grades 0, 1, and 2, respectively (p Conclusions ECVCT during routine CT TAVR evaluation can reliably detect AS-amyloid, and the measured ECVCT tracks the degree of infiltration. Another measure of interstitial expansion, the voltage/mass ratio, also performed well.

Aims Cardiac amyloidosis is common in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI). We hypothesized that patients with dual aortic stenosis and cardiac amyloid pathology (AS-amyloid) would have different baseline characteristics, periprocedural and mortality outcomes. Methods and results Patients aged ≥75 with severe AS referred for TAVI at two sites underwent blinded bone scintigraphy prior to intervention (Perugini Grade 0 negative, 1–3 increasingly positive). Baseline assessment included echocardiography, electrocardiogram (ECG), blood tests, 6-min walk test, and health questionnaire, with periprocedural complications and mortality follow-up. Two hundred patients were recruited (aged 85 ± 5 years, 50% male). AS-amyloid was found in 26 (13%): 8 Grade 1, 18 Grade 2. AS-amyloid patients were older (88 ± 5 vs. 85 ± 5 years, P = 0.001), with reduced quality of life (EQ-5D-5L 50 vs. 65, P = 0.04). Left ventricular wall thickness was higher (14 mm vs. 13 mm, P = 0.02), ECG voltages lower (Sokolow–Lyon 1.9 ± 0.7 vs. 2.5 ± 0.9 mV, P = 0.03) with lower voltage/mass ratio (0.017 vs. 0.025 mV/g/m2, P = 0.03). High-sensitivity troponin T and N-terminal pro-brain natriuretic peptide were higher (41 vs. 21 ng/L, P Conclusions AS-amyloid is common and differs from lone AS. Transcatheter aortic valve implantation significantly improved outcome in AS-amyloid, while periprocedural complications and mortality were similar to lone AS, suggesting that TAVI should not be denied to patients with AS-amyloid.

To assess the impact of balloon use for predilation, valve implantation, or postdilation on in-hospital mortality among patients undergoing transcatheter aortic valve replacement (TAVR).TAVR utilizes self-expanding, mechanically expanding, or balloon-expandable valves. Balloon inflation is inherent to deployment of balloon-expandable valves. Balloons may additionally be used with all valve types for pre- and postdilation. The relationships between valve mechanism, balloon use, and in-hospital mortality are not fully characterized.Prospective data were collected on 4063 patients undergoing TAVR for aortic stenosis at 4 high-volume centers in the United Kingdom. In-hospital mortality was analyzed according to valve expansion mechanism, use of balloons for pre- and postdilation, and specific cause of death.Mean patient age was 83 ± 8 years. Implanted valves were self expanding (n = 2241; 55%), mechanically expanding (n = 1092; 27%), or balloon expandable (n = 727; 18%). In-hospital death occurred in 66 cases (1.6%). Thirty-six deaths (54.5%) were classified as implantation-related mortalities, with rates of 0.8%, 0.5%, and 1.7% (P=.04) among self-expanding, mechanically expanding, and balloon-expandable technologies, respectively. Patients who underwent balloon inflation at any stage of their procedure (n = 2556; 63%) had significantly higher implantation-related mortality than those who did not (1.3% vs 0.3%, respectively; P.01). Balloon-expandable valve procedures were associated with significantly higher all-cause mortality (2.6% vs 1.4%; P=.02) and implantation-related mortality (1.7% vs 0.7%; P=.02) than non-balloon-expandable valve procedures. Balloon-related complications accounted for 18 cases (26%) of total in-hospital mortality, including all 12 cases (17.4%) of annular rupture and 5 cases (7.2%) of coronary occlusion.Balloon use for predilation, valve implantation, or postdilation was associated with an increased mortality risk. Balloon-related complications were the largest contributor to in-hospital mortality, comprising all cases of annular rupture and the majority of coronary occlusion cases.

Objectives To assess whether single-photon emission computed tomography (SPECT/CT) quantification of bone scintigraphy would improve diagnostic accuracy and offer a means of quantifying amyloid burden. Background Transthyretin-related cardiac amyloidosis is common and can be diagnosed noninvasively using bone scintigraphy; interpretation, however, relies on planar images. SPECT/CT imaging offers 3-dimensional visualization. Methods This was a single-center, retrospective analysis of 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scans reported using the Perugini grading system (0 = negative; 1 to 3 = increasingly positive). Conventional planar quantification techniques (heart/contralateral lung, and heart/whole-body retention ratios) were performed. Heart, adjacent vertebra, paraspinal muscle and liver peak standardized uptake values (SUVpeak) were recorded from SPECT/CT acquisitions. An SUV retention index was also calculated: (cardiac SUVpeak/vertebral SUVpeak) × paraspinal muscle SUVpeak. In a subgroup of patients, SPECT/CT quantification was compared with myocardial extracellular volume quantification by CT imaging (ECVCT). Results A total of 100 DPD scans were analyzed (patient age 84 ± 9 years; 52% male): 40 were Perugini grade 0, 12 were grade 1, 41 were grade 2, and 7 were grade 3. Cardiac SUVpeak increased from grade 0 to grade 2; however, it plateaued between grades 2 and 3 (p, Central Illustration

Background: Rapid ventricular pacing is often required during transcatheter aortic valve replacement (TAVR) procedures. Pacing via the retrograde left ventricular guidewire (LV-GW) is an al...

ObjectiveThe coexistence of wild-type transthyretin cardiac amyloidosis (ATTR) is common in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). However, the impact of ATTR and AS on the resultant AS-ATTR is unclear and poses diagnostic and management challenges. We therefore used a multicohort approach to evaluate myocardial structure, function, stress and damage by assessing age-related, afterload-related and amyloid-related remodelling on the resultant AS-ATTR phenotype.MethodsWe compared four samples (n=583): 359 patients with AS, 107 with ATTR (97% Perugini grade 2), 36 with AS-ATTR (92% Perugini grade 2) and 81 age-matched and ethnicity-matched controls. 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy was used to diagnose amyloidosis (Perugini grade 1 was excluded). The primary end-point was NT-pro Brain Natriuretic Peptide (BNP) and secondary end-points related to myocardial structure, function and damage.ResultsCompared with older age controls, the three disease cohorts had greater cardiac remodelling, worse function and elevated NT-proBNP/high-sensitivity Troponin-T (hsTnT). NT-proBNP was higher in AS-ATTR (2844 (1745, 4635) ng/dL) compared with AS (1294 (1077, 1554)ng/dL; p=0.002) and not significantly different to ATTR (3272 (2552, 4197) ng/dL; p=0.63). Diastology, hsTnT and prevalence of carpal tunnel syndrome were statistically similar between AS-ATTR and ATTR and higher than AS. The left ventricular mass indexed in AS-ATTR was lower than ATTR (139 (112, 167) vs 180 (167, 194) g; p=0.013) and non-significantly different to AS (120 (109, 130) g; p=0.179).ConclusionsThe AS-ATTR phenotype likely reflects an early stage of amyloid infiltration, but the combined insult resembles ATTR. Even after treatment of AS, ATTR-specific therapy is therefore likely to be beneficial.

Percutaneous mechanical closure of the left atrial appendage (LAA) is a valuable stroke prevention strategy in patients with atrial fibrillation and contraindication to oral anticoagulation. LAA thrombus is a common finding in patients with atrial fibrillation and frequently fails to resolve despite therapeutic anticoagulation. In this scenario, LAA occlusion device implant is generally discouraged due to the high risk of thrombus dislodgement and embolization; however, alternative management options are limited. We report the first case of a successful LAA occlusion device (Watchman-FLX) implant in the presence of a proximal thrombus.

Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation onbehalf AS-Amyloidosis consortium Background The coexistence of severe aortic stenosis (lone AS) and transthyretin cardiac amyloidosis (lone amyloidosis) is common, but the resultant AS-amyloidosis phenotype is unclear. Purpose We characterised AS-amyloidosis, hypothesizing that the dual insult of AS-amyloidosis results is a severe phenotype. Methods We compared four cohorts with deep phenotyping: 81 older age controls, 359 lone AS, 36 AS-amyloidosis (Perugini grade 2 and 3) and 107 lone amyloidosis (Perugini grade 2 and 3). Results AS-amyloidosis was similar to lone AS with respect to left ventricular mass and LVEF (57 (45, 64)%). It was similar to lone amyloidosis with respect to lateral S" (0.04 (0.03, 0.06) m/s), NT-proBNP (4149 (1449, 6459) ng/L) and troponin T (56 (34, 100) ng/L). Whilst, prevalence of carpal tunnel syndrome (CTS) (17%) and diastolic function (E/A ratio 1.1 (0.8, 2.8)) were intermediate. Conclusion AS-amyloidosis is not a double insult from AS and amyloidosis, but a mixed phenotype with features similar to lone amyloidosis (cardiac biomarkers), lone AS (remodelling and LVEF) or intermediate (diastology and CTS). Characteristics across all 4 groups Variable Older age controls (n = 81) Lone AS (n = 359) AS-amyloidosis (n = 36) Lone amyloidosis (n = 107) P value Age (years) 82 (80, 84)*†‡ 85 (80, 88)§∞ 88 (85, 92)# 80 (75, 84)

ObjectiveThe study aims were (1) to identify the community prevalence of moderate or greater mitral or tricuspid regurgitation (MR/TR), (2) to compare subjects identified by population screening with those with known valvular heart disease (VHD), (3) to understand the mechanisms of MR/TR and (4) to assess the rate of valve intervention and long-term outcome.MethodsAdults aged ≥65 years registered at seven family medicine practices in Oxfordshire, UK were screened for inclusion (n=9504). Subjects with known VHD were identified from hospital records and those without VHD invited to undergo transthoracic echocardiography (TTE) within the Oxford Valvular Heart Disease Population Study (OxVALVE). The study population ultimately comprised 4755 subjects. The severity and aetiology of MR and TR were assessed by integrated comprehensive TTE assessment.ResultsThe prevalence of moderate or greater MR and TR was 3.5% (95% CI 3.1 to 3.8) and 2.6% (95% CI 2.3 to 2.9), respectively. Primary MR was the most common aetiology (124/203, 61.1%). Almost half of cases were newly diagnosed by screening: MR 98/203 (48.3%), TR 69/155 (44.5%). Subjects diagnosed by screening were less symptomatic, more likely to have primary MR and had a lower incidence of aortic valve disease. Surgical intervention was undertaken in six subjects (2.4%) over a median follow-up of 64 months. Five-year survival was 79.8% in subjects with isolated MR, 84.8% in those with isolated TR, and 59.4% in those with combined MR and TR (p=0.0005).ConclusionsModerate or greater MR/TR is common, age-dependent and is underdiagnosed. Current rates of valve intervention are extremely low.

The purpose of this study was to validate computed tomography measured ECV (ECVAS-amyloid affects 1 in 7 elderly patients referred for transcatheter aortic valve replacement (TAVR). Bone scintigraphy with exclusion of a plasma cell dyscrasia can diagnose transthyretin-related cardiac amyloid noninvasively, for which novel treatments are emerging. Amyloid interstitial expansion increases the myocardial extracellular volume (ECV).Patients with severe AS underwent bone scintigraphy (Perugini grade 0, negative; Perugini grades 1 to 3, increasingly positive) and routine TAVR evaluation CT imaging with ECVA total of 109 patients (43% male; mean age 86 ± 5 years) with severe AS and 20 control subjects were recruited. Sixteen (15%) had AS-amyloid on bone scintigraphy (grade 1, n = 5; grade 2, n = 11). ECVECV

Ease of use, rapid data provision, portability, and safety mean that echocardiography has become the principal investigation for almost all cardiac conditions. A modern transthoracic echocardiography examination combines real-time two-dimensional (2D) imaging of the myocardium and valves with information about velocity and direction of blood flow obtained by Doppler and colour-flow mapping. A complete examination can be performed in most patients in less than 30 min. There are three main echocardiographic techniques: two-dimensional (cross-sectional), M-mode, and Doppler. Despite the rapid and substantial advances in ultrasound technology and the widespread use of echocardiography, it is important to recognize and understand the limitations of the technique. These include reliance on acoustic windows, evaluation at rest, subjective assessments, evaluation of complex structures such as the right ventricle remains a major challenge, and the fact that the scope of an ‘echo’ is broad.

Background Over the last ten years, an increase in admission rates for acute heart failure (HF) has been noted in England and Wales, with one year mortality rates varying between 30% and 60%. Transthoracic echocardiography (TTE) is recommended within 48 hours of admission for suspected acute heart failure, so to guide treatment accordingly. Our centre has a specialist team who assesses patients with suspected HF on admission, and refers them for urgent in-patient TTE, using two priority in-patient echo slots per day. Patients are initially referred for HF assessment by general medics and geriatricians, across non-specialist medical wards. We audited the referrals and results of those who received TTE in this context. Methods and results We screened the medical notes of 252 patients admitted with suspected HF between January and December 2017, and reviewed the echocardiography results of those who received it during their admission. 50% of these patients were female and 59% were elderly (over 80 years old). 245 of these patients (97.2%) had in-patient echocardiography performed during their hospital stay. The mean wait for echocardiography was 0.58 days, with 92% of the scans being performed within 24 hours. The mean admission duration was 8.6 days (SD 10.9). 17.9% of patients were readmitted with suspected heart failure within six months, 69% of which were elderly. The majority of this cohort presented with heart failure with preserved ejection fraction (HFpEF), 50%), followed by heart failure with reduced ejection fraction (HFrEF, 29%) and heart failure with mid-range ejection fraction (HFmrEF, 16%). 41% of the patients who received an echocardiogram were in atrial fibrillation, 51% of which were diagnosed with HFpEF. All patients had their HF medical treatment optimised post-echocardiography and only 18.4% were readmitted within 6 months of the first admission. The majority of these patients was elderly (68.9%). 38.8% of patients who received echocardiography were referred for specialist clinic follow-up, with HFrEF patients more likely to be seen in this setting (42%). Six-month mortality occurred in 19.8% of patients; cause of death (COD) was undocumented in 25.8% of cases. In those where a post-mortem was conducted, the main COD was HF (16.7%), followed by sepsis (13.6%), cardiac (6.1%) and respiratory arrest (6.1%). 66% of the deceased patients were elderly and 48% presented with HFpEF. Conclusion Our cohort is an accurate representation of the current HF statistics seen nationwide. Appropriate treatment was offered to the large majority of patients who received in-patient echocardiography within the first 24 hours of their admission, with low six-month readmission rates. This approach also allowed for the inclusion of these patients on a systematic review plan, including specialist cardiology follow-up. Our numbers are consistent with the higher awareness about HFpEF currently seen in the medical community.

OBJECTIVES To identify clinical and procedural practice predictors of avoidable complications during transcatheter aortic valve replacement (TAVR). BACKGROUND TAVR is evolving as a viable strategy for treatment of aortic stenosis (AS). Vascular complications, major bleeding, or pericardial tamponade may be influenced by procedural practice. METHODS The Oxford TAVR (OxTAVI) prospective registry was retrospectively analyzed to identify predictors of avoidable procedural complications in a contemporary cohort of transfemoral TAVR between January 2015 and September 2018. The primary endpoint was defined as a hierarchic composite of in-hospital mortality, pericardial effusion/cardiac tamponade, major bleeding, and vascular access complications. Individual components of the primary endpoint have been analyzed separately. RESULTS Five-hundred-twenty-nine patients underwent transfemoral TAVR using contemporary techniques during the study period and were enrolled in the OxTAVI registry. Female sex and high frailty were associated with a higher risk of death, major bleeding, vascular complication or pericardial tamponade. The use of ultrasound (US) guidance for vascular access management was independently associated with a reduced composite primary endpoint (OR = 0.35, CI:0.14-0.86, p = .02) after adjustment for clinical confounders, largely driven by a threefold reduction in vascular access complication (OR = 0.29, CI:0.15-0.55, p

Learning objectives Transoesophageal echocardiography (TOE) is an invaluable technique in clinical practice providing immediate, accurate and cost-effective cardiac diagnostics at the bedside at low risk.1 Recent advances have been driven primarily by improvements in TOE transducer technology. An important innovation, the ‘game changer’, has been the introduction of three-dimensional (3D) TOE transducers that are increasingly used in clinical practice. The last decade has seen the rapid expansion of non-coronary structural interventions and has changed the TOE case load of the general cardiologist. Familiarity with percutaneous structural procedures and potential complications is now essential. In this article, we aim to provide a brief overview for the general cardiologist of the main uses of TOE in the clinical routine, emergency, intensive care and interventional setting and to outline future developments in the field. Frazin published the first case report using a primitive TOE probe (single M-mode crystal probe attached to a rigid endoscope) in 1976.2 Introduction of a flexible endoscope, reduction in transducer size, development of multiplane probes enabling two-dimensional (2D), colour, spectral and tissue Doppler acquisition led to the birth of the present day 5–7.5 MHz TOE probe with excellent spatial and temporal resolution. Current technology allows 3D imaging, both real-time 3D (RT3D) and multiple-beat 3D (MB3D) imaging. RT3D acquires data continuously; with MB3D, several data sets over many heartbeats are acquired offering higher temporal and spatial resolution than RT3D. Stitch artefact may arise to due movement and irregular heartbeat with MB3D.3 The European Association of Echocardiography (EAE) and the British Society of Echocardiography (BSE) set standards for the quality of echocardiography service provided by the …

Introduction 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy offers a sensitive, non-invasive test for cardiac transthyretin amyloid. The Perugini grading system relies on a visual score of the planar image – from grade 0 (negative) to 3 (strongly positive). SPECT allows the 3D visualisation of radioactivity within the body. SPECT/CT quantification may improve diagnostic accuracy and offer a means of measuring amyloid burden. Methods The software algorithm (Hermes Medical) converts recorded counts per voxel into activity per unit volume, enabling quantitative reconstructions and display of standardised uptake values (SUV). Volumes of interest were placed over the heart, adjacent vertebra, paraspinal muscle and liver and peak SUV (SUVpeak) recorded. P-values were calculated using a one-way ANOVA. Results We identified 32 patients (aged 82±9 years, 59% male), with a range of DPD results (10 grade 0, 6 grade 1, 12 grade 2, 4 grade 3). Cardiac SUVpeak increased from Perugini grade 0 to 2, but plateaued at 3 (1.39±0.47 vs 3.82±1.66 vs 12.89±4.39 vs 10.79±1.12; p Vertebral SUVpeak decreased from Perugini grade 0 to 3 (11.75±3.79 vs 9.60±2.28 vs 8.34±2.25 vs 5.85±1.53; p Conclusion SPECT/CT quantification in DPD scintigraphy has diagnostic and discriminatory power. Competition for tracer between skeletal muscle and the heart in grade 3 cases may confound quantification of cardiac amyloid burden.

Objectives The objective of this study was to determine the safety and efficacy of intracardiac echocardiography (ICE) to guide percutaneous paravalvular leak (PVL) closure. Background PVL following surgical valve replacement occurs in 2%–15% of patients. Percutaneous treatment is an accepted management strategy in patients deemed to be too high risk for redo surgery. This is most commonly performed with transesophageal (TOE) guidance requiring general anesthesia that both potentially further increase the risk of intervention. ICE can be used to guide intervention, facilitating procedures to be performed under local anesthesia without esophageal intubation potentially making procedures shorter and safer and further enabling the treatment of patients that may have been turned down for intervention. Methods All patients that underwent ICE-guided percutaneous transcatheter PVL closure between 2006 and 2016 at the John Radcliffe Hospital, Oxford, United Kingdom were retrospectively analyzed. Results Twenty-one procedures were performed in 18 patients during the study period. Fourteen patients (77.8%) underwent successful ICE guided PVL closure. There were no ICE-related complications. Eleven patients (78.6%) reported symptomatic improvement of at least one New York Heart Association (NYHA) Class and the remaining 3 patients had no change. No patient demonstrated objective evidence of persistent hemolysis following successful closure. There was one death within 30 days of the procedure and 1 year survival was 71.4%. Conclusions Percutaneous paravalvular leak closure guided by ICE without the requirement of general anesthesia is feasible, safe, and associated with acceptable procedural success rates.

Background / Purpose The Lotus valve (Boston Scientific, Natick, MA, USA) is a contemporary transcatheter aortic valve implantation (TAVI) device that is fully repositionable and retrievable to aid implantation and optimise procedural results. The ability to implant the device without routine pre-dilatation is another possible advantage reducing associated risks and procedure times. The aim of this study is to report procedural and 30-day outcomes following TAVI in a consecutive patient group presenting with severe symptomatic aortic stenosis with the Lotus valve system without routine pre-dilatation. Methods / Materials 146 consecutive patients that underwent TAVI at the John Radcliffe Hospital, Oxford between January 2015 – December 2016 were retrospectively analysed. Results The mean age was 81.1 ± 7.4 years and the mean logistic EuroSCORE was 14.6 ± 10. 134 (91.8%) of patients were treated under conscious sedation. 144 (98.6%) of procedures were successful. Two patients (1.4%) died during the follow-up period. None or mild residual aortic regurgitation was achieved in 98.6% of patients. The mean and peak transvalvular gradients were 8.6 ± 3.6mmHg and 16.6 ± 6.6mmHg respectively. Eight patients (5.5%) suffered a stroke. Over time, there was a reduction in major vascular complications (14.3% vs. 2.2%, p = 0.03) and a trend toward shorter procedure times (97.6 ± 44.3 vs. 86.8 ± 31.4 minutes, p = 0.14) and the administration of less contrast (104.4 ± 45.2 vs. 91.7 ± 37.6 millilitres, p = 0.16). The overall new pacemaker implantation rate was 36.3%. Conclusions The use of the Lotus valve as a ‘workhorse’ device without routine pre-dilatation is safe and efficacious and is associated with a very low incidence of residual aortic regurgitation and acceptable transvalvular haemodynamics.

In contrast to invasive techniques, the goal of non-invasive cardiac imaging is to identify or exclude heart disease in response to a patient's clinical history of cardiac localizing symptoms. Imaging also aims to establish the risk of an individual developing future heart disease with a view to preventing major cardiovascular events such as myocardial infarction. As well as a role in risk stratification, non-invasive cardiac imaging also helps with decision making for future medical and procedural interventions. This review outlines the non-invasive imaging modalities available to physicians to identify and risk stratify cardiovascular disease. It discusses the strengths of each imaging technique, in which circumstances it is most useful and its diagnostic accuracy.

Despite significant advancements in the field of cardiovascular imaging, transoesophageal echocardiography remains the key imaging modality in the management of valvular pathologies. This paper provides echocardiographers with an overview of the modern role of TOE in the diagnosis and management of valvular disease. We describe how the introduction of 3D techniques has changed the detection and grading of valvular pathologies and concentrate on its role as a monitoring tool in interventional cardiology. In addition, we focus on the echocardiographic and Doppler techniques used in the assessment of prosthetic valves and provide guidance for the evaluation of prosthetic valves. Finally, we summarise quantitative methods used for the assessment of valvular stenosis and regurgitation and highlight the key areas where echocardiography remains superior over other novel imaging modalities.

Objectives: We sought to characterize UK-wide balloon aortic valvuloplasty (BAV) experience in the TAVI era. Background: BAV for acquired calcific aortic stenosis is in a phase of renaissance, largely due to the development of transcatheter aortic valve implantation (TAVI). Methods: Data from 423 patients at 14 centers across the UK were analyzed. Results: Patients were aged 80.9 6 9.5 years; 52.5% were male. Mean logistic EuroScore was 27.3% 6 16.8%. Mean peak transaortic gradient fell from 62.0 6 26.3 to 28.3 6 16.2 mm Hg. Aortic valve area increased from 0.58 6 0.19 to 0.80 6 0.25 cm 2 echocardiographically. Procedural complication rate was 6.3%, comprising death (2.4%), blood transfusion � 2 U (1.2%), cardiac tamponade (1.0%), stroke (1.0%), vascular surgical repair (1.0%), coronary embolism (0.5%), and permanent pacemaker (0.2%). Mortality was 13.8% at 30 days and 36.3% at 12 months. Subsequently, 18.3% of patients underwent TAVI and 7.0% sAVR, with improved survival compared to those who had no further intervention (logrank < 0.0001). Multivariate Cox proportional hazard analysis demonstrated that survival was adversely effected by the presence of coronary artery disease (HR 1.53, 95%CI 1.08‐2.17, P 5 0.018), poor LV function (HR 1.54, 95%CI 1.09‐2.16, P 5 0.014), and either urgent (HR 1.70, 95%CI 1.18‐2.45; P 5 0.004) or emergent presentation (HR 3.72, 95%CI 2.27‐6.08; P < 0.0001). Conclusion: Balloon aortic valvuloplasty offers good immediate hemodynamic efficacy at an acceptable risk of major complications. Medium-term prognosis is poor in the absence of definitive therapy. V C 2013 Wiley Periodicals, Inc.

Melanoma has a great propensity for cardiac involvement but most cases are diagnosed post-mortem. We present the case of a 67-year-old man with history of malignant melanoma who presented with increasing dyspnea, fatigue and peripheral edema. A large myocardial metastasis was identified on transthoracic echocardiography, and further characterized with cardiovascular magnetic resonance prior to surgery. © 2009 Elsevier Ireland Ltd. All rights reserved.

Background: Radiotherapy (RT) forms a vital component of treatment for breast cancer, contributing to the increasing number of survivors worldwide. It is known from historical cohorts that breast RT increased the risk of developing heart disease 10 years or more following treatment. It is less certain whether the lower cardiac radiation doses received during modern RT still increase cardiac risk. Cardiovascular Magnetic Resonance (CMR) imaging has the potential to provide early surrogate markers of radiation-induced heart disease that may help predict which women will be at increased risk in the future. Methods: This is a prospective longitudinal imaging study to evaluate CMR findings in a cohort of women receiving adjuvant RT for early breast cancer at the Oxford Cancer Centre. The patients undergo CMR imaging (with gadolinium enhancement and adenosine stress), Doppler echocardiography, blood testing (including BNP and troponin), ECG and clinical examination prior to RT, within 72 hours of completing RT, and at 3 months, 6 months and 5 years following RT. The results of these investigations will be related to cardiac radiation exposure estimated using 3D-dosimetric data obtained by analysis of CT-based RT planning. Recruitment and Provisional Results: As of May 2011, 30 women have been recruited. The women had a mean age of 57.1 years (range = 42.0 to 63.9). All women had left-sided cancer and none received adjuvant cytotoxic chemotherapy. The mean whole heart dose was 1.47 Gray (range = 0.65 to 4.20), the mean left ventricle dose was 2.03 (range = 0.88 to 6.99) and the mean left coronary artery dose was 7.55 Gray (range = 1.50 to 24.59). Preliminary analysis of the first 10 participants showed that all had a normal left ventricular ejection fraction at baseline (mean 76%, range 60–82%) and immediately following RT (mean reduction 3%, p=0.18). None had myocardial oedema as detected by T2-STIR imaging or fibrosis and scarring as demonstrated by late gadolinium enhancement (LGE). Conclusion and Future Plans: Preliminary results suggest that the relatively low heart doses received by the women undergoing modern CT-planned left breast RT at the Oxford Cancer Centre do not result in any cardiovascular abnormality detectable by CMR imaging. Further and updated results will be available for the San Antonio Breast Cancer Symposium. Recruitment will continue until at least 20 women have completed baseline scans and follow-up scans up to 6 months. At this stage a full analysis will be performed including a wider range of CMR endpoints including: - Overall LV systolic function (EF and volumes) - Regional wall motion analysis - T2-weighted imaging (oedema) - T1 and T2 mapping (quantitative T1 and T2 relaxation times) - Tagged myocardial strain analysis - Stress perfusion defects (endothelial/microcapillary damage) - Late gadolinium (LGE) imaging (fibrosis/scarring) Depending on the results of this analysis, recruitment may be expanded to include women with either lower cardiac risk (e.g. with right-sided breast cancer) or higher cardiac risk (e.g. receiving anthracycline chemotherapy). Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-13-06.

Aims To investigate the relationship between Eustachian valve (EV) length and degree of atrial septal movement in patients with patent foramen ovale (PFO) and presumed paradoxical cerebral embolism. PFO is a well-established risk factor for cryptogenic stroke. However, due to the high prevalence of PFO, many of these are bystanders rather than true pathological entities. Other studies have sought to define which patients with PFO are particularly at risk of cryptogenic stroke by measuring various parameters of right atrial anatomy. We investigated the relationship between EV length and atrial septal movement. Methods and results Measurements of EV length and atrial septal movement were made prospectively from 72 consecutive patients referred to our centre for PFO closure following presumed cryptogenic stroke, by intracardiac phased array echocardiography. The most significant finding from this study was that patients with fewer than 10 mm atrial septal movement had significantly longer EVs than those in whom there was >10 mm septal movement ( P = 0.003). The mean EV length with >10 mm septal movement is 6.35 mm, and 13.33 mm with fewer than 10 mm movement. The prevalence of septal movement beyond 10 mm was significantly less in our series than in previously published papers. Conclusion We propose that while a large degree of atrial septal movement significantly increases propensity to cerebral embolism in patients with PFO, its absence does not negate this risk. We have shown that long EV may function independently from atrial septal movement to potentiate paradoxical embolism.

Alcohol septal ablation (ASA) in hypertrophic obstructive cardiomyopathy reduces left ventricular outflow tract gradients. A third of patients do not respond; inaccurate localisation of the iatrogenic infarct can be responsible. Transthoracic echocardiography (TTE) using myocardial contrast can be difficult in the laboratory environment. Intra-cardiac echocardiography (ICE) provides high-quality images. We aimed to assess ICE against TTE in ASA. The ability of ICE and TTE to assess three key domains (mitral valve (MV) anatomy and systolic anterior motion, visualisation of target septum, adjacent structures) was evaluated in 20 consecutive patients undergoing ASA. Two independent experts scored paired TTE and ICE images off line for each domain in both groups. The ability to see myocardial contrast following septal arterial injection was also assessed by the cardiologist performing ASA. In patients undergoing ASA, ICE was superior in viewing MV anatomy (P=0.02). TTE was superior in assessing adjacent structures (P=0.002). There was no difference in assessing target septum. Myocardial contrast: ICE did not clearly identify the area of contrast in 17/19 patients due to dense acoustic shadowing (8/19) and inadequate opacification of the myocardium (6/19). ICE only clearly localised contrast in 2/19 cases. ICE does not visualise myocardial contrast well and therefore cannot be used to guide ASA. TTE was substantially better at viewing myocardial contrast. There was no significant difference between ICE and TTE in the overall ability to comment on cardiac anatomy relevant to ASA.

The authors describe treating a 6-cm right coronary artery bypass graft aneurysm that was causing recurrent angina. With use of the combined skills of interventional radiologists and cardiologists, the aneurysm was successfully occluded by using a stent-graft typically used to treat aneurysms in the peripheral circulation. One month after the procedure, the aneurysm had sealed at follow-up computed tomographic angiography.

A 69-year-old man presented with severe aortic regurgitation and ongoing hemolysis 14 years after the insertion of a 23-mm ATS Medical mechanical aortic valve. His symptoms were progressive, and on admission he was not able to walk farther than 100 meters on a flat surface and was generally fatigued

Introduction Successful alcohol septal ablation (ASA) in hypertrophic obstructive cardiomyopathy (HOCM) reduces LVOT gradients. A third of patients do not respond; inaccurate location of the iatrogenic infarct can be responsible. Myocardial contrast studies following injection into a septal coronary artery guide ASA. Transthoracic echocardiography (TTE) is the current gold standard. TTE can be difficult in the lab environment. The ideal echocardiographic modality will see crucial anatomy relevant to ASA and delineate myocardial contrast well. We assessed ICE against TTE in ASA. Methods The ability of ICE and TTE to see relevant anatomy was assessed in two phases. Phase one recruited 25 successive patients undergoing PFO closure under ICE guidance. This was predominantly a feasibility study. Phase 2 recruited 20 successive HOCM patients undergoing ASA. The ability to assess myocardial contrast was assessed in phase 2. A scoring system to assess three key domains was used (see Table 1). Two independent experts scored paired, off-line TTE and ICE images, a score was allocated to each modality in each domain. Results Phase 1: ICE catheter manipulation to visualise the relevant anatomy was quick and safe. TTE was superior in viewing MV anatomy and SAM (score 1.4 vs. 0.4, p Phase 2: ICE was superior in viewing MV anatomy (1.88 vs 1.6; p = 0.02), superior catheter manipulation caused better scores in ICE. There was no difference in assessing target septum. TTE was superior in assessing adjacent structures (1.03 vs 0.63, p = 0.002). Myocardial Contrast injection was performed in 19/20 patients: ICE was able to visualise contrast satisfactorily in just 2/19. This was due to dense acoustic shadowing with inability to comment on surrounding myocardium (8/19), and inadequate opacification of the myocardium (6/19). Contrast localised to myocardium outside the field in 3/19 (RV cavity). This was not seen on ICE due to a narrower field of echo. TTE saw myocardial contrast location in all. Conclusions ICE cannot be used to guide ASA due to the inability to describe myocardial contrast distribution. ICE was better at seeing the motion of the MV, but TTE saw adjacent structures better. The ability of ICE to see SAM of the MV may lend itself to non-surgical septal reduction therapies that are not reliant on myocardial contrast.

Thirteen years following the first human transcatheter aortic valve implantation (TAVI),1 the procedure is now established as a proven therapy for patients with symptomatic severe aortic stenosis (AS) who are at high or excessive risk for conventional surgical aortic valve replacement (AVR). Remarkable efficacy demonstrated in pivotal randomised controlled studies2 ,3 has been confirmed within large-scale, real-world international multicentre registries, and TAVI is now approved by regulatory bodies and embedded within international guidelines as a Class I recommendation. More than 100 000 TAVI procedures have now been performed worldwide. A predictable consequence of this widely publicised success story is the move to consider the wider use of TAVI in patients conventionally treated by means of open surgery, either as a result of physician preference or patient choice. While further randomised controlled trials to evaluate TAVI in intermediate or low-risk cohorts are planned or underway, valid long-term outcome data concerning the durability of percutaneously implanted valves will ultimately determine whether TAVI becomes the default treatment of choice for the majority of patients with AS. Patients with AS are frequently elderly and frail with attendant comorbidity, and selection of the optimal treatment option is frequently challenging as a consequence. The development of a robust ‘Heart Team’ to evaluate, discuss and treat these patients is a fundamental principle of a successful TAVI service, and this multidisciplinary approach is strongly endorsed by the European Society of Cardiology and American College of Cardiology/American Heart Association Guidelines on Valvular Heart Disease. Guiding a patient and their family in the choice between AVR and TAVI (or no intervention in some patients where high-risk intervention …

Objectives Infective endocarditis (IE) is a severe complication in Staphylococcus aureus bacteraemia (SAB) and recent guidelines from the BSAC recommend all patients undergo echocardiography. We assessed the use of echocardiography at a major tertiary referral centre and sought to identify those patients most likely to have positive findings. Methods We retrospectively evaluated all cases of SAB at Oxford University Hospitals NHS Trust between September 2006 and August 2011. Results Three-hundred-and-six out of 668 patients with SAB underwent cardiac imaging on average 9.8 ± 1.3 days from the first culture. Thirty-one patients (10.1%) had echocardiographic evidence of IE. Risk factors for observing evidence of IE on scanning included the presence of prosthetic heart valves (32% versus 4%, P Conclusions We propose that the use of scarce echocardiography resources could be prioritized. Patients with prosthetic heart valves or a CRM device should receive early cardiological input and transoesophageal echocardiography. In patients with a clearly defined line-related bacteraemia who do not have a prosthetic valve or CRM device or clinical features of IE, response to treatment could be closely monitored and imaging deferred. Patients without a line-related infection or prosthetic valve/device could receive a transthoracic echocardiogram as a screening tool.

The first surgical heart valve replacement was undertaken over half a century ago since when there has been a continuing quest to develop a prosthesis with the perfect combination of durability, haematological compatibility and haemodynamic performance. Early caged ball mechanical valves were robust but associated with red cell trauma and rapidly followed by introduction of mono-leaflet and bi-leaflet designs which remain in use today. Introduced later in the 1960s, bioprosthetic valves consisting of pericardial or valve tissue mounted on a frame and sewing ring were initially conceived for use in elderly patients unlikely to outlive the valve, or in other patients at risk of bleeding complications associated with anticoagulation. Until recently, mechanical valves have remained the logical choice in patients

In the setting of mitral valve stenosis and atrial fibrillation, left atrial ball thrombus is a rare but recognized cause of stroke and can occur even in the presence of therapeutic anticoagulation. This case report highlights the need for echocardiography to rule out treatable cardioembolic substrates for stroke. We report a case of cardioembolic stroke as a result of free floating left atrial ball thrombus presenting as a complication of rheumatic mitral valve disease. This case highlights that, in all patients with a history of structural heart disease, atrial fibrillation, or rheumatic fever, prompt cardiac ultrasound to exclude free floating atrial thrombus is essential.

A 31-year-old man suffered 6 months of rigors with only partial benefit from treatment of presumed chest infections. He previously had an internal cardioverter-defibrillator (ICD) fitted 7 years earlier for ventricular tachycardia ( Figure A and B ) due to arrhythmogenic right ventricular cardiomyopathy (ARVC). His general practitioner consulted a rheumatologist who suggested a whole body 18 F fluorodeoxyglucose positron emission tomography (FDG-PET) scan to …

Left atrial appendage (LAA) occlusion is increasingly accepted to reduce the risk of stroke in patients with atrial arrhythmia who are unsuitable for routine anticoagulation. It is generally performed under general anesthesia, guided by transoesophageal echocardiography with accurate imaging being essential for correct deployment of the device. We present a case where LAA occlusion was done under local anesthesia in a high-anesthetic risk patient, using novel placement of an intracardiac echo probe via a Mullins sheath in the right ventricular outflow tract and pulmonary artery. This allowed accurate visualization of device deployment in the LAA. This technique may increase the spectrum of patients who may benefit from the procedure and decrease procedure time, fluoroscopy, and procedure-related morbidity.

For video material relating to echocardiography, please go to Echocardiography Videos. Ease of use, rapid data provision, portability, and safety mean that echocardiography has become the principal investigation for almost all cardiac conditions. A modern transthoracic echocardiography examination combines real-time two-dimensional (2D) imaging of the myocardium and valves with information about velocity and direction of blood flow obtained by Doppler and colour-flow mapping. A complete examination can be performed in most patients in less than 30 min....

A 45-year-old male presented with 2 days of nausea, sweating, and abdominal pain. Examination revealed tachycardia, hypertension, diaphoresis, widespread crepitations, and diffuse abdominal tenderness. Profound hypotension developed, despite intravenous fluids, and was treated with noradrenaline and dobutamine; hypoxia required endotracheal intubation, followed by chest radiograph, which demonstrated extensive pulmonary edema. Echocardiography revealed severe global left ventricular systolic impairment, with an estimated ejection fraction of only 10% (Data Supplement Movies I and II). The patient was transferred to our hospital for the consideration of intraaortic balloon counterpulsation or left ventricular assist device support or both. An intraaortic balloon pump was inserted, and inotropic support was changed to adrenaline with modest improvement. Examination revealed a large mobile nonpulsatile mass in the left paraumbilical region, confirmed as a paraganglionoma on computed tomography (Figure 1). α-Blockade with …

A 71-year-old man underwent implantation of a single-chamber system in 1988 for sinoatrial disease, which was then upgraded to dual-chamber 7 years later following recurrent syncope. He presented with pacemaker erosion but without clinical or laboratory evidence of infective endocarditis. The pacemaker system was uneventfully extracted 5 days later via a transfemoral approach using a needle-eye snare. A post-procedure trans-thoracic echocardiogram was performed, which demonstrated an echogenic structure in the right atrium-this was initially felt to be a retained fragment of pacing lead. A short-axis view of the tricuspid valve with a bright linear echo crossing is shown in Figure 1. However, a post-procedural chest X-ray confirmed the absence of any retained intra-cardiac lead. The reverberant cast-like structure noted is a heavily calcified fibrous sheath as the pacing leads were confirmed to be intact at the time of removal.

Since their introduction several years ago, the 3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitors-the statins-have been widely used for hyperlipidemia and for the primary/secondary prevention of cardiovascular diseases. They have been shown to be safe as well as efficacious in a number of different clinical trials; however, studies have suggested that they can interact with other co-administered therapies. More recently, the thienopyridines have been successfully integrated with the conventional medical treatment of coronary disease as they showed effectiveness in reducing platelet activity both in stable and unstable settings. They also improve the outcome of patients treated with percutaneous coronary intervention. The potential interaction of statins and thienopyridines is a matter of concern. Despite some preclinical data suggesting an interaction between statins metabolized by the liver cytochrome P3A4-such as atorvastatin, lovastatin and simvastatin-and clopidogrel, there is no compelling clinical evidence to stop their co-administration.