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ObjectiveEchocardiography-guided Percutaneous IntraMyocardial Septal Radiofrequency Ablation (PIMSRA, Liwen procedure) is a novel treatment option for hypertrophic obstructive cardiomyopathy (HOCM). The impact of PIMSRA on myocardial mechanics is unknown.MethodsBetween October 2016 and June 2019, PIMSRA and 3-dimentional speckle tracking echocardiography were performed in 82 patients. Echocardiographic imaging, qualitative and quantitative clinical assessment were completed at baseline, immediately postprocedure and 1-year follow-up.ResultsThere was a significant reduction in the peak left ventricular outflow tract (LVOT) gradients immediately following PIMSRA and at 1-year follow-up (resting gradients: from 83.50 (61.25) to 23.00 (41.75) mm Hg, pConclusionsPIMSRA is an effective treatment for symptomatic HOCM that resulted in a sustained improvement in exercise capacity, a persistent decrease in LVOT gradient, and a measurable increase in myocardial contractile function.Trial registration numberNCT04777188.

To examine the outcomes of percutaneous closure of large atrial septal defects (ASDs) (≥25 mm).Data on long-term results after closure of large ASDs are limited.We reviewed the records of 275 consecutive patients who underwent transcatheter closure of large (≥25 mm) ASDs from January 1999 until December 2016 in our center. The most common indication for closure was a large left-to-right shunt. Follow-up (FU) was performed at regular intervals thereafter. Results after closure of ASDs with diameters of 25-30 mm,30-35 mm and35 mm were compared.Percutaneous closure was technically successful in 99.6%. Mean FU time was 4.8 years (0-15.5 years). Peri-operative (30-day) adverse events occurred in 20.4% and included death in 0.7% (one unrelated to the procedure and one of unknown cause), device erosion in 0.7%, device embolization in 2.9%, pericardial effusion in 5.5%, air embolism in 0.4%, new onset atrial fibrillation in 10.5%, transient supraventricular tachycardia in 0.4% and fever in 0.7%. Late (30 days after the procedure) atrial fibrillation occurred in 5.8%. There was one device erosion15 years after the implantation treated successfully surgically. Complete defect closure was achieved in 95.6%.Device closure of large ASDs is feasible, safe and effective with high technical success and low risk of serious periprocedural complications. Nevertheless, in very large defects (40 mm), both options, surgery and percutaneous closure should be considered. Device or procedural long-term adverse events are rare.

Background A patent foramen ovale (PFO) has been associated with embolic strokes and transient ischemic attacks (TIAs). Catheter closure of PFO is effective in preventing recurrent events. Residual shunts and procedure or device related complications can occur, including atrial fibrillation and thrombus formation . This study examines the initial experience with a new PFO closure device, the IrisFIT PFO-Occluder (Lifetech Scientific, Shenzhen, China). Methods 95 patients with indications for PFO closure underwent percutaneous closure with the IrisFIT PFO-Occluder. The primary endpoint was the rate of accurate device placement with no/small residual shunt at 3 or 6 months follow-up. All patients underwent transoesophageal echocardiography (TEE) after 1 to 6 months. In case of a residual shunt, an additional TEE was performed after 12 months. Clinical follow-up was performed up to a mean of 33.1 ± 3.6 months. Results The device was successfully implanted in 95 (100%) patients with no relevant procedural complications. At final TEE follow-up (7.6 ± 3.9 months) the effective closure rate was 96.8% with 1 moderate and 2 large residual shunts. There were 8 cases of new onset atrial fibrillation and 2 TIAs. There were no cases of device embolization or erosion. Conclusion The IrisFIT occluder is a new PFO closure device with several advantages compared to other devices. In this small study cohort , technical success rate, closure rate and adverse event rate were comparable to other devices. The rate of new onset atrial fibrillation was higher in comparison to other studies and warrants further investigation.

Thrombus formation due to atrial fibrillation is the most common cause of embolic stroke. Anticoagulation offers an effective prophylaxis. However, anticoagulation in turn has an inherent increased risk of bleeding. Patients with non-valvular atrial fibrillation who have contraindications for anticoagulation may profit from a closure of the left atrial appendage. The most commonly and best studied devices for this are the WATCHMAN™ and the AMPLATZER Amulet™ Occluders.In this How-To article, the aim is to offer a general overview of the indications, contraindications and complications as well as the implantation and postoperative management of patients receiving LAA closure by example of the WATCHMAN FLX™ Occluder.

Stroke remains an important risk during transcatheter aortic valve implantation (TAVI). Though the use of the double-filter Sentinel cerebral protection system (Boston Scientific, Marlborough, MA, USA) may lower the stroke risk, the deployment of this device requires manipulation within the aortic arch and cranial arch vessels potentially causing dislodgment of atherosclerotic debris in the process thereby possibly offsetting its benefit with regards to reducing cerebral embolization. Apart from patient selection, minimizing maneuvering during deployment may improve the safety of device deployment. In this context, we illustrate a case using three-dimensional computed tomography (CT) - overlay to facilitate Sentinel cerebral protection system deployment during TAVI. Emphasis in this case rests on demonstration of how aforementioned periprocedural imaging may facilitate negotiation of anatomical variants and avoid inadvertent cannulation of an anomalous left vertebral artery originating from the aortic arch. Imaging guidance with this concept may minimize device manipulation and reduce the risk of cerebral embolization. Further systematic evaluation is needed to demonstrate whether this approach improves clinical outcomes.

Transcatheter mitral valve-in-ring implantation (TMViR) poses unique challenges when compared to valve-in-valve implantation due to the large variation in the different annuloplasty rings used. Annuloplasty rings are often classified according to whether they are complete or incomplete, rigid, semi-rigid, or flexible, and whether their three-dimensional geometry is saddle-shaped or flat. A limited number of annuloplasty rings are available which are adjustable allowing the surgeon to increase or decrease the size of the ring once it has been sutured in place. To our knowledge there has been no description of TMViR in such adjustable complete rings and recommendations on THV sizing and implantation are not available on the Valve-in-Valve application. Here we report a case of TMViR in an adjustable annuloplasty ring (Attune ring, Abbott, Chicago, IL, USA) and review the literature on TMViR.

This is a case of an anomalous left circumflex coronary artery (LCX) originating from the right coronary cusp with a retroaortic course in a patient with severe aortic valve stenosis requiring transcatheter aortic valve implantation (TAVI). In the context of TAVI, an anomalous LCX has been described only in a few case reports. In some, the LCX remains unaffected. However, occlusion after TAVI valve deployment has been described. We report pre-procedural imaging and procedural precautions prior to valve deployment in our case in which the LCX remained unaffected by the TAVR valve. More case reports or series are needed to help assess which characteristics are associated with an increased risk of anomalous LCX obstruction.

Background Endovascular treatment for acute stroke with large vessel occlusion became the mainstay therapy but remains limited due to lack of trainees and specialized centers. To offer this therapeutical option to a vast population, interventional cardiologists joined interdisciplinary stroke teams. Because of limited experience, it remains unclear if the timing of the procedure (i.e., regular hours vs. on-call time) may influence quality, time-effectiveness and outcomes. Purpose To investigate if the timing of the procedure (i.e., regular hours vs. on-call time) significantly influences procedural parameters and outcomes of patients undergoing acute endovascular stroke treatment. Methods Consecutive patients undergoing acute endovascular stroke treatment from 07/2012 – 10/2020, treated by cardiologists, were reviewed. Baseline characteristics, procedural aspects and clinical outcomes were retrospectively collected. Cases were divided into two groups, depending on the timing of the procedure: on-call time (OC, i.e., weekend days, public holidays and documented “call in” of the on-call service) vs. regular hours (RH, i.e., all other procedures) and outcomes subsequently compared. Results One-hundred-thirteen consecutive patients underwent endovascular treatment for acute stroke; of those 77 (68.1%) during regular hours and 36 (31.9%) during on-call time. Patients were in their early 70ies and risk factors such as arterial hypertension, diabetes mellitus, dyslipidemia and atrial fibrillation were evenly distributed. Modified Ranking Scale (mRS) at presentation was 5 in both groups and decreased to 3 at discharge. The anterior circulation was most often affected (RH: 90.9% vs. OC: 94.4%, p=0.518) and a stent retriever only strategy commonly chosen (RH: 42.8% vs. OC: 30.5%, p=0.211), followed by a combined approach of stent retriever use and aspiration (RH: 25.9% vs. OC: 27.7%, p=0.752). Door-to-needle time (RH: 0:55h IQR [0:45–1:22] vs. OC: 1:05h IQR [0:54–1:30], p=0.237) and procedure duration (RH: 0:48h IQR [0:30–1:25] vs. OC: 0:58h IQR [0:35–1:46], p=0.214) were comparable. Contrast agent use and radiation time (RH: 17.6 min IQR [11.7–29.3] vs. OC: 17.6 min IQR [12.1–33.6]) did not differ between groups, however patients in the OC group experienced a higher dose area product (RH: 4827mGy cm2 IQR [1567–14092] vs. 12727mGy cm2 [6732–18889], p Conclusions Endovascular intervention for acute stroke treatment during on-call time is as effective and safe as if performed during regular hours but associated with a higher dose area product. Funding Acknowledgement Type of funding sources: None.

Background Endovascular treatment for acute stroke because of large vessel occlusion became the standard of care in certain clinical settings. Due to lack of trainees and specialized centers, interventional cardiologists joined multidisciplinary stroke teams, and contribute their extensive knowledge on acute cardiovascular interventions and catheter skills to optimize patient management and outcomes. Purpose To investigate if a learning curve exists for interventional cardiologists performing acute stroke interventions. Methods Consecutive patients undergoing acute endovascular stroke treatment from 07/2012 – 10/2020 at our center were reviewed. The interventional approach, lesion preparation and material selection were at the discretion of the performing cardiologist. Baseline characteristics, procedural information and in-hospital outcomes were retrospectively collected. Cases were chronologically sorted, divided into quartiles and outcomes were compared. Results One-hundred-thirteen patients underwent endovascular procedures for acute stroke treatment. Patients were 72.9 SD 13.3 years old, and 51.5% were female. NIHSS at baseline was 15 [12–18]. In 92% the blood flow of the anterior circulation was affected. The door to needle (DTN) time decreased over time (Q1 1:19h [range0:54–1:58] vs. Q2 0:49h [range 0:34–1:32] vs. Q3 1:13h [range 0:56–1:31] vs. Q4 0:54 [range 0:37–1:08], p=0.003), as well as the procedure duration (time of vascular access to (full) reperfusion Q1 1:24h [range 0:44–2:23] vs. Q2 0:52h [range 0:32–1:16] vs. Q3 0:49h [range 0:27–1:15] vs. 0:44h [range 0:28–1:17], p=0.014) and the use of contrast medium (Q1 103.3mL [range 75.1–147.7] vs. Q2 123.5mL [range 60.5–149.9] vs. Q3 99.8mL [range 73–132] vs. Q4 74.8 mL [range 52.4–94.6], p=0.014). A stent retriever only strategy was preferred in the early stages (Q1 42.8% vs. Q2 53.5% vs. Q3 32.1% vs. Q4 17.2%. p=0.010), whereas a stent retriever plus aspiration strategy (Q1 17.8% vs. Q2 14.2% vs. Q3 28.5% vs. Q4 50%, p=0.122) became more popular later on. The combined quality endpoint comprising of TICI IIb/III flow after the procedure, no embolization to new territories and no symptomatic intracranial bleeding was reached 84%, with no difference between groups. Vascular access site complications were low (overall 3.5%) and NIHSS prior to discharge was comparable (Q1 3 [range 1.75–7.25] vs. Q2 4.5 [range 1.75–8.25] vs. Q3 5 [range 2–8] vs. Q4 4 [range 2–7], p=0.725). In-hospital death occurred in 21 (18.5%) patients. Conclusions A learning curve for interventional cardiologist performing acute stroke interventions could be observed in terms of optimized management strategies such as a reduced door to needle time and procedural aspects, like decreased procedure duration and contrast medium use over time. However, the quality of care was unaffected and continuously high. Funding Acknowledgement Type of funding sources: None.

OBJECTIVES: The current analysis utilized core laboratory angiographic data from a prospective, single-arm, open-label, multi-center feasibility study to ascertain whether the location of alcohol infusion within main renal arteries during renal denervation (RDN) had an impact on the BP-lowering effect at 6 months. BACKGROUND: The influence of the location of alcohol infusion during RDN, within the main renal artery (proximal, middle, or distal), on the magnitude of the blood pressure (BP) lowering is unstudied. METHODS: The Peregrine Catheter was used to perform alcohol-mediated RDN with an infusion of 0.6 mL of alcohol per artery as the neurolytic agent in 90 main arteries and four accessory arteries of 45 patients with hypertension. RESULTS: No relationship between the site of alcohol infusion and change from baseline in both office systolic and 24-hour systolic ambulatory BP (ABP) at 6 months was observed. When analyzed at the artery level, the least squares (LS) mean changes ± SEM from baseline to 6 months post-procedure in 24-hour systolic ABP when analyzed by renal arterial location were -11.9 ± 2.4 mmHg (distal), -10 ± 1.6 mmHg (middle), and -10.6 ± 1.3 mmHg (proximal) (all p < 0.0001 for change from baseline within groups). The results were similar for office systolic BP. There was no difference between treated locations (proximal is reference). CONCLUSION: In this post-hoc analysis, the location of alcohol infusion within the main renal artery using the Peregrine system, with alcohol as the neurolytic agent for chemical RDN, did not affect the magnitude of BP changes at 6 months.

Background: The current American Association of Neurology guidelines do not recommend patent foramen ovale (PFO) closure for prevention of cryptogenic strokes, however recent findings from randomiz...

Thrombus formation due to atrial fibrillation is the most common cause of embolic stroke. Anticoagulation offers an effective prophylaxis. However, anticoagulation in turn has an inherent increased risk of bleeding. Patients with non-valvular atrial fibrillation who have contraindications for anticoagulation may profit from a closure of the left atrial appendage. The most commonly and best studied devices for this are the WATCHMAN™ and the AMPLATZER Amulet™ Occluders.In this How-To article, the aim is to offer a general overview of the indications, contraindications and complications as well as the implantation and postoperative management of patients receiving LAA closure by example of the WATCHMAN FLX™ Occluder.

Acute ischemic stroke is a feared complication during cardiovascular procedures associated with high morbidity and mortality if not immediately recognized and treated. We conducted a review of cases at our center where patients experienced an acute, procedure-related ischemic stroke and underwent immediate endovascular stroke treatment by the interventional cardiologists trained in acute endovascular stroke intervention. Baseline demographics, procedural and follow-up data were collected. Three patients were identified in whom the percutaneous procedure (peripheral arterial intervention, transapical NeoChord [NeoChord Inc, Minnesota, USA] implantation and transcatheter aortic valve implantation, respectively) was complicated by an acute embolic ischemic stroke. In all cases, cerebral vessel re-canalization was technically successful with thrombolysis in cerebral infarction (TICI) IIB/III flow. Follow-up computed tomography scans showed no infarct demarcation, oedema or intracranial hemorrhage. One patient survived with no neurological symptoms at 6-month follow-up whereas the two other patients died of unrelated intensive care complications and decompensated heart failure. We conclude that endovascular stroke treatment during cardiovascular interventions can be performed by interventional cardiologists with appropriate training. It offers the unique opportunity to treat cerebral embolization in a time-efficient manner, potentially improving morbidity and mortality of affected patients.

Introduction: Cardiac conduction abnormalities are among the most frequent complications of transcatheter aortic valve replacement (TAVR). A small case series has raised the possibility that junctional rhythm (JR) following TAVR may be associated with poor outcomes. However, the prevalence and implications of JR during TAVR have not been systematically studied. Methods: We retrospectively reviewed intra-procedural continuous 6-lead telemetry of 300 consecutive patients undergoing TAVR between April 2015 and April 2019 to identify JR that occurred after deploying the valve . Forty-two patients with pre-existing permanent pacemaker (PPM) were excluded. JR was defined as regular rhythm without P waves but with QRS morphology that was identical to baseline. Results: A total of 258 patients fulfilled the inclusion criteria (mean age of 77.5±8.5 years and 99% men). During TAVR, 79 (30.6%) patients developed new JR. The mean ventricular rate was 74.6±31.0 bpm. Patients who developed JR had similar baseline characteristics compared to those without JR (Table). After TAVR, 57 (22.1%) patients required PPM for complete atrioventricular block. There was a trend for a higher rate of PPM implantation in patients with rapid JR (39%) vs. slow JR (26%) vs. no JR (19.0%, p=0.10). In logistic regression analysis, patients who had a rapid JR (rate >100 bpm) were 2.71 times (95% CI 0.98-7.52, p=0.055) more likely to require PPM than those without JR. Conclusions: Junctional rhythm after deploying the valve is common in TAVR. There was a trend for higher PPM implantation risk among patients who developed rapid JR. Further investigation of these observations in larger cohorts is needed.

To summarize the outcomes of acute ischemic stroke (AIS) intervention by interventional cardiologists (IC) working on a stroke team.There is a geographic maldistribution of dedicated neuro-interventionalists (NI) to treat large vessel occlusion (LVO) AIS.Results of 166 consecutive patients who received endovascular therapy (EVT) for AIS due to LVO by IC at three centers between 2009 and 2019 are reported. A modified Rankin score (mRs) of ≤ 2 at 90 days after EVT was used as the primary measurement of a good neurological outcome. Univariate logistic regression was used to evaluate predictors of the mRS 2 and mortality. Those variables with significance of p .2 from the univariate analysis were included in a multivariate analysis.All-cause mortality at 30 days was 22%. A favorable clinical outcome, mRS ≤ 2 at 90 days, was 49%. After multivariate analysis and controlling for confounders, a higher baseline NIHSS was predictive of 30-day mortality (OR 1.20 [95% CI 1.09-1.32] p .001) and unfavorable clinical outcome (mRS 2) at 90 days (OR 1.16 [95% CI 1.07-1.25] p .001).Outcomes for carotid stent capable IC performing EVT for AIS are comparable to those achieved by NI physicians in major randomized clinical trials. Our data supports conducting a clinical trial of carotid stent capable IC working on multidisciplinary stroke teams to perform EVT for AIS due to LVO in communities and hospitals without timely access (60 min by ground transport) to dedicated NI.

Renal sympathetic denervation using conventional non-irrigated radiofrequency catheters has potential technical shortcomings, including limited penetration depth and incomplete circumferential nerve damage, potentially impacting therapeutic efficacy. Against this background, second generation multi-electrode, radiofrequency and ultrasound renal denervation systems have been developed to provide more consistent circumferential nerve ablation. Irrigated catheters may allow deeper penetration while minimizing arterial injury. In this context, catheter-based chemical denervation, with selective infusion of alcohol, a potent neurolytic agent, into the perivascular space, may minimize endothelial, intimal and medial injury while providing circumferential neurolysis. Animal studies demonstrate pronounced renal norepinephrine level reductions and consistent renal nerve injury after perivascular alcohol infusion using the Peregrine Catheter. Early clinical studies demonstrated significant blood pressure reductions and a reasonable safety profile. Randomized sham-controlled trials (NCT03503773, NCT02910414) are underway to examine whether the aforementioned theoretical advantages of alcohol-medicated denervation with the Peregrine System™ Kit translate into clinical benefits.

OBJECTIVES: The aim of this multicenter, open-label trial was to evaluate the safety and efficacy of alcohol-mediated renal denervation using a novel catheter system (the Peregrine System Infusion Catheter) for the infusion of dehydrated alcohol as a neurolytic agent into the renal periarterial space. BACKGROUND: The number of hypertensive patients with uncontrolled blood pressure (BP) remains unacceptably low. The renal sympathetic nervous system has been identified as an attractive therapeutic target. METHODS: Forty-five patients with uncontrolled hypertension on ≥3 antihypertensive medications underwent bilateral renal denervation using the Peregrine Catheter with 0.6 ml alcohol infused per renal artery. RESULTS: All patients were treated as intended. Mean 24-h ambulatory BP reduction at 6 months versus baseline was -11 mm Hg (95% confidence interval [CI]: -15 to -7 mm Hg) for systolic BP and -7 mm Hg (95% CI: -9 to -4 mm Hg) for diastolic BP (p < 0.001 for both). Office systolic BP was reduced by -18/-10 mm Hg (95% CI: -25 to -12/-13 to -6 mm Hg) at 6 months. Antihypertensive medications were reduced in 23% and increased in 5% of patients at 6 months. Adherence to the antihypertensive regimen remained stable over time. The primary safety endpoint, defined as the absence of periprocedural major vascular complications, major bleeding, acute kidney injury, or death within 1 month, was met in 96% of patients (95% CI: 85% to 99%). Two patients had major adverse events of periprocedural access-site pseudoaneurysms, with major bleeding in one. There were no deaths or instances of myocardial infarction, stroke, transient ischemic attack, or renal artery stenosis. Transient microleaks were noted in 42% and 49% of the left and right main renal arteries, respectively. There were 2 cases of minor vessel dissection that resolved without treatment. CONCLUSIONS: Primary results from this trial suggest that alcohol-mediated renal denervation using the Peregrine Catheter safely reduces blood pressure and as such may represent a novel approach for the treatment of hypertension.

The anatomy of patent foramen ovale (PFO) was described centuries ago and the pathophysiology of paradoxical embolism was recognized as early as the mid-19th century. Surgical closure of interatrial septal communications was first described in the early to mid-20th century and, with the availability of endovascular techniques, the first percutaneous device closures of interatrial septal communications were performed in the 1970s. Initial enthusiasm was dampened by the first randomized trial of PFO closure for stroke, CLOSURE I, which did not show a significant difference between device closure and standard of care medical therapy. However, initial early trials were followed by 4 randomized studies that demonstrated a significant stroke risk reduction with PFO closure when compared with medical therapy. The journey from initial skepticism to a now wide acceptance for this procedure illustrates a few important lessons. First, it takes centuries from the recognition of a medical condition to an effective treatment. Second, not all devices are created equally. Third, for a medical condition associated with a low annual event rate, prolonged follow-up may be essential to prove a long-term benefit. Fourth, appropriate patient selection is paramount. There are a number of questions that remain unanswered regarding which PFO should be closed and, though effective, no device currently available is perfect. Hence we need to continue our efforts to improve our understanding of PFO, its high-risk features, and the technologies used to treat this common congenital heart defect.

Since the early beginning of the transesophageal echocardiography (TEE) era, standardized tomographic views describing cardiac key structures have been provided. They have become the basis of TEE and have not been modified for decades. During our recent structural interventional cases, it has come to our attention that the structure frequently labeled “inferior vena cava” in textbooks and journal articles illustrating the bicaval TEE view is, in fact, the coronary sinus. Our manuscript illustrates our observation.

Supplemental Digital Content is available in the text., Background: Primary results of this prospective, open-label, multicenter trial suggested that alcohol-mediated renal denervation with perivascular injection of dehydrated alcohol using the Peregrine System Infusion Catheter safely reduces blood pressure (BP) in patients with resistant hypertension. To date, maintenance of the BP-lowering effect beyond 6 months using this novel technology has not been reported. This article describes the final, 12-month follow-up data on the safety and efficacy of alcohol-mediated renal denervation in these patients. Methods: Forty-five patients with resistant hypertension on a stable regimen of on average 5.1±1.5 antihypertensive medications underwent successful bilateral renal denervation using the Peregrine Catheter with alcohol as the neurolytic agent (0.6 mL per renal artery). Apart from 2 vascular access pseudoaneurysms (both without sequelae), no major procedural complications occurred. Results: At 12 months post-procedure, mean 24-hour ambulatory systolic and diastolic BP were reduced by 10 mm Hg (95% CI, −16 to −5) and 7 mm Hg (−10 to −3), respectively (P

Objectives The study examined the frequency in which a right coronary artery (RCA) anomaly resulting in intra-atrialization of the vessel might increase risk of RCA damage during routine radiofrequency ablation in the right atrium even with low power or temperature. Background Right coronary artery (RCA) injury with endocardial RF ablation of the right atrium is a rare complication. Methods This prospective observational study comprised an analysis of coronary artery anatomies in 331 patients who underwent autopsies at our institution from 2005 to 2014. The presence of intra-atrial RCA including the number and length of intra-atrial RCA segments with accompanying atherosclerosis and coronary anomalies were evaluated. Results The authors report a case series of 6 of 331 (1.8%) patients in whom autopsies showed evidence of an intra-atrial RCA. The patients were all men (average 69 ± 12 years of age). They observed 3 variations of the intra-atrial RCA course. In 2 similar variations, the RCA entered the anterolateral aspect of the right atrium, returning to its normal distribution to supply the distal RCA (case 4 of 6) and the atrioventricular nodal artery (case 1 of 6). In the sixth case, the atrialized artery was an anterior branch of the RCA, in which the artery similarly coursed across the pectinate muscles, extending to the region of the anterior crista terminalis, before diving into the muscle. Conclusions The prevalence and variants of the intra-atrial RCA have not been reported before. In the presence of an intra-atrial artery, RCA damage may occur due to direct injury rather than collateral injury due to transmural extension of an ablation lesion.

The interest in RDN for hypertension has fluctuated recently, with a flurry of initial enthusiasm followed by sudden loss of interest by researchers and device manufacturers, with an almost as sudden resurgence in clinical trials activity and device innovation more recently. There is widespread consensus that this therapeutic strategy can be effective, at least for some of the technologies available. Major uncertainties remain as to the clinical role of RDN, and whether any of the emerging technologies such as AV-anastomosis formation, carotid body ablation, carotid bulb expansion, or baroreflex stimulation will have a future as effective treatment options in patients with hypertension. In our first consensus report in 2015, the European Expert Group pointed to the major unmet need of standardization of measurements, trial design and procedural performance.6 With the large number of different technologies currently in the pipeline, this need has even increased. Only through high-quality, collaborative research and openness to new methods for recruitment, patient selection, and assessment of outcomes will it be possible to establish incontrovertibly whether device therapies for hypertension are effective and what are preferred patient populations. Once the proof of concept is established, further studies with a design relevant to clinical reality will be needed to establish the place of new devices in the treatment armoury. The clinical and research community has a large responsibility to prove or disprove the value of new therapies, in order to ensure that antihypertensive devices provide future patients with the greatest benefit and the smallest risk. copy; The Author 2017. Published by Oxford University Press on behalf of the European Society of Cardiology.

In patients with an Alfieri Stitch transcatheter mitral valve replacement (TMVR) may be difficult due to the double orifice configuration of the mitral valve. We report a case of simultaneous and completely percutaneous TAVR and TMVR using LAMPOON-related techniques prior to TMVR to allow for optimal valve deployment.

An der Frage, ob der katheterbasierte Verschluss des linken Vorhofohrs bei Patienten mit Vorhofflimmern eine ebenso wirksame — oder gar bessere — Schlaganfallprophylaxe ist, wie eine orale Antikoagulation, scheiden sich die Geister. Fur welche Therapie gibt es die bessere Evidenz? Lesen Sie, was unsere Experten dazu sagen.

Background Outcomes after transcatheter aortic valve implantation (TAVI) have been demonstrated to be at least equivalent in the short term compared to surgical valve implantation (SAVI). However, Conduction abnormalities are more common after TAVI than SAVI and the need for permanent pacemaker implantation is more common after TAVI with the currently commercially available self-expanding valves than after SAVI. Temporary pacemaker implantation may be associated with inability to ambulate, lead migration or perforation and infection. Depending on the monitoring system, some arrhythmias may not be detected. We examined the feasibility and safety of permanent pacemaker lead implantation connected to an external generator in patients undergoing TAVI at our institution. Methods This is a retrospective analysis of consecutive patients (between April 1st 2014 and April 30th 2016) at a single center without permanent pacemaker at the time of TAVI who underwent implantation of a permanent pacemaker lead after TAVI connected to an external generator. Focus was the examination of feasibility and safety of our aforementioned approach. In addition, data analysis was performed separating patients into two groups depending on whether (group 1) or not (group 2) permanent pacemaker implantation was ultimately needed. Results Per our institutional protocol, all consecutive 114 patients underwent insertion of a permanent pacemaker lead after TAVI connected to an external generator. There was one pericardial effusion on postoperative day one that may have been related to the left ventricular wire for TAVI valve delivery. However, perforation due to the pacemaker lead cannot be excluded. Specifically, no access site complications, lead dislodgments or infections occurred. All patients were able to ambulate after the procedure without delay. The permanent pacemaker lead remained in place on average for 4.3 days in group 1 (n = 10) and 4.4 days in group 2 (n = 104) (variance of 3.8 and 3.4 days respectively, [minimum/maximum 0/11 days and 1 and 12 days]). Of the ten patients (9%) who required permanent pacemaker implantation, 8 had a complete atrioventricular block and two had tachy-brady arrhythmias in the context of atrial fibrillation. None of the baseline characteristics including baseline conduction abnormalities were predictors for PPI. Conclusion Implantation of a permanent pacemaker lead connected to an external generator is feasible and safe and could be a better option than implantation of a temporary lead connected to an external generator. It may allow earlier ambulation and facilitate monitoring.

Coronary vasospasm is a well-known entity causing acute chest syndrome and can lead to myocardial infarction, ventricular arrhythmias, and even sudden cardiac death. While there are extensive case series showing the association of coronary vasospasm with cocaine, studies reporting marijuana-induced coronary vasospasm are limited in number. We herein present a case of coronary vasospasm in a middle-aged African-American male who presented to the emergency department after an episode of syncope. His urine drug screen was positive only for marijuana. He had a transient elevation of ST segments on his EKG with concomitant wall motion abnormalities on echocardiogram and was later found to have vasospasm of coronary arteries on coronary angiogram without any evidence of focal atherosclerotic disease. Another interesting finding was the persistent inter-coronary communication or coronary arcade connecting the left circumflex artery to the right coronary artery. There was bi-directional flow through the inter-coronary communication and hence, we believe this communication prevented our patient from experiencing acute chest symptoms or myocardial infarction. It is important for the clinicians to recognize the association of marijuana with coronary vasospasm. At the same time, these patients should be treated as acute coronary syndromes until proven otherwise by ischemia evaluation.

Transcatheter left atrial appendage (LAA) occlusion is an alternative strategy for stroke prevention in patients with atrial fibrillation (AF).This study sought to determine the incidence, predictors, and prognosis of thrombus formation on devices in patients with AF who were treated with LAA closure.The study retrospectively analyzed data from patients treated with 2 LAA closure devices seen in 8 centers in France from February 2012 to January 2017.A total of 469 consecutive patients with AF underwent LAA closure (272 Watchman devices [Atritech, Boston Scientific, Natick, Massachusetts] and 197 Amplatzer devices [St. Jude Medical, Minneapolis, Minnesota]). Mean follow-up was 13 ± 13 months, during which 339 (72.3%) patients underwent LAA imaging at least once. There were 98 major adverse events (26 thrombi on devices, 19 ischemic strokes, 2 transient ischemic attacks, 18 major hemorrhages, 33 deaths) recorded in 89 patients. The incidence of device-related thrombus in patients with LAA imaging was 7.2% per year. Older age (hazard ratio [HR]: 1.07 per 1-year increase; 95% confidence interval [CI]: 1.01 to 1.14; p = 0.02) and history of stroke (HR: 3.68; 95% CI: 1.17 to 11.62; p = 0.03) were predictors of thrombus formation on the devices, whereas dual antiplatelet therapy (HR: 0.10; 95% CI: 0.01 to 0.76; p = 0.03) and oral anticoagulation at discharge (HR: 0.26; 95% CI: 0.09 to 0.77; p = 0.02) were protective factors. Thrombus on the device (HR: 4.39; 95% CI: 1.05 to 18.43; p = 0.04) and vascular disease (HR: 5.03; 95% CI: 1.39 to 18.23; p = 0.01) were independent predictors of ischemic strokes and transient ischemic attacks during follow-up.Thrombus formation on the device is not uncommon in patients with AF who are treated by LAA closure. Such events are strongly associated with a higher risk of ischemic stroke during follow-up. (REgistry on Real-Life EXperience With Left Atrial Appendage Occlusion [RELEXAO]; NCT03279406).

Objectives The aim of this study was to evaluate long-term outcomes in patients with atrial fibrillation undergoing percutaneous left atrial appendage (LAA) closure with the Watchman device. Background Atrial fibrillation is one of the most common arrhythmias and is associated with a high risk for cardioembolic ischemic events, most notably stroke. Percutaneous LAA closure is an alternative to oral anticoagulation, because most thrombi originate from the LAA. Methods All consecutive patients with minimum CHADS2 or CHA2DS2-VASc scores of 1 who underwent LAA closure with the Watchman device between June 2006 and August 2010 were eligible. Follow-up examinations were performed after 45 days to 3 months, 6 months, and 1 year and thereafter annually. Afterward, alternating office visits and telephone follow-up were performed every 6 months. Results A total of 102 patients were included. The mean age was 71.6 ± 8.8 years, and 37.3% were women. The mean CHADS2 and CHA2DS2-VASc scores were 2.7 ± 1.3 and 4.3 ± 1.7, respectively. Procedural success was achieved in 96.1% of patients. During a mean follow-up period of 3.0 ± 1.6 years, the annual rates of transient ischemic attack, stroke, intracranial hemorrhage, and death were 0.7%, 0.7%, 1.1%, and 3.5%, respectively. Conclusions LAA closure with the Watchman device is safe and feasible for stroke protection in patients with atrial fibrillation. Low ischemic events rates demonstrate its effectiveness during long-term follow-up.