A 50-year-old man underwent heart transplantation due to ischemic cardiomyopathy. At 8 weeks after the transplantation, coronary angiography showed mild stenosis in the right coronary artery (Figures 1A and 1B), and optical coherence tomography (OCT) demonstrated calcified sheets in the intima. Serial OCT follow-up demonstrated the time-dependent rapid growth of nodular calcification (NC) (Figures 1C, 1D, 1E, 1F, and 1G). At 5 years, coronary angiography showed severe stenosis (Figures 1H and 1I), and OCT images showed neovascularization extending into the NC (Figure 2).
An 81-year-old woman with hypertrophic obstructive cardiomyopathy was referred for alcohol septal ablation. Coronary angiogram revealed a rare anomalous pattern: the left anterior descending, circumflex, and right coronary arteries all arose from the right cusp via separate ostia. A basal septal perforator arose from a fourth takeoff, through which the ablation procedure was performed with successful gradient reduction (Figure 1).
A 62-year-old man with coronary artery disease, heart failure (ejection fraction 25%), and diabetes presented with angina and was found to have severe 90% stenosis of the left circumflex coronary artery (LCx) and chronic total occlusions (CTOs) of the left anterior descending coronary artery (LAD) and right coronary artery (Figure 1). He was deemed not a surgical candidate and was referred for percutaneous coronary intervention (PCI) of the last remaining vessel (LCx) and LAD CTO.
A 63-year-old woman with systemic scleroderma, lungs fibrosis requiring home oxygen therapy, pulmonary hypertension, permanent atrial fibrillation, a history of ischemic stroke in 2010, urinary tract polyps, and other comorbidities underwent left atrial appendage occlusion (LAAO) due to recurrent bleeding from her urinary tract while on direct oral anticoagulant agents (CHA2DS2-VASc = 3, HAS-BLED = 2). An Amplatzer Amulet 22 mm (Abbott Vascular, Santa Clara, California) was chosen for the landing zone measuring 16 to 17 mm (Supplemental Figures 1A, 1B, 1C, 2A, 2B, 2C, and 2D, Videos 1, 2, and 3). The 1-month follow-up transesophageal echocardiography showed a peridevice leak (PDL) measuring 10 mm, reaching no farther than the device lobe (Supplemental Figure 3) with a decision to continue dual antiplatelet therapy until further imaging. The 6-month follow-up computed tomography (CT) study showed the device implanted in a “chicken-wing” appendage using the “sandwich” technique, but with significant undersizing causing the device to slide low, leaving the entire superoposterior portion of the appendage uncovered, with a tunnel-shaped PDL (diameter 8 × 13 mm, depth 18 mm) extending beyond both the device disc and lobe (Figures 1A, 1B, and 1C). While awaiting PDL closure, the patient had an ischemic stroke. Finally, the leak was sealed with an AVPII 12-mm device (Abbott Vascular) as confirmed by the 6-week follow-up CT study (Videos 4, 5, 6, 7, 8, and 9, Figures 1D, 1E, and 1F, Supplemental Figures 2D, 2E, and 2F).
A 63-year-old woman with a complex cardiac history of pulmonary atresia and 6 prior sternotomies presented with severe symptomatic tricuspid valve regurgitation (TR) secondary to a flail septal leaflet. Because of high surgical risk, the patient was evaluated for transcatheter edge-to-edge tricuspid repair (TEETR) with the MitraClip system (Abbott Vascular, Santa Clara, California).
An 89-year-old man with history of 2-vessel coronary artery bypass surgery and dual-chamber pacemaker presented with worsening dyspnea and pedal edema. Transthoracic echocardiogram demonstrated newly reduced left ventricular (LV) ejection fraction of 25%, severely calcified aortic valve (valve area 0.97 cm2, mean gradient 22.4 mm Hg, peak velocity 3.31 m/s), concerning for low-flow, low-gradient severe aortic stenosis. Given his clinical picture consistent with SCAI stage C cardiogenic shock, a pulmonary artery catheter was placed via the right internal jugular vein. He was referred to the cardiac catheterization laboratory for assessment of aortic stenosis severity.
Transcatheter aortic valve replacement (TAVR) for aortic stenosis in the setting of atrial fibrillation (AF) and left atrial appendage (LAA) thrombus portends a high risk of systemic thromboembolism. We present a novel strategy to enable TAVR in a patient with severe symptomatic aortic stenosis, AF and an incidental finding of a LAA filling defect, identified during routine computed tomography evaluation for TAVR. The proposed strategy may be applicable to a select group of AF patients undergoing TAVR, who are found to have a LAA filling defect on computed tomography with delayed-phase imaging, and where transesophageal echocardiography cannot definitely differentiate sludge from thrombus.
A recently available 3-dimensional (3D) echocardiographic rendering tool known as transillumination has utility in structural heart intervention planning. We show how it may be used for evaluating the mechanism of mitral regurgitation and guidance of its management in the setting of a cardiomyopathy and prior mitral valve repair with an incomplete annuloplasty ring (Figures 1, 2, and 3, Videos 1, 2, and 3).
We present the explanted heart of a 39-year-old patient with a nonischemic dilated cardiomyopathy who underwent heart transplantation. In 2012, a first MitraClip (Abbott, Abbott Park, Illinois) was implanted in a mid-lateral position. In 2016, recurrent mitral regurgitation progressed because of progressive left ventricle remodeling and the patient underwent a second MitraClip implantation in a more medial position with mitral regurgitation reduction (Figures 1A and 1B). Despite the initial clinical improvement, dilated cardiomyopathy progressed, and the patient was listed for heart transplantation. In January 2021, the patient underwent heart transplantation and dissection of the explanted heart was performed (Figures 1C and 1D show the auricular and ventricular view of the mitral valve). A close inspection of the MitraClip devices (Figures 1E, 1F, and 1G, Videos 1 and 2) showed proper endothelization of both devices with a remarkable anatomic fusion of the clips with the native subvalvular apparatus as depicted by the emerging chordae coming out from the endothelium that covered the devices. Of note, only a slightly increased thickness of the endothelium was observed in the older clip as compared with the newer one (orange arrows).
A 73-year-old female patient with a history of permanent atrial fibrillation, coronary artery disease with a recent left anterior descending coronary artery stent, and moderate aortic and mitral valve regurgitation presented with exertional dyspnea to our hospital. She was admitted with acute decompensated heart failure. A transesophageal echocardiogram confirmed severe aortic and mitral valve regurgitation with an estimated ejection fraction of 60% to 65%. A repeated cardiac catheterization was done and showed a patent, previously placed, left anterior descending coronary artery stent (Figure 1). Ultimately, the patient underwent minimally invasive aortic valve replacement with a 23-mm Avalus valve (Medtronic, Dublin, Ireland), mitral valve replacement with a 31-mm Mosaic valve (Medtronic), aortic root endarterectomy, and left atrial appendage (LAA) ligation with a 40-mm AtriClip (AtriCure, Mason, Ohio). Approximately 2 h after the procedure, she had a sudden ventricular fibrillatory arrest. Bedside transesophageal echocardiogram showed severe left ventricular dysfunction with left ventricular ejection fraction of 20% and normally functioning bioprosthetic valves. Following this, she was taken for emergent coronary angiogram, which demonstrated compression and near subtotal occlusion of the ostial circumflex coronary vessel and at least 60% compression of the distal left main from the heel of the AtriCure clip (Figure 2). No acute ST-segment changes were seen in the electrocardiogram because of paced rhythm. Emergency salvage coronary bypass grafting ×2 with a left internal mammary artery graft to the left anterior descending coronary artery, and saphenous vein graft from the aorta to the second obtuse marginal coronary. Unfortunately, the patient passed away shortly after emergent surgery despite successful revascularization.
A 41-year-old gentleman presented with exertional chest pain for 1 week. A 12-lead electrocardiogram showed nondynamic ST-segment depression in leads V2 to V6 and leads II and III. High-sensitivity troponin T rose from 192 to 3,108 ng/l. Echocardiography confirmed normal left ventricular systolic function with hypokinesia in the lateral wall. He received standard treatment with aspirin and ticagrelor alongside bisoprolol, ramipril, and atorvastatin.
Coronary sinus (CS) defects are rare and often associated with a left superior vena cava (LSVC) (1). They have traditionally been considered unsuitable for device closure. An asymptomatic 18-year-old man with dextrocardia with normal (S, D, S) segmental anatomy and situs visceralis solitus was found to have a LSVC with a partially unroofed midportion of the CS (type III according to Kirklin and Barratt-Boyes classification ) during a cardiac magnetic resonance for bicuspid aortic valve evaluation. There was moderate right ventricular dilation and anomalous drainage of the left hepatic veins into the CS. The defect was adjacent to a left common pulmonary vein (LCPV) and left circumflex coronary (LCx) artery. Computed tomography angiography (CTA) was obtained for further anatomic delineation and creation of 3-dimensional (3D) models (Figure 1). After evaluation of multimodality imaging, transcatheter closure was attempted (Video 1).
A 58-year-old woman with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and pheochromocytoma presented a few days after laparoscopic right adrenalectomy with recurring resting chest pain, elevated troponin levels, normal electrocardiogram, and no regional left ventricular wall motion abnormalities on cardiac ultrasound. The coronary angiography showed multiple distal saccular aneurysms on the 3 vessels and an occlusion of the distal left anterior descending coronary artery (Figure 1, Videos 1 to 4).
Finding the ideal candidate for percutaneous closure of a ventricular septal rupture (VSR) complicating an acute myocardial infarction is invariably challenging given the heterogeneous morphological features of this often deadly complication.
Objectives This study sought to determine the safety of the BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) procedure.
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