Challenges in Device Closure of a Large Patent Ductus Arteriosus in Infants Weighing Less Than 6 Kg

Introduction

Transcatheter closure of patent ductus arteriosus (PDA) has replaced surgery in most institutions. Despite improvements in techniques and the devices available, closure of large PDA in very small infants remains a challenge.

Aim

To assess the challenges, feasibility, and efficacy of device closure of large PDA, in infants weighing ≤6 kg.

Materials and Methods

Analysis of device closure of a PDA was done in 61 infants ≤6 kg. Their ages, ranged from 9 days–12 months (mean 8.9 months), weight ranged from 2.2 to 6 kg (mean 5.3 kg), and PDA measured 3.2–8.7 mm (mean 4.8 mm). The fluoroscopy time was 3–18 minutes. The largest device used was 12 × 10 mm.

Results

Successful device placement was achieved in 60/61 infants (98.4%). Mild aortic obstruction occurred in 2 cases (3.3%), as the device got displaced towards the aorta after release. The device embolized in 2 cases (3.3%). In one it was retrieved by a novel method like fastening the screw in the aorta and was closed with a 4 × 6 ADO II. In the other infant, with a single kidney, died of uremia after device retrieval. Mild left pulmonary artery (LPA) obstruction occurred in one case (1.6%). Four cases (6.6%) had minor vascular complications. The postprocedure weight gain after 3 months was between 2.5 kg ± 250 mg.

Conclusions

Device closure of large PDA in infants weighing ≤6 kg with left ventricular failure is challenging but possible, safe and effective. Retrieval of embolized device could be tricky. (J Interven Cardiol 2013;26:69–76)

     

Transcatheter Closure of Patent Ductus Arteriosus in Under 6 kg and Premature Infants

Background

Transcatheter closure of a patent ductus arteriosus (PDA) has always been considered risky for infants weighing <6 kg and preterms. We present our findings regarding transcatheter closures of PDA.

Methods

The inclusion criteria were a weight of <6 kg and the presence of PDA symptoms. The study subjects were divided into two groups: <6 kg and premature infants.

Results

A total of 69 infants were included. The mean ages and weights of the <6 kg and the preterms were 5.4 ± 2.7 months and 30.3 ± 19.9 days, and 4.6 ± 0.8 and 1.7 ± 0.3 kg, respectively. Type C PDAs were most frequently observed in the premature group, and type A was in <6 kg. Sixteen of the patients were premature infants, and 81.2% of them had an extremely low birth weight. All of the premature infants had comorbidities, and had been receiving respiratory support therapy. Transcatheter closure was successfully completed in 81.2% of the premature infants and 94.3% of the <6‐kg infants. Major complications occurred in 4 patients (one death and three device embolizations). The patient's age was found to be the main risk factor. The most frequently used device was the Amplatzer duct occluder II in additional sizes (84.6%) in the preterms and the Amplatzer duct occluder I (34%) and II (34%) in the <6‐kg group.

Conclusion

The transcatheter closure of PDA is relatively safe and effective in preterms and in infants <6 kg. The selection of a suitable device based on the type of PDA is critical to the success of the procedure.

     

Short‐Term Outcomes of Patent Ductus Arteriosus Closure With New Occlutech® Duct Occluder: A Multicenter Study

Aim

Over the past 2 decades, transcatheter occlusion of patent ductus arteriosus (PDA) with coils and the duct occluders evolved to be the procedure of choice. A new device, the Occlutech PDA® occluder (ODO) device has been designed. Herein, we aimed to evaluate the characteristics and short‐term results of patients who underwent transcatheter closure of PDA using the ODO.

Methods

We reviewed the clinical records of 60 patients from different centers in Turkey between December 2013 and January 2016. The medical records were reviewed for demographic characteristics and echocardiographic findings. Device size was selected on the narrowest diameter of PDA.

Results

The median patient age was 2.5 years (6 months–35 years), and median PDA diameter was 2.5 mm (1.2–11 mm). Fifty‐eight of 60 patients (96.6%) had successful ODO implantation. The occlusion rates were 37/58 (63.7%) at the end of the procedure, 51/58 (87.9%) at 24–48 hours post‐procedure, and 57/58 (98.2%) on echocardiography at a median follow‐up of 7.6 months.

Conclusion

Our results indicate that transcatheter closure of PDA using the ODO is effective. Larger studies and longer follow‐up are required to assess whether its shape and longer length make it superior to other duct occluders in large, tubular, or window‐type ducts. (J Interven Cardiol 2016;29:325–331)

     

Effect of patent foramen ovale closure for prevention on recurrent stroke or transient ischemic attack in selected patients with cryptogenic stroke

Objectives

This study was sought to evaluate the effectiveness of patent foramen ovale (PFO) closure in selected patients (PFO shunt grade more than moderate) with cryptogenic stroke (CS).

Background

Whether closure of PFO is an effective treatment for prevention of CS is still unclear.

Methods

Consecutive 158 patients (mean age: 49.9 years old, closure group: 67 patients, medication group: 91 patients) were enrolled. The primary end point was a composite of recurrent stroke and transient ischemic attack.

Results

Baseline characteristics were similar between the two groups, except age which was younger in the closure group (47.7 ± 10.8 vs 51.9 ± 9.9, P = 0.013), and the presence of shunt at rest was more common in the closure group (35.8% vs 10.4%, P = 0.000). Procedural success was 94.0%. Over a mean follow‐up of 27.8 months, a total of six primary end point, all of which were strokes, occurred only in the medication group (6.6% vs 0%, P = 0.039). Stroke‐free survival rate was significantly higher in the closure group (P = 0.026)

Conclusions

Our study showed that PFO closure may be an effective treatment strategy to prevent recurrent stroke or TIA for patients with CS if it is conducted in selective patients who have PFO shunt more than moderate grade.

     

Transcatheter Closure of Coronary Artery Fistulae: Initial Human Experience With the Amplatzer Duct Occluder II

Objectives

To evaluate the efficacy and safety of the new device Amplatzer Duct Occluder II (ADO II) for the closure of coronary artery fistulae (CAF) with coronary anomaly.

Background

Transcatheter device closure is an alternative treatment for selective patients with CAF. The currently available reports regarding the closure of CAF with the ADO II are limited.

Methods

From April 1, 2011 to July 15, 2012, 5 patients (3 males and 2 females) aged from 3 years to 27 years old (median age 5 years old) underwent CAF closure with the ADO II. The immediate and short‐term outcomes were evaluated.

Results

ADO II was deployed via the femoral vein (2 cases), femoral artery (1 case), brachial artery (1 case), and radial artery (1 case). There were no complications during all the procedures. The median fluoroscopy and procedural times were 20 and 39 minutes, respectively. Immediate trivial and mild residual shunt was present in one patient, respectively, but disappeared 24 hours after the procedure, and there was no recanalization at a median follow‐up of 6 months.

Conclusions

The new device ADO II was safely deployed with complete resolution of CAF shunt with tortuous coronary artery to the drainage. The reduced sheath sizes and softer shape of this device allow for venous or arterial approach. The ADO II might be a preferable alternative device for closure of small‐tortuous CAFs.

     

Percutaneous Closure of Post‐Infarction Ventricular Septal Defects—An Over Decade‐long Experience

Objectives

To report an over decade‐long experience with percutaneous post‐infarction ventricular septal defect (PIVSD) closure.

Background

PIVSDs remains a major clinical challenge with extremely high mortality. Data concerning interventional closure of PIVSD is scarce.

Methods

All percutaneous PIVSD closures performed between 2003 and 2016 in 8 participating centres were identified. Data concerning patients and procedures was acquired. Patients were divided into two groups, based on the time interval between VSD diagnosis and closure (≤14 days—acute phase, >14 days—non‐acute phase).

Results

Twenty‐one percutaneous PIVSD closures were performed on 20 patients (9 females, mean age: 70 years). Mean interval between the diagnosis and the procedure was 182.6 ± 500 days (range: 7–2228). Defects were mostly located in apical (55%) segments of the septum. In 7 cases (33%) the procedure was performed in the acute phase. The closure was technically successful in 17 cases (81%). Four patients died within 48 hours after the procedure. 30‐days survival rate of the entire cohort was 70%. Univariate analysis revealed impact of technical success of the procedure (HR 0.13, CI 0.03–0.68 P = 0.016) and white blood cell count (HR 1.36 per unit increase, CI 1.1–1.69, P = 0.005) on 30‐day mortality.

Conclusions

In a selected population of patients percutaneous PIVSD closure is feasible and provides satisfactory survival rate. Procedural success has a protective impact on survival. Timing of the closure remains controversial. Procedure in the non‐acute phase carries lower mortality, but at the same time introduces a selection bias. Larger registry‐based studies are required.

     

Using the GORE® Septal Occluder (GSO) in Challenging Patent Foramen Ovale (PFO) Anatomies

Objectives

We assessed efficacy and safety of the Gore^® Septal Occluder (GSO) for patent foramen ovale (PFO) closure focusing on patients with challenging septal anatomies.

Background

In times of controversial discussion whether percutaneous PFO closure is superior to medical therapy for the prevention of recurrent embolic events after cryptogenic stroke, patient selection should mainly focus on individuals with an increased likelihood that the ischaemic event is related to the PFO. In this context, specific septal anatomies—such as the presence of an atrial septal aneurysm as well as long PFO tunnel anatomy—have been associated with a higher rate of cerebrovascular accidents.

Methods

The GSO was used for PFO closure in 41 patients presenting with either atrial septal aneurysm (ASA; 27/41; 65.9%) or long PFO tunnel (> 10 mm; 32/41; 78%). Seven of these patients even presented with a tunnel length ≥ 20 mm (7/41; 17.1%). Eighteen patients had both, long‐tunnel anatomy and ASA (18/41; 43.9%).

Results

The GSO was successfully implanted in all cases. No procedural complications occurred and all patients were discharged the day after the procedure. Short‐term follow‐up, including TEE examination, in all patients was performed 37.6 ± 9.0 days after the procedure. Mid‐term follow‐up was performed after 192.7 ± 45.3 days. Later complications occurred in 7.3% (2 new onset atrial fibrillation, 1 device thrombus). Only 3 patients (7.3%) had more than trace residual shunts at 6‐weeks follow‐up. At 6‐months follow‐up, the complete closure rate was 95.1% (39/41).

Conclusions

The Gore^® Septal Occluder is an efficient device for patent foramen ovale closure in challenging anatomies, including long‐tunnel PFOs and atrial septal aneurysms.

     

Long‐Term Outcomes and Complications of Intracardiac Echocardiography‐Assisted Patent Foramen Ovale Closure in 1,000 Consecutive Patients

Backgrounds

Long‐term fate of patients submitted to patent foramen ovale (PFO) closure is still unclear. The aim of the study was to evaluate the incidence of atrial fibrillation (AF), aortic or atrial free wall erosion, device thrombosis (DT), new onset or worsening of mitral valve regurgitation (MVR), and recurrent cerebral ischemic events in the long‐term follow up after intracardiac echocardiography (ICE)—aided PFO closure in a large population.

Methods

We reviewed the medical and instrumental data of 1,000 consecutive patients (mean age 47.3 ± 17.1 years, females) prospectively enrolled in 2 centres over a 13 years period (February 1999–February 2012) for R‐to‐L shunt ICE‐aided catheter‐based closure using different devices.

Results

Immediate success was 99.8%. Implanted devices were Amplatzer PFO Occluder in 463 patients (46.3%), Amplatzer ASD Cribriform Occluder in 420 patients (42.0%), Premere Occlusion System in 95 patients (9.5%), and Biostar Occluder in 22 patients (2.2%). On a mean follow‐up of 12.3 ± 0.6 years (minimum 4‐ maximum 17 years), permanent AF occurred in 0.5%, DT was apparent in 0.5%, new onset or worsening of MVR was observed in 0.2%, whereas recurrent cerebral ischemic events were 0.8%. Occlusion rate was 93.8%. No aortic or atrial free wall erosion has been observed.

Conclusion

ICE‐aided closure of PFO using different devices, appeared very safe and effective on very long‐term follow up with low incidence of erosion, DT, recurrent ischemic events, MVR new onset or worsening, and permanent AF.

     

Recurrent and Residual Shunts After Patent Foramen Ovale Closure: Results From a Long‐Term Transcranial Doppler Study

Objectives

Assess the evolution of right‐to‐left shunt (RLS) after transcatheter patent foramen ovale (PFO) closure.

Background

Despite the high number of interventional procedures performed worldwide, limited systematic data on the long‐term abolition of RLS after percutaneous closure are available.

Methods

All patients treated at our Institution between February 2001 and July 2009 were included in this single center, prospective study, and were asked to repeat late contrast transcranial Doppler (cTCD). Rate of complete closure, residual RLS (i.e., a shunt that persists after closure), and recurrent RLS (i.e., a shunt that reappears after a previous negative cTCD) was assessed.

Results

Long‐term follow‐up was completed in 120 patients (56% male). RLS was still detectable 4.9 ± 2.3 years (range 1.3–10.3) after the procedure in 55 patients; 20 (17%) had residual RLS and 35 (29%) had recurrent RLS. Multivariate analysis revealed that significant predictors of residual RLS included post‐procedural shunt at transesophageal echocardiography (OR 3.07, 95%CI 0.97–9.7), use of a bigger device (35 vs 25 mm, OR 3.85, 95%CI 1.22–12.2) and length of follow‐up (OR 0.75, 95%CI 0.57–0.98), while only length of follow‐up (OR 0.77, 95%CI 0.62–0.95) was associated with recurrent RLS. Neurological recurrences (1 stroke, 6 transient ischemic attacks) were equally distributed between the groups.

Conclusion

A significant number of recurrent and residual shunts may be observed by cTCD up to 5 years after PFO closure. Management of late RLSs includes periodic re‐evaluation, exclusion of device‐induced complications or secondary sources of RLS, and optimization of antithrombotic treatment with or without a second intervention. (J Interven Cardiol 2015;28:600–608)

     

Percutaneous Closure of Atrial Septal Defects Under Transthoracic Echocardiography Guidance Without Fluoroscopy or Intubation in Children

Objective

Demonstrate the benefits of percutaneous atrial septal defect (ASD) closure under guidance of transthoracic echocardiography (TTE) without fluoroscopy.

Methods

From February 2013 to April 2014, 127 consecutive patients with an isolated type II ASD were recruited to undergo percutaneous closure under either TTE (n = 60, TTE group) or TEE (n = 67, TEE group) guidance. The TTE group received local anesthesia or sedation with propofol, and the TEE group received general anesthesia with endotracheal intubation. Follow‐up examinations were performed for both groups at 1 month, 3 months, 6 months, and 1 year after discharge and annually thereafter.

Results

The TTE group had a significantly shorter procedure time and respirator ventilation duration than the TEE group. The dose of propofol required, the cost, and the pharyngeal complication rate were significantly lower in the TTE group than in the TEE group. The median follow‐up of 11.6 months was uneventful in all patients.

Conclusions

Percutaneous ASD closure with TTE guidance as the only imaging tool avoids fluoroscopy, endotracheal intubation, and probe insertion and is associated with a satisfactory procedural success rate and lower costs. This procedure is a safe and reliable treatment for ASD.

     

Intracardiac versus transesophageal echocardiography to guide transcatheter closure of interatrial communications: Nationwide trend and comparative analysis

Objectives

This study aimed to assess current temporal trends in utilization of ICE versus TEE guided closure of interatrial communications, and to compare periprocedural complications and resource utilization between the two imaging modalities.

Background

While transesophageal echocardiography (TEE) has historically been used to guide percutaneous structural heart interventions, intracardiac echocardiography (ICE) is being increasingly utilized to guide many of these procedures such as closure of interatrial communications.

Methods

Using the Nationwide Inpatient Sample, all patients aged >18 years, who underwent ASD or PFO closure with either ICE or TEE guidance between 2003 and 2014 were included. Comparative analysis of outcomes and resource utilization was performed using a propensity score‐matching model.

Results

ICE guidance for interatrial communication closure increased from 9.7% in 2003 to 50.6% in 2014. In the matched model, the primary endpoint of major adverse cardiovascular events occurred less frequently in the ICE group versus the TEE group (11.1% vs 14.3%, respectively, P = 0.008), mainly driven by less vascular complications in the ICE group (0.5% vs 1.3%, P = 0.045). Length of stay was shorter in the ICE group (3 ± 4 vs 4 ± 4 days, P < 0.0001). Cost was similar in the two groups 18 454 ± 17 035$ in the TEE group vs 18 278 ± 15 780$ in the ICE group (P = 0.75).

Conclusions

Intracardiac echocardiogram utilization to guide closure of interatrial communications has plateaued after a rapid rise throughout the 2000s. When utilized to guide interatrial communication closure procedure, ICE is as safe as TEE and does not increase cost or prolonged hospitalizations.

     

Transcatheter Closure of Coronary Artery Fistulae: Considerations and Approaches Based on Fistula Origin

Objectives

To investigate technical approaches for transcatheter closure of coronary artery fistula based on anatomic type of the fistula.

Background

The variability in coronary artery fistulae (CAF) anatomy that necessitates different transcatheter closure (TCC) approaches has not been well documented.

Methods

Records of patients with CAF who underwent TCC at 2 centers were reviewed for technical details and procedural outcome. CAF were classified as proximal and distal. TCC approaches employed were arterio‐venous or arterio‐arterial loop, retrograde arterial, and antegrade venous.

Results

Eighteen patients with CAF, mean age 12.6 years (0.07–60), 11 male (61%), underwent TCC. All CAF drained predominantly into the right side of the heart. Types of CAF were proximal in 15 and distal in 3 patients. CAF calibers were large in 7, medium in 9, and small in 2 patients. The arterio‐venous loop approach was used in the majority of the cases (11 patients) and the CAF size were medium to large. The retrograde arterial approach was used in 4; of these, 3 patients had small to medium sized CAF. In 2 patients with long tortuous CAF an antegrade venous approach was employed. TCC was successful in 17 of the 18 patients (94.4%). There were no peri‐procedural deaths or vascular complications.

Conclusions

This study documents transcatheter closure approaches for CAF and device selection based on fistula origin. The choices of TCC technique and device selection vary, and are primarily determined by the heterogeneous anatomic characteristics of the fistulae.

     

Mid‐Term Outcomes after Percutaneous Closure of the Secundum Atrial Septal Defect with the Figulla‐Occlutech Device

Objectives

To evaluate the mid‐term outcomes after percutaneous closure of the secundum atrial septal defects (ASD) using the Figulla‐Occlutech device (FOD).

Background

Transcatheter closure has become the method of choice for most patients with ASD. Although the FOD may have some advantageous characteristics there is a paucity of data on later outcomes after the use of this relatively new device.

Methods

Observational, single arm study including 200 non‐consecutive patients who underwent ASD closure between 04/09 and 07/15 in 2 centers. Device performance, deployment technique, and immediate and mid‐term outcomes were assessed.

Results

Median age and weight were 24 years (4–72) and 58 kg (15–92), respectively. Single defects were observed in 171 patients (median size of 19 mm). The remainder had multiple or multifenestrated defects. Implantation of FOD (median size of 24 mm) was successful in all (99%), but 2 patients (1 with deficient postero–inferior rim; 1 with a large ASD for the size of the child). Embolization with device retrieval occurred in 2 (1%). Median follow‐up of 36 months was obtained in 172 patients. Serial echocardiographic assessment showed complete closure in all but 2 patients, in whom an additional small non‐significant posterior defect was purposely left untouched. There have been no episodes of late arrhythmias, device embolization, cardiac erosion, endocarditis, thromboembolism, wire fracture, or death.

Conclusions

Transcatheter closure of ASDs in older children, adolescents, and adults using the FOD was highly successful in a wide range of anatomical scenarios with high closure rates and no complications in mid‐term follow‐up. (J Interven Cardiol 2016;29:208–215)

     

Echocardiographic Estimates of Left Ventricular Diastolic Dysfunction Do Not Predict the Clinical Course in Elderly Patients Undergoing Transcatheter Atrial Septal Defect Closure: Impact of Early Diastolic Mitral Annular Velocity

Objective

This study evaluated the effect of echocardiographic left ventricular (LV) diastolic dysfunction on acute congestive heart failure after transcatheter atrial septal defect (ASD) closure in elderly patients.

Background

Although there is concern that LV diastolic dysfunction develops acute congestive heart failure after ASD closure, limited information is available regarding the influence, especially in elderly patients with severe LV diastolic dysfunction.

Methods

Two hundred consecutive patients older than 60 years were divided into 3 groups according to echocardiographic LV diastolic dysfunction: severe (early diastolic mitral annular velocity [e’] <5.0 cm/s), mild (5.0≤ e’ <8.0 cm/s), and normal (e’ ≥ 8.0 cm/s). Changes in plasma B‐type natriuretic peptide (BNP) levels were evaluated.

Results

No patients with severe LV diastolic dysfunction developed acute congestive heart failure immediately after the procedure. BNP levels unchanged after the procedure in patients with severe LV diastolic dysfunction (126 ± 181 to 131 ± 148 pg/ml, P = 0.885), and this increase in BNP levels was not different from that between the diagnosis of ASD and the procedure. The change in BNP levels in patients with severe LV diastolic dysfunction, who were frequently treated with diuretics before the procedure, was equivalent to that in patients with mild LV diastolic dysfunction and normal LV diastolic function (5 ± 119 vs. 16 ± 101 vs. 9 ± 131 pg/ml, P = 0.724).

Conclusions

Our findings suggest that transcatheter ASD closure under volume management is safe and valuable in elderly patients with echocardiographic severe LV diastolic dysfunction.

     

Evolving Techniques to Improve Radial/Ulnar Artery Access: Crossover Rate of 0.3% in 1,000 Consecutive Patients Undergoing Cardiac Catheterization and/or Percutaneous Coronary Intervention via the Wrist

Objectives

To evaluate several techniques to reduce crossover rates in wrist artery access in patients undergoing cardiac catheterization (CC)/percutaneous coronary intervention (PCI).

Background

Palpation‐guided radial artery (RA) access for CC/PCI is associated with a crossover rate to femoral artery (FA) access in up to 7.6%.

Methods

A retrospective analysis of a single‐center consecutive series of patients undergoing CC/PCI was performed. After one 0.4 mg sublingual NTG tablet, the RA and UA were assessed by intraprocedural ultrasound imaging to select the more suitable artery for ultrasound‐guided access. A tight “knuckle wire” technique using a 0.014 inch Prowater® coronary wire was used to negotiate RA, UA, and brachial loops when a standard wire would not easily cross. Crossover was defined as any reason requiring secondary arterial access from the contralateral arm or FA.

Results

A total of 1,162 consecutive patients treated from January 2012 to April 2014 were evaluated. Primary arterial access from the wrist (RA/UA) was performed in 1,000 (86.1%, RA: 977, UA 23) and planned FA access in 162 patients (13.9%). The overall crossover rate from the wrist was 0.3% as a result of 3/1,000 patients requiring crossover to the contralateral arm (radial loop: n = 1, brachial loop: n = 1, vessel injury: n = 1). No crossover to the FA was necessary. All primary FA access sites were successful.

Conclusions

Crossover rates of primary wrist artery access to alternative arterial access for CC/PCI can be reduced to less than 1% applying the aforementioned techniques.

     

ADO II in Percutaneous VSD Closure in Pediatric Patients

Objectives

Main aim of our study to show that ADO II device can be used for the small ventricular septal defects successfully and safely with low complication rates in pediatric population.

Background

It is hard to find an ideal device to use for every VSD successfully. If inappropriate device was chosen; complication rate increases, procedure time gets longer that prolongs exposure to ionizing radiation. Therefore interventionalists are in the search for new ideal devices.

Material

Between the dates April 2011–October 2014, 21 VSD closures with ADO‐II device. were performed. Twenty patients were included, age ranged between 4 months 18 years. Weight of the patients was between 5–76 kg.

Results

VSD diameter ranges between 2–6 mm (3.75 ± 1.25). VSD types were muscular in 2 patients, rest of them were perimembranous type. Most of the perimembranous defects (19/21) were aneursymatic and tunnel shaped. All the cases were successfully closed, no major complications were reported. There was no incidence of left bundle branch block, P‐R prolongation, or complete heart block.

Conclusion

Considering perimembraneous ventricular septal defects as difficult and risky for percutaneous closure because of its proximity to aortic, atrioventricular valves and conduction tissue, we suggest that ADO II device can be safely and effectively used for such defects in particular if an aneurysm formation is present which is also compatible with the literature. (J Interven Cardiol 2015;28:479–484)

     

Prospective Radial Artery Study Following Induction of Reactive Hyperemia Looking at Degree of Diameter Growth in Healthy Subjects

Objectives

This “proof of concept” study sought to determine the magnitude of radial artery diameter change in 20 healthy subjects by induction of flow mediation dilatation (FMD) via reactive hyperemia.

Background

Transradial access in the cardiac catheterization laboratory is becoming more commonplace due to lower bleeding complications and increase in patient comfort. However, access to the radial artery can be challenging due to small vessel size. We sought to examine whether FMD can be used to increase radial artery diameter, potentially allowing improved transradial access.

Methods

We obtained baseline radial artery diameter via a high frequency ultrasound probe on 20 healthy subjects. A standard reactive hyperemia protocol was employed in the right arm, followed by successive measurements of the subject's radial artery at pre‐specified intervals. Radial artery diameter measurements were performed offline by the sonographer and also a blinded reader to which agreement was sought.

Results

We found a mean increase in radial artery size of 0.48 ± 0.13 mm at peak reactive hyperemic states. This correlated to a mean increase in overall radial artery diameter of 21.7 ± 6.7%. The median time to peak dilation was 30 seconds (95% CI; 15–45 seconds), and the median duration of maximal dilation was 60 seconds (95% CI; 45–75 seconds).

Conclusions

Among healthy subjects, we demonstrated a mean maximal increase in radial artery diameter of 21.7 ± 6.7% via FMD. This finding supports the notion that radial artery diameter can be increased noninvasively via a reactive hyperemia protocol. (J Interven Cardiol 2013;26:310–316)

     

Is it Safe to Close ASD with the Guidance of Transthoraxic Echocardiography in Pediatric Population “Ten Years' Experience of a Single Center”

Objective

Main purpose of this study is to emphasize the usage and safety of transthoracic echocardiography (TTE) in percutaneous atrial septal defect (ASD) closure in appropriate pediatric cases.

Background

Nowadays, percutaneous closure is preferred as treatment modality for ASD in pediatric age group.

Methods

Between the dates December 2003–August 2013; 340 patients whose ASD were closed included in this study. Physical examination, electrocardiogram, TTE were done before the procedure, at the 24th hour, 1st and 6th month after the procedure. After the 6th month, routine control was done annually. Transesophageal echocardiography (TEE) was performed in 184 cases with large, multifenestrated ASD and when TTE views were poor in quality. We selected the 201 patients whose ASD diameter between 10–20 mm and formed 2 homogeneous groups according to the type of echocardiography used (TEE or TTE) in order to compare the role of echocardiography.

Results

The demographic features of patients of 2 groups were similar. There was not any statistically difference between ASD, balloon sizing diameters between the groups. No statistically significant difference in the success, complication, and residual shunt rates was found between the groups. Procedure, fluoroscopy time, and amount were significantly higher in TEE group. When hemodynamic variables except pulmonary blood flow to systemic blood flow (Qp/Qs; right–left atrium mean pressure, pulmonary vascular resistance, and peak‐mean pulmonary arterial pressure) were compared, there was not statistically difference.

Conclusion

TEE is an invasive procedure and requires general anesthesia, therefore, it should not be done routinely in ASD but only in selected cases. If the size and the anatomy of ASD is appropriate, TTE should be preferred primarily in percutaneous ASD closure.

     

Thrombus aspiration in late presenters with ST‐elevation myocardial infarction: A single‐center randomized trial

Objectives

To examine whether routine thrombus aspiration (TA) is associated with improved myocardial salvage in patients with ST‐elevation myocardial infarction (STEMI) presenting ≥12 h after onset of symptoms.

Background

TA is a recognized treatment option in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) especially in the setting of heavy thrombus burden. However, data on the role of TA in STEMI patients presenting late after onset of symptoms are limited.

Methods

In this single‐center prospective randomized study, patients with subacute STEMI presenting ≥12 and ≤48 h after symptom onset were randomized to primary PCI with or without manual TA in a 1:1 ratio. The primary endpoint was the myocardial salvage index assessed with Single Photon Emission Computed Tomography (SPECT) on admission and 4 days later.

Results

A total of 60 patients underwent randomization. Baseline characteristics were comparable between groups. TA was associated with improved myocardial salvage index compared with control group (60.1 ± 11.1% vs 28.1 ± 21.3%; P = <0.001). Furthermore, TA was associated with improved post‐procedural TIMI flow (2.9 ± 0.3 vs 2.5 ± 0.6; P = 0.003), myocardial blush grade (2.9 ± 0.3 vs 2.2 ± 0.8, P = <0.001), and reduction in left ventricular end‐diastolic dimensions (50.4 ± 4.3 mm vs 54.4 ± 5.8 mm, P = 0.004) compared with the control group. Clinical outcomes at 30 days and 6 months were similar between both groups.

Conclusions

TA might be associated with improved reperfusion and myocardial salvage especially in STEMI patients presenting after 12 h from symptom onset who are likely to have a heavy thrombus burden.

     

Comparative analysis of right heart chamber remodeling after surgical and device secundum atrial septal defect closure in adults

Background

To determine differences in right heart remodeling for patients with ASD who underwent surgical compared to device closure.

Methods

Retrospective analysis of echo data of 121 adult patients with ASD from 2005 to 2015 performed prior to closure and within 6‐8 weeks, 6 months, and 1 year post closure.

Results

121 patients with median age of 39 were studied. Patients who underwent device closure were older (46 vs 37 years, P < 0.05) with smaller mean ASD size (1.9 cm vs 2.3 cm, P < 0.05). We observed a similar and significant reduction in right heart parameters and PASP for both surgical and device closure groups on serial echos up to 1 year. Device closure was associated with preservation of TAPSE compared to surgical closure (reduction of 0.2 cm vs 0.6 cm, P < 0.001). Younger adults with ASD intervention (<40 years) had lower baseline PASP (33 mmHg vs 40 mmHg, P < 0.05) compared to older adults (>40 years). This difference persisted up to 1 year with no difference in rate of right heart remodeling. The effects of device closure with better preservation of TAPSE and S’ compared to surgery were consistent within both groups of younger and older adults.

Conclusion

Device and surgical closure of ASD both result in similar improvements in right heart parameters. However, device closure is associated with better preservation of TAPSE at 1 year post intervention. Intervention for older adults with ASD, when compared to younger ones, did not result in a difference in rate of right heart remodeling.