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Qualitative and Quantitative Coronary Angiography

Key Points An enhanced understanding of coronary lesion complexity remains a valuable tool for estimating early and late procedural risk after percutaneous coronary intervention (PCI). Aggregate scores that consider the vessel patency and underlying lesion morphology provide the most relevant information for estimating outcome. The SYNTAX trial score, a quantitative assessment of the extent of coronary artery disease, has proven a valuable tool for identifying appropriate…

Interventional Heart Failure

Key Points Despite current guideline-directed drug and electrophysiologic device therapies, many heart failure patients remain highly symptomatic, and outcomes remain poor. New therapies are needed to improve patients’ clinical status and outcomes. Several causes of heart failure are amenable to interventional device-based therapies, an observation that led to emergence of the field of interventional heart failure. Interventional heart failure targets include primary or secondary valve disease,…

Percutaneous Treatment of Paravalvular Leak

Key Points Paravalvular regurgitation (leak) affects 5% to 17% of all surgically implanted prosthetic heart valves. Echocardiography is pivotal in the evaluation of both mitral and aortic paravalvular leaks. Surgical repair is effective but has significantly higher complications rates compared with a percutaneous approach. Percutaneous paravalvular leak closure is feasible and safe with long-term outcomes comparable to a surgical approach. Resolution of symptoms and hemolysis as…

Stem Cell Therapy for Ischemic Heart Disease

Key Points Advances in reperfusion therapy have led to the development of a large population of patients with chronic heart failure. Modulation of cardiac tissue is the next great frontier to lessen symptoms of heart failure and improve patient outcomes. In general, the field has failed to demonstrate robust results in large scale studies. The time for small studies with multiple subgroups is past. Improvements in…

Transcatheter Therapies for Congenital Heart Disease

Key Points Catheter-based therapies are available for a wide variety of congenital structural cardiovascular defects. Balloon dilation provides relief of obstruction for patients with congenital pulmonary or aortic valve stenosis. This therapy may not be adequate if the valve is hypoplastic or calcified. Congenital pulmonary artery stenosis can be effectively relieved with balloon-expandable stents; late stent redilation may be necessary in a growing child. Coarctation of…

Percutaneous Balloon Pericardiotomy for Patients With Pericardial Effusion and Tamponade

Key Points Pericardiocentesis is a catheter-based procedure in which fluid is aspirated from the pericardium. It is indicated in patients with cardiac tamponade, for large pericardial effusions (usually >2 cm), for moderate effusions (10 to 20 mm) in symptomatic patients, or if the fluid is needed for diagnostic purposes; it is also used to drain purulent, tubercular, or neoplastic effusions in patients who are resistant to…

Hypertrophic Cardiomyopathy

Key Points Hypertrophic cardiomyopathy is a disease process that varies broadly in its clinical presentation and has been associated with many different genetic mutations. Obstructive disease is present in a subset of patients, where the severity of obstruction varies depending on loading conditions and adrenergic state in the individual patient. Imaging with echocardiography and magnetic resonance imaging are primarily used to make the diagnosis. Medical management…

Percutaneous Tricuspid Valve Repair

Key Points The clinical burden of severe functional tricuspid regurgitation can be substantial, with limited transcatheter options for those at prohibitive risk for surgical repair The tricuspid apparatus is complex and far more heterogeneous (with respect to number of leaflets and the associated subvalvular apparatus) than the mitral valve. Percutaneous tricuspid valve edge-to-edge repair carries the most clinical experience, with larger-scale randomized trials under way. Many…

Pulmonary Valve Interventions

Key Points Percutaneous pulmonary valvuloplasty is the first-line treatment for all patients with more than moderate isolated pulmonary stenosis. Even in critical neonatal pulmonary stenosis, simple efficacious balloon dilatation can provide a definitive solution and avoid the need for future medical intervention. Percutaneous pulmonary valve implantation (PPVI) is suitable for patients with dysfunctional right ventricle–to–pulmonary artery conduits and for dysfunctional patch reconstructed outflow tracts in selected…

Percutaneous Transcatheter Valve-in-Valve Implantation

Key Points All tissue valves will fail if the patients live long enough. The average time from implant to valve-in-valve procedures has been approximately 8 years. Valve-in-valve procedures are less invasive and often lower risk than redo open-heart surgery. Improvements in functional status and quality of life are often dramatic. A detailed knowledge of surgical valves is required to choose the correct type, size, and position…

Self-Expanding Transcatheter Aortic Valve Replacement

Key Points Transcatheter aortic valve replacement (TAVR) has become the default therapy for patients with aortic stenosis who, based on an expanding randomized evidence base, are at increased risk for surgery. TAVR procedures have now surpassed the number of surgical aortic valve replacements in the United States. The most frequently used self-expanding bioprotheses—the CoreValve family of CoreValve Classic, Evolut-R, Evolut-34 mm, and Evolut-PRO—have specific design features…

Balloon-Expandable Transcatheter Aortic Valve Replacement Systems

Key Points Balloon aortic valvuloplasty is used to palliate the symptoms of severe aortic stenosis and as a bridge to more definitive therapy when benefit is uncertain. Transcatheter aortic valve replacement (TAVR) provides a survival and symptomatic advantage for patients with severe aortic stenosis who are at high or extreme risk for surgical complications, and it is the treatment of choice for this patient population. TAVR…

Percutaneous Mitral Valve Repair and Replacement

Key Points Mitral regurgitation (MR) is a significant problem, and the number of patients with MR is growing together with increased numbers of patients with congestive heart failure. Various percutaneous approaches to mitral valve repair are under preclinical and clinical investigation and show promise. These approaches are predominantly based on established surgical strategies and include edge-to-edge repair, direct and indirect annuloplasty methods, and chamber remodeling strategies.…

Mitral Valvuloplasty

Key Points The efficacy, safety, and applicability of the Inoue balloon technique make it the point of reference for percutaneous mitral commissurotomy (PMC). Technical experience is essential for the safety of the procedure and the selection of patients. PMC provides good immediate and long-term clinical results and carries a low risk when performed by experienced teams. Patient selection is based on anatomy and other predictors of…

Left Atrial Appendage Closure and Stroke: Local Device Therapy for Cardioembolic Stroke Protection

Key Points Atrial fibrillation (AF) is associated with substantial morbidity and mortality due to stroke and systemic embolism. The left atrial appendage (LAA) appears to be the primary source of thromboembolism in AF and therefore is a target for mechanical therapies for stroke reduction. Although concomitant LAA excision or exclusion is commonly performed during cardiac surgery in high-risk patients, insufficient resection or postoperative residual leaks occur…

Percutaneous Closure of Patent Foramen Ovale and Atrial Septal Defect

Key Points Although patent foramen ovale (PFO) and atrial septal defect (ASD) both involve an abnormal communication across the interatrial septum, their causes are different. PFO results from lack of fusion between the septum primum and the septum secundum, whereas a secundum ASD is caused by the absence of a segment of the atrial septum. PFO has been associated with paradoxical embolization, cryptogenic stroke, migraine headache,…

Imaging for Intracardiac Interventions

Key Points Structural heart disease interventions rely on multimodality imaging, including fluoroscopy and echocardiography (intracardiac, transthoracic, or transesophageal) during the procedure, and computed tomography and cardiac magnetic resonance for procedural planning. These modalities are complimentary. During the procedure, fluoroscopy allows real-time imaging of radio opaque devices, while intraprocedural ultrasound is ideal for soft tissue visualization including valvular structures. Fluoroscopy projects three-dimensional anatomy in two dimensions. Therefore,…

Stroke Centers and Interventional Cardiology

Key Points The three broad categories of stroke are hemorrhagic, thrombotic, and embolic (i.e., artery to artery and chamber to artery). Carotid plaque, unlike coronary lesions, most often causes symptoms due to atheroembolization rather than thrombotic occlusion. The size of a brain infarction is determined by the time it takes for reperfusion to occur, the patency of the circle of Willis as a collateral source, and…

Carotid and Cerebrovascular Intervention

Key Points Carotid intervention for the treatment of atherosclerotic disease has evolved considerably. The potential for serious neurologic complications during such procedures places a premium on careful studies documenting the overall clinical efficacy of intervention compared with medical therapy. Carotid bifurcation disease and intracranial atherosclerosis account for 15% to 20% of all ischemic strokes and represent an important target for stroke prevention. Contemporary carotid bifurcation intervention…

Venous Intervention

Key Points Venous disease, both acute (deep vein thrombosis [DVT], pulmonary embolism [PE]) and chronic (postthrombotic syndrome, ulcers, varicose veins), is widely prevalent, affecting up to a quarter of the population. Superficial vein disease can be highly symptomatic but often easily treated with minimally invasive ablative techniques. The superior vena cava (SVC) syndrome manifests as severe congestion and edema of the face, arms, and upper thorax,…