Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

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,…

Aortic Vascular Interventions (Thoracic and Abdominal)

Key Points Acute aortic dissection is an uncommon but potentially catastrophic illness that occurs with an incidence of approximately 3.5 per 1 million person-years, with at least 8000 cases occurring annually in the United States. Aortic stent grafts are primarily used to reconstruct the compressed true lumen cranial to major aortic branches and to increase distal aortic flow. Proximal communications are sealed to direct flow into…

Device Therapy for Resistant Hypertension

Key Points Uncontrolled hypertension presents a significant health care problem with far-reaching public health and economic consequences. Novel therapies target neurohumoral modulation and mechanical alteration of vascular compliance to treat hypertension. Reduction of the sympathetic nervous output from the renal nerves has some supporting clinical data but remains experimental at the time of this publication. A variety of technologies can be used to modulate renal sympathetic…

Renal Artery Stenosis

Key Points Renal artery stenosis (RAS) is caused by a heterogeneous group of diseases with various causes, clinical manifestations, courses, treatments, and outcomes. Atherosclerotic renal artery sclerosis and fibromuscular dysplasia are the most common causes of renal artery sclerosis. Patients in whom atherosclerosis is progressive may have signs and symptoms of chronic ischemic renal disease, resulting in renovascular hypertension and renal dysfunction. However, the causal relationship…

Chronic Mesenteric Ischemia: Diagnosis and Intervention

Key Points Atherosclerotic stenoses commonly involve the major mesenteric arteries (celiac, superior mesenteric, and inferior mesenteric) but rarely cause symptomatic mesenteric ischemia because of the excellent collateral circulation that interconnects the visceral vascular beds. The classic presentation is postprandial abdominal pain with weight loss. Patients with functional bowel complaints rarely have significant weight loss. Patients with suspected chronic mesenteric ischemia (CMI) commonly have atherosclerosis involving other…

Upper Extremities and Aortic Arch

Key Points Arterial disease in one vascular bed is a harbinger of disease in other vascular beds. The differential diagnosis of diseases involving the upper extremity (UE) and aortic arch branch vessels is vast and requires extensive knowledge and a thorough history and physical examination. In patients with suspected arterial disease, blood pressure should be measured in both UEs, and if Takayasu arteritis is suspected, blood…

Lower Extremity Interventions

Key points Individuals at risk for lower extremity peripheral artery disease (PAD) should undergo a vascular review of symptoms to assess walking impairment, claudication, ischemic rest pain, and the presence of nonhealing wounds. Despite recent advances in noninvasive evaluation of lower extremity PAD, contrast angiography remains the gold standard for definitive evaluation. Contrast angiography provides detailed information about arterial anatomy and is recommended for evaluation of…

Diagnosis and Treatment of Coronary Microvascular Disease

Key Points Vascular physiology is grounded in the following basic equation: CO (flow) equals the pressure difference (Δ P ) divided by the resistance ( R ). Resultantly, coronary blood flow (CBF) is largely driven by supply/demand mismatches in myocardial oxygenation, requiring increased delivery of substrate to the myocardium. The coronary microcirculation is the primary regulator of myocardial perfusion and is largely dependent on vessel tone…