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Percutaneous Relief of Vascular Obstruction: Potpourri

23.1 Key Points 1. Cardiovascular obstructions in adult congenital heart disease (CHD) often involve branch pulmonary artery stenosis and postsurgical baffles, homografts, and conduits. 2. Stenting various cardiovascular obstructions in adult CHD requires a good understanding of available stents and balloons of all sizes and all of their unique characteristics. 3. Intravascular stenting should accommodate for adult growth potential of the patient. 4. Accurate measurements and…

Unwanted Vascular Communications: Patent Ductus Arteriosus, Coronary Fistulas, Pulmonary Arteriovenous Malformations, and Aortopulmonary Collaterals

Patent ductus arteriosus (PDA), coronary fistulas, pulmonary arteriovenous malformations (PAVMs), and aortopulmonary collaterals (APCs) represent unwanted vascular communications that can potentially cause severe clinical sequelae such as heart failure, myocardial infarction, or even endarteritis. Although surgical ligation or expectant management have previously been the only available options, transcatheter techniques have evolved to become a powerful and minimally invasive method for managing these vessels. This chapter will…

Atrial Septal Defect Creation

Pulmonary hypertension (HTN) with end-stage pulmonary vascular disease results in right heart failure, low output, and death, with few therapeutic options other than lung transplantation. Opening of the atrial septum (most common), ventricular septum, or ductus arteriosus allows for right-to-left shunt decompression of the right heart volume and pressure at the expense of systemic desaturation. Opening of the atrial septum is the preferred approach in most…

Patent Foramen Ovale

20.1 Embryology and Anatomy The foramen ovale is pivotal during intrauterine life and facilitates the passage of oxygenated blood from the placenta to the fetal circulatory system. The blood flow from the umbilical veins enters the right atrium through the inferior vena cava (IVC) and bypasses the nonfunctional lungs across the foramen to enter the systemic circulation. Most blood flow from the superior vena cava (SVC)…

Percutaneous Treatment of Pulmonary Vein Stenosis

Atrial fibrillation (AF) remains the most common arrhythmia encountered in clinical practice; it is estimated that by the year 2050 the number of patients in the United States may exceed 12 million. Traditionally, AF has been treated medically with the aim of either restoring sinus rhythm or slowing down the arrhythmia to levels tolerated by the cardiovascular system. More recently, catheter mapping and utilization of surgically…

Percutaneous Closure of Aortic, Coronary, and Ventricular Pseudoaneurysms and Coronary Fistulae

Although many transcatheter closure techniques are closely related, aortic, ventricular, and coronary pseudoaneurysms each involve unique approaches. Likewise, coronary fistulas are discussed separately. Most closure techniques are improvisations of methods applied in more commonly encountered congenital defects (e.g., atrial septal defects [ASD] and ventricular septal defects [VSD]). There is no standard approach to either of these conditions because the location and relation to surrounding structures varies…

Percutaneous Closure of Congenital, Acquired, and Postinfarction Ventricular Septal Defects

Ventricular septal defects (VSDs) are the most common congenital heart disease, accounting for 25% of all congenital heart defects and occurring in 3 to 3.5 infants per 1000 live births. Congenital VSDs often close spontaneously in childhood or are otherwise treated. However, they may be left undiagnosed until adulthood. Previously undiagnosed VSDs can present in adulthood with a murmur, bacterial endocarditis, or cyanosis and exercise intolerance…

Transcatheter Left Atrial Appendage Occlusion

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and a major cause of stroke in the elderly. An estimated 12 to 16 million Americans will have a diagnosis of AF by 2050. The risk of stroke attributable to AF increases with age from 1.5% in the 50- to 59-year-old age group to 23.5% in the 80- to 89-year-old age group. The annual incidence of stroke…

Percutaneous Approach to Pericardial Window

15.1 Background The management of chronic pericardial effusions by cardiologists and cardiothoracic surgeons poses significant challenges and is burdened with limitations because of the generally moribund state of patients stricken with this condition. Malignancy and infection most commonly cause pericardial effusions in developed countries representing 23% and 27% of cases, respectively. In the case of malignant pericardial effusions, recurrence rates after pericardiocentesis range from 13% to…

Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy

14.1 Key Points In appropriate patients with hypertrophic cardiomyopathy (HCM), alcohol septal ablation using contrast echocardiographic guidance causes targeted necrosis, thinning of the basal interventricular septum, and widening of the left ventricular outflow tract (LVOT) and relieves outflow tract obstruction. Alcohol septal ablation is indicated as an alternative option for septal reduction therapy for patients with HCM who have significant symptoms refractory to medical therapy and…

Valve-in-Valve Therapy

13.1 Key Points Transcatheter valve implantation is feasible in failing surgical aortic, mitral, pulmonic and tricuspid bioprostheses. Access may be transarterial (femoral, subclavian, axillary), transvenous (femoral, subclavian, jugular), transapical, transatrial, or direct transaortic. Paravalvular regurgitation (PR) must be distinguished from valvular regurgitation, because it will not respond to valve-in-valve (VIV) implants. The specific model and the labeled (external) diameter of the bioprosthesis must be confirmed. The…

Percutaneous Repair of Paravalvular Leaks

Paravalvular leak (PVL) complicating mechanical or bioprosthetic surgical valve replacement is an uncommon but occasional occurrence. Various series have demonstrated an incidence of 2% to 12% after mitral valve replacement (MVR) and 1% to 5% after aortic valve replacement (AVR). Furthermore, transcatheter aortic valve replacement (TAVR) is a burgeoning technology, with moderate to severe aortic regurgitation (AR) in up to 17% of patients, the majority of…

The MitraClip Device and Procedural Overview

11.1 Key Points Percutaneous transcatheter therapies for mitral regurgitation (MR) have found a role for patients at high operative risk with both degenerative and functional pathologies. The MitraClip (Abbott Vascular Structural Heart, Menlo Park, Calif.) therapy utilizes a catheter-based system to deliver a clip-type implant to provide apposition between anterior and posterior mitral leaflets. Careful patient selection with a thoughtful eye to appropriate mitral pathology remains…

Percutaneous Approaches for Treating Mitral Regurgitation

Percutaneous treatment of mitral regurgitation (MR) remains one of the most important areas of innovation and unmet clinical need in the field of adult structural heart disease. It is also one of the most challenging areas for device development because of the complexity of mitral valve (MV) function and the numerous pathologies that have traditionally required highly individualized surgical corrective therapy. Mitral leaflet mobility and coaptation…

Percutaneous Balloon Valvuloplasty for Patients with Rheumatic Mitral and Tricuspid Stenosis

Before 1982, cardiac surgery was the conventional form of treatment for symptomatic stenotic valvular heart disease lesions. Today, percutaneous balloon dilation of stenotic cardiac valves is being used in many centers for the treatment of patients with pulmonic, mitral, aortic, and tricuspid stenosis. Since its introduction in 1984 by Inoue et al., percutaneous mitral balloon commissurotomy or percutaneous mitral valvuloplasty (PMV) has been used successfully as…

Percutaneous Pulmonary Valve Implantation

As the twenty-first century progresses, a new chapter in cardiac therapeutics is being written with the development of transcatheter valve technologies. Percutaneous pulmonary valve implantation (PPVI) has the distinction of being the first percutaneous valve replacement in humans and has allowed treatment of a growing patient population with congenital heart disease (CHD). These patients are at risk for traditional surgery because of multiple prior procedures or…

Self-Expanding Transcatheter Aortic Valve Replacement Using the CoreValve Transcatheter Heart Valve

7.1 Key Points Transcatheter aortic valve replacement (TAVR) using the self-expanding Medtronic CoreValve Revalving System (Medtronic, Maple Grove, Minn.) transcatheter heart valve (THV) provides an alternative to surgical aortic valve replacement (SAVR) in patients who are poor candidates for surgery. Unique features of the CoreValve design are its ability to conform to the eccentric annulus, a supraannular location of the low-profile porcine pericardial valve with a…

Transcatheter Aortic Valve Replacement: Edwards SAPIEN Valve

Aortic stenosis (AS) remains the most common form of adult acquired valvular heart disease in developed countries, increasing in prevalence with age. As noted by Ross and Braunwald, the natural history of symptomatic AS carries a poor prognosis. Medically treated patients with symptomatic AS have 1 and 5 year survival rates of 60% and 32% respectively. Aortic valve replacement (AVR) is the only effective treatment for…

Aortic and Pulmonic Balloon Valvuloplasty

5.1 Balloon Aortic Valvuloplasty Balloon aortic valvuloplasty (BAV) for severe aortic stenosis (AS), a common disease of the elderly, was introduced by Dr. Cribier in 1986. Initial experience demonstrated the technical feasibility, acceptable safety, and fairly modest improvement in valve areas. In spite of an only modest improvement in valve area, patients experienced significant symptomatic benefit, resulting in an initially enthusiastic embrace by interventional cardiologists. However,…

Transseptal Heart Catheterization

4.1 Importance of Transseptal Puncture The transseptal puncture has been in use since its description in 1959 by Drs. Ross, Braunwald and Morrow. Until recently, transseptal puncture has been used relatively rarely, primarily for diagnostic purposes and percutaneous balloon mitral valvuloplasty (PBMV). In recent years, with the advent of complex structural heart interventions and electrophysiology ablation procedures, the use of transseptal puncture has increased. In the…