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Tanenbaum MT, Figueroa AV, Lee KB, Costa Filho JE, Gonzalez MS, Baig MS, Timaran CH. Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms. J Vasc Surg Cases Innov Tech 2024; 10:101467. [PMID: 38591014 PMCID: PMC10999806 DOI: 10.1016/j.jvscit.2024.101467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Objective Endovascular repair of chronic dissecting aortoiliac aneurysms is challenging given the rigid septum, compressed true lumen (TL), and target vessels frequently originating in the false lumen. We have used transcatheter electrosurgical aortic septotomy (TEAS) before stent graft implantation under intravascular ultrasound (IVUS) and fusion guidance. The purpose of this study is to assess the outcomes of TEAS during complex endovascular repair of dissecting aneurysms. Methods From 2021 to 2023, 17 patients underwent TEAS. The primary end point was technical success, with secondary end points of proximal and distal seals, target vessel instability, aortic and iliac TL and cross-sectional area (CSA) expansion, and aortic-related death. During the procedure, the aortic septum is crossed through a pre-existing entry or via electrocautery-activated 0.018-in. Astato XS20 wire (Asahi-Intecc) under IVUS and fusion guidance. The penetrated wire is then snared in the false lumen and pulled through the ipsilateral femoral access. A 1-cm length of the middle of the Astato wire coating is kinked in a three-sided polygonal configuration, denuded the inner surface of the wire using a no. 15 blade, and positioned at the apex of the septum. Both ends of the Astato wire are insulated with 0.018-in. microcatheters, and the back end of the wire is denuded and connected to cautery. Gentle traction is applied to the wire, and short bursts of electrocautery cutting are applied at 60 to 80 W. Results The technical success of the septotomy was 100%. No incidence of visceral or lower extremity malperfusion, vascular injury, or distal embolization occurred. Of the 17 patients, 4 underwent thoracic endovascular aneurysm repair, 2 underwent endovascular aortic repair, and 11 underwent fenestrated/branched endovascular aneurysm repair after septotomy. All target vessels were successfully stented. A distal landing zone seal with exclusion of the false lumen was achieved in 16 of the 17 patients (94.1%). One patient required embolization of the false lumen of the celiac artery after septotomy. The TL mean diameter and CSA of the descending thoracic aorta after septotomy was expanded by 7.01 ± 1.9 mm (relative mean diameter expansion, 42.3%; P < .0001) and 2.71 ± 0.4 cm2 (relative mean CSA expansion, 57.3%, P<.0001). For patients who required septotomy through the common iliac arteries, the mean TL was expanded by 8.1 ± 3.7 mm (relative mean diameter expansion, 76%; P < .0001) and 1.76 ± 0.91 cm2 (relative mean CSA expansion, 209%; P < .0001). The 1-year freedom from target vessel instability was 91%. Conclusions The use of IVUS and fusion-guided TEAS offers a promising technique to facilitate TL expansion and false lumen exclusion in chronic dissecting aortic aneurysms before repair. The durability and long-term outcomes of this technique in a larger cohort remain to be elucidated.
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Affiliation(s)
- Mira T. Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Andres V. Figueroa
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - K. Benjamin Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jose Eduardo Costa Filho
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Marilisa Soto Gonzalez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mirza S. Baig
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H. Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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Suc G, Himbert D, Brochet E, Ducrocq G, Vahanian A, Urena M. Direct Transcatheter Mitral Valve-in-Ring Replacement to Treat a Failing Alfieri Valve Repair. JACC Cardiovasc Interv 2023; 16:1292-1294. [PMID: 37225297 DOI: 10.1016/j.jcin.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 05/26/2023]
Affiliation(s)
- Gaspard Suc
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Unité mixte de recherche en santé 1148, Institut national de la santé et de la recherche médicale, Paris, France; Université de Paris, Paris, France
| | - Dominique Himbert
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Unité mixte de recherche en santé 1148, Institut national de la santé et de la recherche médicale, Paris, France
| | - Eric Brochet
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Gregory Ducrocq
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Unité mixte de recherche en santé 1148, Institut national de la santé et de la recherche médicale, Paris, France; Université de Paris, Paris, France
| | - Alec Vahanian
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Unité mixte de recherche en santé 1148, Institut national de la santé et de la recherche médicale, Paris, France; Université de Paris, Paris, France
| | - Marina Urena
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Unité mixte de recherche en santé 1148, Institut national de la santé et de la recherche médicale, Paris, France; Université de Paris, Paris, France.
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Bruce CG, Khan JM, Rogers T, Yildirim DK, Babaliaros VC, Greenbaum AB, Lederman RJ. Transcatheter Electrosurgery: A Narrative Review. Circ Cardiovasc Interv 2023; 16:e012019. [PMID: 36799217 PMCID: PMC10108249 DOI: 10.1161/circinterventions.122.012019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/04/2023] [Indexed: 02/18/2023]
Abstract
Transcatheter electrosurgery describes the ability to cut and traverse tissue, at a distance, without an open surgical field and is possible using either purpose-built or off-the-shelf devices. Tissue traversal requires focused delivery of radiofrequency energy to a guidewire tip. Initially employed to cross atretic pulmonary valves, tissue traversal has enabled transcaval aortic access, recanalization of arterial and venous occlusions, transseptal access, and many other techniques. To cut tissue, the selectively denuded inner curvature of a kinked guidewire (the Flying-V) or a single-loop snare is energized during traction. Adjunctive techniques may complement or enable contemporary transcatheter procedures, whereas myocardial slicing or excision of ectopic masses may offer definitive therapy. In this contemporary review we discuss the principles of transcatheter electrosurgery, and through exemplary clinical applications highlight the range of therapeutic options offered by this versatile family of procedures.
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Affiliation(s)
- Christopher G. Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jaffar M. Khan
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- MedStar Washington Hospital Center, Washington, DC, USA
| | - D. Korel Yildirim
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Adam B. Greenbaum
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA, USA
| | - Robert J. Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Use of Electrosurgery in Interventional Cardiology. Interv Cardiol Clin 2022; 11:257-266. [PMID: 35710281 PMCID: PMC9596132 DOI: 10.1016/j.iccl.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Transcatheter electrosurgery is a versatile tool that can be used to cut cardiac tissue without the need for a sternotomy, cardiopulmonary bypass, and cardioplegia. With adequate imaging and suitable anatomy, any cardiac tissue can be cut. Thus, transcatheter electrosurgery can provide bespoke therapies for complex patients who often have no other good treatment options. In this review, we will discuss the common applications for electrosurgical tissue traversal and laceration, including transcaval access, BASILICA, LAMPOON, and ELASTA-Clip, summarizing the evidence and the key technical steps for each.
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Condado JF, Greenbaum A, Kamioka N, Rogers T, Khan JM, Lederman RJ, Babaliaros V. Leaflet Modification Technologies. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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The Art of SAPIEN 3 Transcatheter Mitral Valve Replacement in Valve-in-Ring and Valve-in-Mitral-Annular-Calcification Procedures. JACC Cardiovasc Interv 2021; 14:2195-2214. [PMID: 34674861 DOI: 10.1016/j.jcin.2021.08.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 11/20/2022]
Abstract
The SAPIEN 3 is the only transcatheter heart valve commercially available for compassionate transcatheter mitral valve replacement in patients with previous mitral surgical rings and mitral annular calcification (valve in ring [VIR] and valve in mitral annular calcification [VIM]). Reported outcomes have been inconsistent or poor. The review provides an overview of the authors' approach to achieve largely consistent results despite the intrinsic limitations of SAPIEN 3 VIM and VIR. The approach includes bedside modifications of the valve implant, the delivery system, and of the cardiac substrate itself. Until purpose-built devices are readily available, VIR and VIM procedures will require aggressive multidisciplinary cooperation, meticulous planning and execution, and postprocedure management by experienced, high-volume operators.
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Reasons for Screen Failure for Transcatheter Mitral Valve Repair and Replacement. Am J Cardiol 2021; 148:130-137. [PMID: 33667453 DOI: 10.1016/j.amjcard.2021.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 01/01/2023]
Abstract
Despite an expanding armamentarium of devices, many patients with mitral regurgitation referred for transcatheter mitral valve repair (TMVr) or replacement (TMVR) do not meet strict clinical trial inclusion and exclusion criteria. We sought to understand the rates that patients were excluded from transcatheter mitral valve therapies and reasons why. We retrospectively analyzed the medical charts and correspondence related to patients referred to our tertiary valve center for TMVr or TMVR between June 2016 and September 2019. Patients were screened for eligibility by our structural Heart Team for either TMVr or TMVR. If TMVr or TMVR was not offered, the reason for screen failure was recorded and categorized. Over the 3-year period, 564 patients were referred for TMVr and orTMVR. Out of these, 15.9% were determined to be eligible for, and underwent, surgical repair or replacement. Ninety-two patients (16.3%) underwent TMVr or TMVR. The majority of patients (343 of 564, 60.8%) ultimately did not undergo intervention. The primary reason for exclusion was clinical in 38.5%, issues related to patient preference of care delivery in 38.8%, anatomical in 13.7%, and futility in 9.0%. In contemporary real-world practice, the majority of patients with mitral regurgitation referred for transcatheter therapies are excluded. Clinical trials testing new transcatheter devices should be encouraged to record and report reasons for screen failure and follow these patients to better understand optimal timing of intervention, address challenging anatomies, and, ultimately, improve penetrance of these novel therapies.
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Khan JM, Rogers T, Greenbaum AB, Babaliaros VC, Lisko JC, Yildirim DK, Bruce CG, Herzka DA, Ratnayaka K, Lederman RJ. Advances in Transcatheter Electrosurgery for Treating Valvular Heart Disease. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Delivery of electrosurgery energy through catheters and guidewires enables interventionists to ‘cut’ through obstructive intravascular lesions or across cardiac chambers. A novel application of transcatheter electrosurgery is to make controlled lacerations in heart valve leaflets. This review describes three applications of transcatheter electrosurgery of aortic and mitral valve leaflets to enable transcatheter heart valve implantation. Intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow obstruction splits and splays the anterior mitral valve and enables transcatheter mitral valve replacement without left ventricular outflow tract obstruction. Technique modifications and novel applications are described. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction enables transcatheter aortic valve replacement without coronary artery obstruction. The technique is described and novel uses, especially in the setting of repeat transcatheter aortic valve replacement, are discussed. Finally, electrosurgical laceration and stabilization of mitral valve clip devices (ELASTA-Clip) enables transcatheter mitral valve replacement after MitraClip implantation. In conclusion, transcatheter electrosurgery is an important and versatile new tool in structural heart intervention.
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Affiliation(s)
- Jaffar M Khan
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD; Medstar Washington Hospital Center, Washington, DC
| | - Adam B Greenbaum
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA
| | | | - John C Lisko
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA
| | - Dursun Korel Yildirim
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Christopher G Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Daniel A Herzka
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Kanishka Ratnayaka
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD; UCSD Rady Children’s Hospital, San Diego, CA
| | - Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
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Lisko JC, Greenbaum AB, Guyton RA, Kamioka N, Grubb KJ, Gleason PT, Byku I, Condado JF, Jadue A, Paone G, Block PC, Alvarez L, Xie J, Khan JM, Rogers T, Lederman RJ, Babaliaros VC. Electrosurgical Detachment of MitraClips From the Anterior Mitral Leaflet Prior to Transcatheter Mitral Valve Implantation. JACC Cardiovasc Interv 2020; 13:2361-2370. [PMID: 33011144 PMCID: PMC7584767 DOI: 10.1016/j.jcin.2020.06.047] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/20/2020] [Accepted: 06/18/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The aim of this study was to test the hypothesis that transcatheter electrosurgery might allow intentional detachment of previously placed MitraClip(s) from the anterior leaflet to recreate a single mitral orifice for transcatheter mitral valve implantation (TMVI), leaving the retained MitraClip(s) securely fastened to the posterior leaflet and without interfering with the mitral bioprosthesis. BACKGROUND Patients with severe mitral regurgitation or stenosis despite edge-to-edge mitral repair with the MitraClip typically have few therapeutic options because the resultant double orifice precludes TMVI. Transcatheter electrosurgery may allow detachment of failed MitraClip(s) from the anterior leaflet to recreate a single orifice for TMVI. METHODS This was a single-center, 5-patient, consecutive, retrospective observational cohort. Patients underwent transcatheter electrosurgical laceration and stabilization of failed MitraClip(s) to recreate a single orifice, leaving the MitraClip(s) securely fastened to the posterior leaflet. Subsequently, patients underwent TMVI with an investigational device, the Tendyne mitral bioprosthesis, on a compassionate basis. Patients were followed up to 30 days. RESULTS MitraClip detachment from the anterior leaflet and Tendyne implantation were successful in all patients. All patients survived to discharge. All patients were discharged with grade 0 central mitral regurgitation. Two patients had moderate perivalvular mitral regurgitation that did not require reintervention. During the follow-up period of 30 days, there were no deaths, cases of valve dysfunction, or reintervention. There was no evidence of erosion or bioprosthetic valve dysfunction attributable to the retained MitraClip(s) still attached to the posterior leaflet. CONCLUSIONS Transcatheter electrosurgical detachment of failed MitraClips from the anterior leaflet followed by TMVI is technically feasible and safe at 30 days. Longer term study is needed to determine the clinical benefit of this approach and new algorithms for TMVI sizing following electrosurgical laceration and stabilization of a failed MitraClip to avoid perivalvular leak.
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Affiliation(s)
- John C Lisko
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Adam B Greenbaum
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Robert A Guyton
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Norihiko Kamioka
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Kendra J Grubb
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Patrick T Gleason
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Isida Byku
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Jose F Condado
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Andres Jadue
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Gaetano Paone
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Peter C Block
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Lucia Alvarez
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Joe Xie
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Jaffar M Khan
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Vasilis C Babaliaros
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia.
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Tiwana J, Aldea G, Levin DB, Johnson K, Don CW, Dvir D, Mackensen GB, Reisman M, McCabe JM. Contemporary Transcatheter Mitral Valve Replacement for Mitral Annular Calcification or Ring. JACC Cardiovasc Interv 2020; 13:2388-2398. [DOI: 10.1016/j.jcin.2020.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/25/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022]
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Preventing Coronary Obstruction During Transcatheter Aortic Valve Replacement: From Computed Tomography to BASILICA. JACC Cardiovasc Interv 2020; 12:1197-1216. [PMID: 31272666 DOI: 10.1016/j.jcin.2019.04.052] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 11/24/2022]
Abstract
Coronary artery obstruction is an uncommon but devastating complication of transcatheter aortic valve replacement (TAVR). Computed tomography appears to be a sensitive but nonspecific predictor of coronary artery obstruction. Transcatheter approaches to prevent and treat coronary artery obstruction, such as "snorkel" stenting, are unsatisfactory because of serious early and late ischemic complications. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction during TAVR (BASILICA) is an early-stage transcatheter procedure to prevent coronary artery obstruction. It works by splitting the native or bioprosthetic leaflets so that they splay after TAVR and preserve coronary artery inflow. Because of the paucity of suitable alternatives, there is interest in the BASILICA technique despite its infancy. This tutorial review summarizes current thinking about how to predict and prevent coronary artery obstruction using BASILICA. First, the authors depict the main pathophysiological mechanisms of TAVR-associated coronary artery obstruction, along with the factors thought to contribute to coronary obstruction. Next, the authors provide a step-by-step guide to analyzing pre-procedural computed tomographic findings to assess obstruction risk and, if desirable, to plan BASILICA. Next, the authors describe the mechanisms underlying transcatheter electrosurgery. Finally, they provide step-by-step guidance on how to perform the procedure, along with a required equipment list.
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Khan JM, Rogers T, Greenbaum AB, Babaliaros VC, Yildirim DK, Bruce CG, Herzka DA, Schenke WH, Ratnayaka K, Lederman RJ. Transcatheter Electrosurgery: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 75:1455-1470. [PMID: 32216915 PMCID: PMC7184929 DOI: 10.1016/j.jacc.2020.01.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 01/28/2023]
Abstract
Transcatheter electrosurgery refers to a family of procedures using radiofrequency energy to vaporize and traverse or lacerate tissue despite flowing blood. The authors review theory, simulations, and benchtop demonstrations of how guidewires, insulation, adjunctive catheters, and dielectric medium interact. For tissue traversal, all but the tip of traversing guidewires is insulated to concentrate current. For leaflet laceration, the "Flying V" configuration concentrates current at the inner lacerating surface of a kinked guidewire. Flooding the field with non-ionic dextrose eliminates alternative current paths. Clinical applications include traversing occlusions (pulmonary atresia, arterial and venous occlusion, and iatrogenic graft occlusion), traversing tissue planes (atrial and ventricular septal puncture, radiofrequency valve repair, transcaval access, Potts and Glenn shunts), and leaflet laceration (BASILICA, LAMPOON, ELASTA-Clip, and others). Tips are provided for optimizing these techniques. Transcatheter electrosurgery already enables a range of novel therapeutic procedures for structural heart disease, and represents a promising advance toward transcatheter surgery.
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Affiliation(s)
- Jaffar M Khan
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland; Medstar Washington Hospital Center, Washington, DC
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland; Medstar Washington Hospital Center, Washington, DC
| | - Adam B Greenbaum
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia
| | | | - Dursun Korel Yildirim
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Christopher G Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Daniel A Herzka
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - William H Schenke
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Kanishka Ratnayaka
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland; UCSD Rady Children's Hospital, San Diego, California
| | - Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
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Khan JM, Babaliaros VC, Greenbaum AB, Foerst JR, Yazdani S, McCabe JM, Paone G, Eng MH, Leshnower BG, Gleason PT, Chen MY, Wang DD, Tian X, Stine AM, Rogers T, Lederman RJ. Anterior Leaflet Laceration to Prevent Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Replacement. J Am Coll Cardiol 2020; 73:2521-2534. [PMID: 31118146 DOI: 10.1016/j.jacc.2019.02.076] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Left ventricular outflow tract (LVOT) obstruction is a leading cause of mortality and exclusion from transcatheter mitral valve replacement (TMVR). Intentional laceration of the anterior mitral valve leaflet to prevent LVOT obstruction (LAMPOON) is a transcatheter mimic of surgical chord-sparing leaflet resection. OBJECTIVES The purpose of this prospective multicenter trial was to study LAMPOON with transseptal (Edwards Lifesciences, Irvine, California) TMVR in annuloplasty rings or native mitral annular calcification (MAC). METHODS Subjects at high or extreme surgical risk and prohibitive risk of LVOT obstruction from TMVR were included. Eligibility was modified midtrial to exclude subjects with threatened LVOT obstruction from a Sapien 3 valve fabric skirt. The primary endpoint was procedure survival with successful LAMPOON, with successful TMVR, without reintervention, and with LVOT gradient <30 mm Hg ("optimal") or <50 mm Hg ("acceptable"). Secondary endpoints included 30-day mortality and major adverse cardiovascular events. There was universal source-data verification and independent monitoring. All endpoints were independently adjudicated. Central laboratories analyzed echocardiogram and CT images. RESULTS Between June 2017 and June 2018, 30 subjects were enrolled equally between the MAC and ring arms. LAMPOON traversal and midline laceration was successful in 100%. Procedure survival was 100%, and 30-day survival was 93%. Primary success was achieved in 73%, driven by additional procedures for paravalvular leak (10%) and high-skirt neo-LVOT gradients observed before a protocol amendment. There were no strokes. CONCLUSIONS LAMPOON was feasible in native and annuloplasty ring anatomies in patients who were otherwise ineligible for treatment, with acceptable safety. LAMPOON was effective in preventing LVOT obstruction from TMVR. Despite LAMPOON, TMVR using Sapien 3 in annuloplasty rings and MAC still exhibits important limitations. (NHLBI DIR LAMPOON Study: Intentional Laceration of the Anterior Mitral Leaflet to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Implantation; NCT03015194).
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Affiliation(s)
- Jaffar M Khan
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Adam B Greenbaum
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia; Center for Structural Heart Disease, Division of Cardiology, and Division of Cardiac Surgery, Henry Ford Health System, Detroit, Michigan
| | | | | | | | - Gaetano Paone
- Center for Structural Heart Disease, Division of Cardiology, and Division of Cardiac Surgery, Henry Ford Health System, Detroit, Michigan
| | - Marvin H Eng
- Center for Structural Heart Disease, Division of Cardiology, and Division of Cardiac Surgery, Henry Ford Health System, Detroit, Michigan
| | - Bradley G Leshnower
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia
| | - Patrick T Gleason
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia
| | - Marcus Y Chen
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Dee Dee Wang
- Center for Structural Heart Disease, Division of Cardiology, and Division of Cardiac Surgery, Henry Ford Health System, Detroit, Michigan
| | - Xin Tian
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Annette M Stine
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland; Medstar Washington Hospital Center, Washington, DC
| | - Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
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14
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Moliterno DJ, Windecker S. Mitral Regurgitation and Evolving Transcatheter Treatments: Insights From the JACC Family of Journals. J Am Coll Cardiol 2019; 73:1353-1357. [PMID: 30898211 DOI: 10.1016/j.jacc.2019.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
| | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center, University of Bern, Bern, Switzerland
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15
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Sorajja P, Bae R, Gössl M, Askew J, Jappe K, Olson S, Schneider L, Sun B. Complementary Transcatheter Therapy for Mitral Regurgitation. J Am Coll Cardiol 2019; 73:1103-1104. [DOI: 10.1016/j.jacc.2018.12.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/14/2018] [Accepted: 12/20/2018] [Indexed: 11/25/2022]
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16
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Garcia S, Mbai M, Kelly R, Bertog S. Simultaneous transfemoral transcatheter aortic valve replacement and trans-septal mitral valve-in-ring implantation after partial laceration of an Alfieri stitch. Catheter Cardiovasc Interv 2019; 93:559-561. [PMID: 30244527 DOI: 10.1002/ccd.27875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/20/2018] [Accepted: 08/26/2018] [Indexed: 11/09/2022]
Abstract
In patients with an Alfieri Stitch transcatheter mitral valve replacement (TMVR) may be difficult due to the double orifice configuration of the mitral valve. We report a case of simultaneous and completely percutaneous TAVR and TMVR using LAMPOON-related techniques prior to TMVR to allow for optimal valve deployment.
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Affiliation(s)
- Santiago Garcia
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota.,Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota.,Minneapolis VA Healthcare System, Minneapolis, Minnesota
| | - Mackenzie Mbai
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota.,Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota.,Minneapolis VA Healthcare System, Minneapolis, Minnesota
| | - Rosemary Kelly
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Division of Cardiothoracic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Stefan Bertog
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota.,Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota.,Minneapolis VA Healthcare System, Minneapolis, Minnesota
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