Transcatheter Myotomy to Reduce Left Ventricular Outflow Obstruction

BACKGROUND

Left ventricular outflow tract (LVOT) obstruction is a source of morbidity in hypertrophic cardiomyopathy (HCM) and a life-threatening complication of transcatheter mitral valve replacement (TMVR) and transcatheter aortic valve replacement (TAVR). Available surgical and transcatheter approaches are limited by high surgical risk, unsuitable septal perforators, and heart block requiring permanent pacemakers.

OBJECTIVES

The authors report the initial experience of a novel transcatheter electrosurgical procedure developed to mimic surgical myotomy.

METHODS

We used septal scoring along midline endocardium (SESAME) to treat patients, on a compassionate basis, with symptomatic LVOT obstruction or to create space to facilitate TMVR or TAVR.

RESULTS

In this single-center retrospective study between 2021 and 2023, 76 patients underwent SESAME. In total, 11 (14%) had classic HCM, and the remainder underwent SESAME to facilitate TMVR or TAVR. All had technically successful SESAME myocardial laceration. Measures to predict post-TMVR LVOT significantly improved (neo-LVOT 42 mm2 [Q1-Q3: 7-117 mm2] to 170 mm2 [Q1-Q3: 95-265 mm2]; P < 0.001; skirt-neo-LVOT 169 mm2 [Q1-Q3: 153-193 mm2] to 214 mm2 [Q1-Q3: 180-262 mm2]; P < 0.001). Among patients with HCM, SESAME significantly decreased invasive LVOT gradients (resting: 54 mm Hg [Q1-Q3: 40-70 mm Hg] to 29 mm Hg [Q1-Q3: 12-36 mm Hg]; P = 0.023; provoked 146 mm Hg [Q1-Q3: 100-180 mm Hg] to 85 mm Hg [Q1-Q3: 40-120 mm Hg]; P = 0.076). A total of 74 (97.4%) survived the procedure. Five experienced 3 of 76 (3.9%) iatrogenic ventricular septal defects that did not require repair and 3 of 76 (3.9%) ventricular free wall perforations. Neither occurred in patients treated for HCM. Permanent pacemakers were required in 4 of 76 (5.3%), including 2 after concomitant TAVR. Lacerations were stable and did not propagate after SESAME (remaining septum: 5.9 ± 3.3 mm to 6.1 ± 3.2 mm; P = 0.8).

CONCLUSIONS

With further experience, SESAME may benefit patients requiring septal reduction therapy for obstructive hypertrophic cardiomyopathy as well as those with LVOT obstruction after heart valve replacement, and/or can help facilitate transcatheter valve implantation.

Left Ventricular Outflow Tract Modification for Transcatheter Mitral Valve Replacement

Left ventricular outflow tract (LVOT) obstruction is a life-threatening complication of transcatheter mitral valve replacement. In-depth analysis of pre-procedural computed tomography enables accurate prediction of this risk. Several techniques for LVOT modification, including Laceration of the Anterior Mitral leaflet to Prevent Outflow ObtructioN, preemptive alcohol septal ablation, preemptive radiofrequency ablation, and Septal Scoring Along the Midline Endocardium, have been described as effective strategies to mitigate this risk. This review aims to explore the indications, procedural steps, and outcomes associated with these LVOT modification techniques.

EDEN (Electrocardiographic Radial Depth Navigation): A Novel Approach to Navigate Inside Heart Muscle

BACKGROUND

Intramyocardial guidewire navigation is a novel technique that allows free transcatheter movement within ventricular muscle. Guidewire radial depth, between endocardial and epicardial surfaces, is ambiguous by x-ray and echocardiography.

OBJECTIVES

The aim of this study was to develop a simple tool, EDEN (Electrocardiographic Radial Depth Navigation), to indicate radial depth during intramyocardial guidewire navigation. Combined with routine imaging, EDEN facilitates a new family of intramyocardial catheter procedures to slice, reshape, pace, and ablate the heart.

METHODS

We mapped intramyocardial electrograms of left and right ventricular walls and septum during open- and closed-chest swine procedures (N = 53), including MIRTH (Myocardial Intramural Remodeling by Transvenous Tether) ventriculoplasty. We identified radial depth-dependent features on unipolar electrograms. We developed a machine learning-based classifier to indicate categorical position, and modeled the findings in silico to test understanding of the physiology.

RESULTS

EDEN signatures distinguished 5 depth zones throughout left and right ventricular free walls and interventricular septum. Relative ST-segment elevation magnitude best discriminated position and was maximum (40.1 ± 6.5 mV) in the midmyocardium. Subendocardial positions exhibited dominant Q waves with lower-amplitude ST segments (16.8 ± 5.8 mV), whereas subepicardial positions exhibited dominant R waves with lower-amplitude ST segments (15.7 ± 4.8 mV). EDEN was unaffected by pacing-induced left bundle branch block. ST-segment elevation declined over minutes and reappeared after submillimeter guidewire manipulation. Modeling recapitulated EDEN features. The machine learning-based classifier was 97% accurate. EDEN successfully guided MIRTH ventriculoplasty.

CONCLUSIONS

EDEN provides a simple and reproducible real-time reflection of categorical guidewire-tip radial depth during intramyocardial guidewire navigation. Used in tandem with x-ray, EDEN enables novel, transcatheter, intramyocardial therapies such as MIRTH, SESAME (Septal Surfing Along Midline Endocardium), and cerclage ventriculoplasty.

Coupling between γ-irradiation and synchrotron-radiation-based XAFS techniques for studying Mn-doped ZnO nanoparticles

γ-Irradiation and synchrotron-radiation-based X-ray absorption fine-structure (XAFS) spectroscopy have been used to induce structure disorder through the interaction of γ-rays (200 kGy) with fabricated Mn-doped ZnO nanoparticles (NPs) and then to examine thoroughly the resultant structural change. The extracted electronic/fine XAFS structural parameters reflect a compositional and γ-irradiation co-dependence. The average crystal structure of samples prepared by the sol-gel method was investigated by X-ray diffraction (XRD). A detailed structural XRD data analysis was carried out by applying a Rietveld refinement using the MAUD program. XAFS spectra were collected at the Zn K-edge (9659 eV) in transmission mode and at the Mn K-edge (6539 eV) in fluorescence mode. Direct evidence of the solubility of Mn ions in the ZnO structure was demonstrated by fitting the extended-XAFS (EXAFS) signal. Near-edge XAFS (XANES) analysis provided the oxidation states of Zn and Mn ions through fingerprint XANES spectra of the sample along with those of standard compounds. Linear combination fitting showed that the most fit chemical forms of Zn and Mn in the samples are ZnO and MnO, respectively. The oxidation states of both Zn and Mn XAFS absorbers were confirmed from pre-edge fitting. The results of the magnetic measurements were explained in light of the average and electronic/local structural information obtained from XRD, XANES and EXAFS techniques. The magnetic properties of the samples translate into an induced change in the average crystal and electronic/local structures upon Mn concentration change and γ-irradiation. XRD confirmed the successful preparation of hexagonal Mn-doped ZnO NPs with a crystallite size in the range 33-41 nm. Both XRD and EXAFS analysis detected a minor amount of Mn₃O₄ as a secondary phase. XANES and EXAFS provided information exploring the outstanding potential of the utilized protocol for detecting precisely the presence of the secondary phase of Mn₃O₄, which changes with Mn content (x). Mean-square relative displacement (σ²) values extracted from the EXAFS fitting were found to grow for Zn-Zn/Mn paths demonstrating the substitution of Mn/Zn into Zn crystal sites. The EXAFS analysis explains the reasons behind the enhancement in the magnetic properties and shows that the Mn doping content at x = 0.05 produces the most local atomic disorder in ZnO NPs. There is a strong harmony among the XRD, XANES, EXAFS and magnetization behavior of the Mn-doped ZnO NPs. Maximum magnetization was acquired at an Mn content of 0.05. γ-Ray-irradiated Zn_1-xMn_xO NPs are recommended as optimized candidates for showing the diversity of the applications.

Emergence of the first XAFS/XRF beamline in the Middle East: providing studies of elements and their atomic/electronic structure in pluridisciplinary research fields

XAFS/XRF is a general-purpose absorption spectroscopy beamline at the Synchrotron-light for Experimental Science and Applications in the Middle East (SESAME), Jordan. Herein, its optical layout is presented along with its powerful capabilities in collecting absorption and fluorescence spectra within a wide energy range (4.7-30 keV). The beamline is equipped with a conventional fixed-exit double-crystal monochromator that allows the collection of an X-ray absorption spectrum within a few minutes in step-by-step mode. An on-the-fly scanning mode will be implemented shortly where the acquisition time will be reduced to less than a minute per scan. The full automation of the beamline allows performing successive measurements under different conditions. The different experimental setups and special features available to users are reported. Examples of XRF and XAFS measurements are presented, showing the performance of the beamline under different standard conditions.

SESAME - a synchrotron light source in the Middle East: an international research infrastructure in the making

SESAME (Synchrotron-light for Experimental Science and Applications in the Middle East) is an international research centre located in Jordan. The centre was established in the late 1990s with the intention to foster scientific cooperation in a region of the world that has been torn by persistent conflicts. The project is built on the idea that science can help to overcome barriers and cultural differences within the common ground of science and research. SESAME's core ambition is to operate an international state-of-the-art synchrotron users' facility in the north of Amman that is accessible to scientists from all of its members: Cyprus, Egypt, Iran, Israel, Pakistan, Palestine, Turkey and Jordan. Accordingly, SESAME has been often praised as a paramount example of science diplomacy. Our intention for this report was to investigate a concrete international research infrastructure with a specific science diplomacy interest. What were the enabling conditions for such a project to come into being and what keeps SESAME running? What were the challenges and obstacles? How does the composition of member states play into that? How is SESAME related to (and embedded in) the global synchrotron community, academia, researchers and political actors in the region and the world? Did the science diplomacy ambition behind the project turn out to be successful and how does it affect SESAME's future?