Publications by authors named "Paul T L Chiam"

31 Publications

Sex differences in patients undergoing transcatheter aortic valve replacement in Asia.

Open Heart 2021 01;8(1)

Department of Cardiology, Sichuan University West China Hospital, Chengdu, China.

Objectives: Transcatheter aortic valve replacement (TAVR) is increasingly performed. Physically small Asians have smaller aortic root and peripheral vessel anatomy. The influence of gender of Asian patients undergoing TAVR is unknown and may affect outcomes. The aim of this study was to assess sex differences in Asian patients undergoing TAVR.

Methods: Patients undergoing TAVR from eight countries were enrolled. In this retrospective analysis, we examined differences in characteristics, 30-day clinical outcomes and 1-year survival between female and male Asian patients.

Results: Eight hundred and seventy-three patients (54.4% women) were included. Women were older, smaller and had less coronary artery and lung disease but tended to have higher logistic EuroSCOREs. Smaller prostheses were used more often in women. Major vascular complications occurred more frequently in women (5.5% vs 1.8%, p<0.01); however, 30-day stroke and mortality (women vs men: 1.5% vs 1.6%, p=0.95% and 4.3% vs 3.4%, p=0.48) were similar. Functional status improvement was significant and comparable between the sexes. Conduction disturbance and permanent pacemaker requirements (11.2% vs 9.0%, p=0.52) were also similar as was 1-year survival (women vs men: 85.6% vs 88.2%, p=0.25). The only predictors of 30-day mortality were major vascular injury in women and age in men.

Conclusions: Asian women had significantly smaller stature and anatomy with some differences in clinical profiles. Despite more frequent major vascular complications, women had similar 30-day stroke or mortality rates. Functional status improvement was significant and comparable between the sexes. Conduction disturbance and permanent pacemaker requirements were similar as was 1-year survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/openhrt-2020-001541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798412PMC
January 2021

Transcatheter aortic valve implantation in Asia: the first decade.

Authors:
Paul T L Chiam

EuroIntervention 2018 05;14(1):35-37

The Heart & Vascular Centre, Mount Elizabeth Hospital, Singapore; Dept of Physiology, YLL School of Medicine, National University of Singapore, Singapore.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4244/EIJV14I1A6DOI Listing
May 2018

Quantified degree of eccentricity of aortic valve calcification predicts risk of paravalvular regurgitation and response to balloon post-dilation after self-expandable transcatheter aortic valve replacement.

Int J Cardiol 2018 05 27;259:60-68. Epub 2017 Dec 27.

Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul 03080, South Korea. Electronic address:

Background: Limited data exist regarding the impact of aortic valve calcification (AVC) eccentricity on the risk of paravalvular regurgitation (PVR) and response to balloon post-dilation (BPD) after transcatheter aortic valve replacement (TAVR). We investigated the prognostic value of AVC eccentricity in predicting the risk of PVR and response to BPD in patients undergoing TAVR.

Methods: We analyzed 85 patients with severe aortic stenosis who underwent self-expandable TAVR (43 women; 77.2±7.1years). AVC was quantified as the total amount of calcification (total AVC load) and as the eccentricity of calcium (EoC) using calcium volume scoring with contrast computed tomography angiography (CTA). The EoC was defined as the maximum absolute difference in calcium volume scores between 2 adjacent sectors (bi-partition method) or between sectors based on leaflets (leaflet-based method).

Results: Total AVC load and bi-partition EoC, but not leaflet-based EoC, were significant predictors for the occurrence of ≥moderate PVR, and bi-partition EoC had a better predictive value than total AVC load (area under the curve [AUC]=0.863 versus 0.760, p for difference=0.006). In multivariate analysis, bi-partition EoC was an independent predictor for the risk of ≥moderate PVR regardless of perimeter oversizing index. The greater bi-partition EoC was the only significant parameter to predict poor response to BPD (AUC=0.775, p=0.004).

Conclusion: Pre-procedural assessment of AVC eccentricity using CTA as "bi-partition EoC" provides useful predictive information on the risk of significant PVR and response to BPD in patients undergoing TAVR with self-expandable valves.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2017.12.052DOI Listing
May 2018

The expanding indications of transcatheter aortic valve implantation.

Future Cardiol 2016 Mar 26;12(2):209-19. Epub 2016 Feb 26.

Department of Cardiology, National Heart Centre, 5 Hospital Dr, 169609, Singapore.

Transcatheter aortic valve implantation (TAVI), also known as transcatheter aortic valve replacement, is increasingly performed worldwide and is a technology that is here to stay. It has become the treatment of choice for inoperable patients and an alternative option for patients at high surgical risk with severe aortic stenosis. Early results of TAVI in intermediate-risk patients appear promising although larger randomized trial results are awaited before the widespread adoption of this technology in this big pool of patients. In patients with bicuspid aortic stenosis and degenerated surgical bioprostheses, TAVI has been shown to be feasible and relatively safe, though certain important considerations remain. Indications for TAVI are likely to grow as newer generation and improved devices and delivery systems become available.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2217/fca.15.86DOI Listing
March 2016

Transcatheter aortic valve implantation in patients with bicuspid aortic valve: A patient level multi-center analysis.

Int J Cardiol 2015 11;189:282-8. Epub 2015 Apr 11.

Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Electronic address:

Objective: We sought to evaluate the safety and efficacy of transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valve (BiAV).

Background: BiAV remains a relative contraindication to TAVI resulting in exclusion from TAVI trials and thus limiting data on the clinical performance of transcatheter valves in these patients.

Methodology: We conducted an international patient level multicenter analysis on outcomes in patients with BiAV undergoing TAVI. The primary outcome of the study was the combined early safety endpoint--a composite of 30 day mortality, stroke, life-threatening bleeding, acute kidney injury, coronary artery obstruction, major vascular complication and valve related dysfunction. Secondary endpoints included the individual components of the primary endpoint as well as post-TAVI paravalvular leak (PVL), rehospitalization, new pacemaker insertion and device success rates at 30 days and 1 year.

Results: A total of 108 patients with BiAV were identified in 21 centers in Canada, Spain, Italy, Poland and Singapore who underwent TAVI between January 2005 and March 2014. The composite primary outcome occurred in one quarter of patients (26.9%)--mainly driven by re-intervention for valve malposition (9.3%). The 30-day and 1 year mortality rates were 8.3% and 16.9% respectively with AR ≥ 3+ occurring in 9.6% of patients. Device success was achieved in 85.2% of cases with pacemaker insertion in 19.4%. While PVL was not associated with an increased risk of 30 day or 1 year mortality--Type I BiAV anatomy with left and right cusp fusion had significantly better outcomes than other valve variants.

Conclusion: In selected patients with BiAV and severe aortic stenosis, TAVI appears both safe and feasible with acceptable clinical outcomes. Clinical studies of TAVI in this patient population are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2015.04.066DOI Listing
April 2016

Post-implantation transcatheter aortic valve migration in a left ventricular assist device patient with severe aortic insufficiency.

Eur Heart J 2014 Jun 13;35(24):1616. Epub 2013 Dec 13.

Department of Cardiothoracic Surgery, National Heart Centre Singapore, Mistri Wing, 17 Third Hospital Avenue, Singapore, Singapore;

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/eurheartj/eht516DOI Listing
June 2014

An update on complications associated with transcatheter aortic valve implantation: stroke, paravalvular leak, atrioventricular block and perforation.

Future Cardiol 2013 Sep;9(5):733-47

Department of Cardiology, National Heart Centre Singapore, 17 Third Hospital Avenue, Mistri Wing, 168752 Singapore.

Transcatheter aortic valve implantation (TAVI) has become an alternative therapeutic option for patients with symptomatic severe aortic stenosis at high surgical risk and the standard of care in patients who are inoperable for open aortic valve replacement. With technological evolution and increasing experience, the procedure has become more predictable. Complications of TAVI, however, are not infrequent, and can range from minor to life-threatening events. Stroke, paravalvular leak, various forms of atrioventricular block, including the need for permanent pacemakers and aortic annular and ventricular perforation will be the focus of the present review. Other complications associated with TAVI (such as vascular injury, acute kidney injury, coronary obstruction, valve malpositioning or migration) are clinically important, but are beyond the scope of this article. Understanding the occurrence and pathophysiology of these complications may provide insights into the improvement of the transcatheter devices and techniques, and aid in extending the application of TAVI to a broader population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2217/fca.13.43DOI Listing
September 2013

Feasibility of transcatheter aortic valve implantation in systemic lupus erythematosus associated non-calcific aortic stenosis.

Eur Heart J 2014 Jun 6;35(24):1624. Epub 2013 Sep 6.

Department of Cardiology, National Heart Centre Singapore, 17 Third Hospital Avenue, Mistri Wing, Singapore 168752, Singapore

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/eurheartj/eht354DOI Listing
June 2014

Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry.

J Am Coll Cardiol 2013 Oct 14;62(17):1552-62. Epub 2013 Aug 14.

Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada.

Objectives: This study sought to evaluate the main baseline and procedural characteristics, management, and clinical outcomes of patients from a large cohort of patients undergoing transcatheter aortic valve implantation (TAVI) who suffered coronary obstruction (CO).

Background: Very little data exist on CO following TAVI.

Methods: This multicenter registry included 44 patients who suffered symptomatic CO following TAVI of 6,688 patients (0.66%). Pre-TAVI computed tomography data was available in 28 CO patients and in a control group of 345 patients (comparisons were performed including all patients and a cohort matched 1:1 by age, sex, previous coronary artery bypass graft, transcatheter valve type, and size).

Results: Baseline and procedural variables associated with CO were older age (p < 0.001), female sex (p < 0.001), no previous coronary artery bypass graft (p = 0.043), the use of a balloon-expandable valve (p = 0.023), and previous surgical aortic bioprosthesis (p = 0.045). The left coronary artery was the most commonly involved (88.6%). The mean left coronary artery ostia height and sinus of Valsalva diameters were lower in patients with obstruction than in control subjects (10.6 ± 2.1 mm vs. 13.4 ± 2.1 mm, p < 0.001; 28.1 ± 3.8 mm vs. 31.9 ± 4.1 mm, p < 0.001). Differences between groups remained significant after the case-matched analysis (p < 0.001 for coronary height; p = 0.01 for sinus of Valsalva diameter). Most patients presented with persistent severe hypotension (68.2%) and electrocardiographic changes (56.8%). Percutaneous coronary intervention was attempted in 75% of the cases and was successful in 81.8%. Thirty-day mortality was 40.9%. After a median follow-up of 12 (2 to 18) months, the cumulative mortality rate was 45.5%, and there were no cases of stent thrombosis or reintervention.

Conclusions: Symptomatic CO following TAVI was a rare but life-threatening complication that occurred more frequently in women, in patients receiving a balloon-expandable valve, and in those with a previous surgical bioprosthesis. Lower-lying coronary ostium and shallow sinus of Valsalva were associated anatomic factors, and despite successful treatment, acute and late mortality remained very high, highlighting the importance of anticipating and preventing the occurrence of this complication.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2013.07.040DOI Listing
October 2013

Iliofemoral anatomy among Asians: implications for transcatheter aortic valve implantation.

Int J Cardiol 2013 Aug 21;167(4):1373-9. Epub 2012 Apr 21.

Department of Cardiology, National Heart Centre Singapore, Singapore.

Background/objectives: This study aims to examine iliofemoral anatomy and predictors of vessel size and tortuosity in Asian patients as transfemoral transcatheter aortic valve implantation (TAVI) may be limited by the smaller Asian physique.

Methods: Characteristics and vessel dimensions of 549 patients undergoing ultrasonography were reviewed. The minimal luminal diameter (MLD) along the iliofemoral vasculature of each side was identified and the larger of the two sides was used to determine suitability for transfemoral TAVI.

Results: The mean age was 66 ± 11 years (68% males). Mean iliac MLD was 7.6 ± 1.7 mm, females smaller than males (7.2 ± 1.7 vs 7.8 ± 1.7, p<0.001). Mean iliac MLD decreased with age: 7.9 ± 1.7 mm, 7.4 ± 1.9 mm and 7.3 ± 1.6mm for ages <70 years, 70-79 years and ≥ 80 years respectively (p=0.038). Mean femoral MLD was 7.0 ± 1.7 mm, females smaller than males (6.3 ± 1.5mm vs 7.3 ± 1.8mm, p<0.001). Females were more likely than males to have iliac and femoral MLD <6mm (20% vs 12%, p=0.019 and 34% vs 21%, p=0.001). Independent predictors of smaller iliofemoral dimensions were female gender, lower body surface area, diabetes mellitus, dyslipidemia and smoking history. Significant iliac tortuosity was present in 11.8%, more frequent in males than females (15% vs 6%, p=0.005), and in those with logistic EuroSCORE ≥ 15 than <15 (27% vs 10%, p=0.001).

Conclusions: This study establishes the mean iliac and femoral artery diameters in a cohort of relatively young Asian patients. Age and female gender were associated with smaller vessel dimension and several independent predictors of smaller vasculature and tortuosity were identified. These results have implications for TF TAVI in Asia.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2012.04.001DOI Listing
August 2013

A survivor of late prosthesis migration and rotation following percutaneous transcatheter aortic valve implantation.

Eur J Cardiothorac Surg 2012 May 6;41(5):1195-6. Epub 2012 Jan 6.

Department of Cardiothoracic Surgery, National Heart Centre, Singapore, Singapore.

Transcatheter aortic valve implantation (TAVI) has emerged as a viable alternative endovascular technique in selected patients with severe aortic stenosis, who are either inoperable or at high risk for surgical aortic valve replacement. We report a case of delayed displacement and rotation of an aortic bioprosthesis, 43 days after successful TAVI via the transfemoral approach, with the patient surviving the subsequent open heart surgery required for device retrieval.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ejcts/ezr195DOI Listing
May 2012

Comparison of novel 6.5 Fr sheathless guiding catheters versus 5 Fr guiding catheters for transradial coronary intervention.

EuroIntervention 2011 Dec;7(8):930-5

Department of Cardiology, National Heart Center Singapore, Singapore.

Aims: To assess the safety and efficacy of a novel sheathless (SH) 6.5 Fr (French) hydrophilic-coated guiding catheter (GC) compared to the standard 5 Fr GCs in transradial coronary interventions (TRI).

Methods And Results: Patients undergoing TRI with 6.5 Fr SH or 5 Fr GCs were included. Baseline characteristics and in-hospital outcomes were recorded. Primary endpoints were procedural success and presence of radial pulse at discharge. Secondary endpoints were successful GC support, in-hospital adverse events, access-site complications, procedural duration and contrast load. There were 269 patients with 146 procedures in each group. The SH GC group had more non-ST elevation MI, in-stent restenosis, high-risk and bifurcation lesions. Procedural success in both arms was 95.2%. One patient in each group (0.7%) experienced radial artery occlusion (RAO) after TRI, without clinical sequelae. One access-site haematoma and one minor stroke occurred in the 5 Fr group (none in the SH group, both p=ns). Mean procedure time (52±21 vs. 45±21 minutes, p=0.004) and contrast load (160±45 ml vs. 140±45 ml, p=0.003) were greater in the SH group.

Conclusions: Both 6.5 Fr SH GCs and 5 Fr GCs achieved high procedural TRI success with low RAO rates. The SH GC eliminated the disadvantages of the 5 Fr GC whilst maintaining the advantage of low RAO rates, and may become the GC of choice in TRI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4244/EIJV7I8A147DOI Listing
December 2011

Clinical outcomes in patients undergoing percutaneous closure of periprosthetic paravalvular leaks.

J Am Coll Cardiol 2011 Nov;58(21):2210-7

Lenox Hill Heart and Vascular Institute,130 East 77th Street, New York, NY 10021-10075, USA.

Objectives: The purpose of this study was to evaluate the feasibility and efficacy of the percutaneous device closure of a consecutive series of patients with periprosthetic paravalvular leaks referred to our structural heart disease center with congestive heart failure and hemolytic anemia.

Background: Clinically significant periprosthetic paravalvular leak is an uncommon but serious complication after surgical valve replacement. Percutaneous closure has been utilized as an alternative to surgical repair of this defect in high-risk surgical patients.

Methods: This is a retrospective review of 57 percutaneous paravalvular leak closures that were performed in 43 patients (67% male, mean age 69.4 ± 11.7 years) between April 2006 and September 2010. Integrated imaging modalities were used for the evaluation, planning, and guidance of the interventions.

Results: Closure was successful in 86% of leaks and in 86% of patients. Twenty-eight of 35 patients improved by at least 1 New York Heart Association functional class. The percentage of patients requiring blood transfusions and/or erythropoietin injections post-procedure decreased from 56% to 5%. Clinical success was achieved in 89% of the patients in whom procedure was successful. The survival rates for patients at 6, 12, and 18 months after paravalvular leak closures were 91.9%, 89.2%, and 86.5%, respectively. Freedom from cardiac-related death at 42 months post-procedure was 91.9%.

Conclusions: Percutaneous closure of symptomatic paravalvular leaks, facilitated by integrated imaging modalities has a high rate of acute and long-term success and appears to be effective in managing symptoms of heart failure and hemolytic anemia.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2011.03.074DOI Listing
November 2011

Percutaneous transcatheter mitral valve repair: a classification of the technology.

JACC Cardiovasc Interv 2011 Jan;4(1):1-13

Department of Cardiology, National Heart Centre, Singapore, Singapore.

Surgical treatment of mitral regurgitation (MR) has evolved from mitral valve replacement (MVR) to repair (MVR(e)), because MVR(e) produces superior long-term outcomes. In addition, MVR(e) can be achieved through minimally invasive approaches. This desire for less invasive approaches coupled with the fact that a significant proportion of patients--especially elderly persons or those with significant comorbidities or severe left ventricular (LV) dysfunction, are not referred for surgery, has driven the field of percutaneous MVR(e). Various technologies have emerged and are at different stages of investigation. A classification of percutaneous MVR(e) technologies on the basis of functional anatomy is proposed that groups the devices into those targeting the leaflets (percutaneous leaflet plication, percutaneous leaflet coaptation, percutaneous leaflet ablation), the annulus (indirect: coronary sinus approach or an asymmetrical approach; direct: true percutaneous or a hybrid approach), the chordae (percutaneous chordal implantation), or the LV (percutaneous LV remodeling). The percutaneous edge-to-edge repair technology has been shown to be noninferior to open repair in a randomized clinical trial (EVEREST II [Endovascular Valve Edge-to-Edge REpair Study]). Several other technologies employing the concepts of direct and indirect annuloplasty and LV remodeling have achieved first-in-man results. Most likely a combination of these technologies will be required for satisfactory MVR(e). However, MVR(e) is not possible for many patients, and MVR will be required. Surgical MVR is the standard of care in such patients, although percutaneous options are under development.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcin.2010.09.023DOI Listing
January 2011

How should I treat a percutaneous transcatheter mitral paravalvular leak closure?

EuroIntervention 2010 Nov;6(5):653-9

Department of Cardiology, National Heart Centre, Singapore.

Background: A 49-year-old female presented with worsening exertional dyspnea (NYHA class III) and orthopnea for several months. Previous medical history was significant for rheumatic mitral regurgitation and three previous mitral valve replacements (MVRs).

Investigation: Transesophageal echocardiography (TEE) revealed severe mitral paravalvular leak (PVL with two jets visualised. Cardiac computed tomography angiography (CTA) revealed a larger PVL and a smaller defect.

Diagnosis: Severe mitral paravalvular leak.

Treatment: Transcatheter mitral paravalvular closure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4244/EIJV6I5A108DOI Listing
November 2010

Risk stratification for sudden cardiac death after acute myocardial infarction.

Ann Acad Med Singap 2010 Mar;39(3):237-46

Department of Cardiology, National Heart Centre, Singapore.

Many patients who survive an acute myocardial infarction (AMI) remain at risk of recurrent cardiac events and sudden cardiac death after discharge, despite optimal medical treatment. Assessment of the degree of left ventricular dysfunction and residual myocardial ischaemia is useful to identify the patients at greatest risk. In addition, there is increasing evidence that a number of other cardiovascular tests can be used to detect autonomic dysfunction and myocardial substrate abnormalities postAMI that increase the risk of life-threatening ventricular arrhythmias. These investigations include ECG-based tests (signal averaged ECG and T-wave alternans), Holter-based recordings (heart rate variability and heart rate turbulence) and imaging techniques (echocardiography and cardiac magnetic resonance), as well as invasive electrophysiological testing. This article reviews the current evidence for the use of these additional cardiac investigations among survivors of AMI to aid in their risk stratification for malignant ventricular arrhythmias and sudden cardiac death.
View Article and Find Full Text PDF

Download full-text PDF

Source
March 2010

Adjunctive pharmacologic agents and mechanical devices in primary percutaneous coronary intervention.

Ann Acad Med Singap 2010 Mar;39(3):230-6

Department of Cardiology, National Heart Centre, Singapore.

Primary percutaneous coronary intervention (PPCI) has been shown to be superior to thrombolysis in patients presenting with ST-segment elevation acute myocardial infarction (STEMI) in reducing death, stroke and re-infarction. However, bleeding and thrombotic complications can occur despite successful PPCI and slow fl ow/no-reflow or poor microvascular reperfusion can occur in a significant minority despite a technically successful procedure. Bleeding or need for peri-procedural transfusion has been shown to increase short- and long-term mortality. Newer anticoagulants appear to reduce the bleeding risk and improve overall clinical outcomes. A novel combination of antiplatelet agents also appears to further improve the outcomes after PPCI. Although PPCI can achieve high rates of epicardial artery patency, some patients experience suboptimal microvascular perfusion, which affects long-term prognosis. Several pharmacologic agents have been shown to improve microvascular perfusion and left ventricular function, although none impacts on clinical outcomes. Of the mechanical devices available to reduce distal embolisation, the simple aspiration catheter holds the most promise in reducing clinical adverse events. Additional research and well designed studies are needed to further enhance the outcomes after PPCI.
View Article and Find Full Text PDF

Download full-text PDF

Source
March 2010

Percutaneous transcatheter aortic valve implantation: assessing results, judging outcomes, and planning trials: the interventionalist perspective.

JACC Cardiovasc Interv 2008 Aug;1(4):341-50

Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York, New York 10021, USA.

Aortic valve stenosis is increasing in frequency as the population ages. Surgical aortic valve replacement is the gold standard for symptomatic patients with severe aortic valve stenosis. However, in a subset of high-risk patients, the surgical option is excluded due to severe comorbidities. Recently, an alternative to surgical aortic valve replacement--percutaneous aortic valve replacement (PAVR)--has emerged. Since the first PAVR in a human in 2002, the percutaneous heart valves (PHVs) have already undergone several modifications from first generation devices. Currently, there are 2 PHVs in clinical application, a balloon-expandable and a self-expandable PHV, with several others achieving first-in-man application. With the extremely rapid technological advancements, PAVR is probably here to stay. The next steps required would be to formulate goals to assess results and outcomes of PAVR, and plan trials to test their clinical applicability. This article discusses how best to assess results and outcomes, which may require a paradigm shift in mindset. Apart from the randomized controlled trial, some of the more novel concepts in trial design, which may be more suitable in this area, are also explored.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcin.2008.03.018DOI Listing
August 2008

One-year clinical outcomes, midterm survival, and predictors of mortality after carotid stenting in elderly patients.

Circulation 2009 May 20;119(17):2343-8. Epub 2009 Apr 20.

Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York, NY 10021, USA.

Background: It has been demonstrated recently that carotid stenting can be performed safely in patients > or =80 years of age. However, it is uncertain whether these patients will derive benefit because longevity after revascularization is an important consideration. This study was conducted to determine survival and predictors of mortality of selected elderly patients after stenting.

Methods And Results: One hundred forty-two consecutive elderly patients who were non-high risk for stenting underwent 153 procedures. Patients had either symptomatic stenosis > or =50% or asymptomatic stenosis > or =70%. Demographics and in-hospital outcomes were entered into a database; subsequent outcomes and mortality data were obtained retrospectively. Mean+/-SD age was 83.3+/-3.1 years. Symptomatic patients accounted for 28%. Overall survival at 3 years was 76% (85% at 2 years). At 1 year, 1 fatal stroke had occurred, with 97% of survivors (n=114) free of neurological events (neurological status was undetermined in the remaining 3%). Predictors of mortality were remote (> or =6 months) transient ischemic attack or cerebrovascular accident, smoking history, and creatinine clearance (hemoglobin level showed a strong trend toward achieving significance); for the asymptomatic subgroup, predictors of mortality were smoking history, previous carotid endarterectomy, hemoglobin level, and increasing age. In particular, symptom status and sex were not independent predictors of mortality.

Conclusions: This study demonstrates that in selected elderly patients, a high proportion (85%) survived 2 years and >75% survived 3 years after stenting. Carotid stenting may be considered a revascularization option in such patients. Better selection of patients using the predictors of mortality may help to reduce unwarranted procedures and to optimize survival likelihood.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.108.805465DOI Listing
May 2009

Percutaneous transcatheter aortic valve implantation: Evolution of the technology.

Am Heart J 2009 Feb;157(2):229-42

Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute of New York, NY 10021, USA.

Aortic stenosis (AS) is currently the most common valvular abnormality in developed countries. The gold standard treatment of severe symptomatic AS is surgical aortic valve replacement. Mechanical valves were initially the prostheses of choice; with improvement of surgical technique and results, and increased durability of bioprosthetic valves, there has been a trend toward increasing use of bioprostheses. Concurrently, percutaneous technology has advanced exponentially, and the first human percutaneous aortic valve replacement (PAVR) became a reality in 2002. Various groups have now reported their early experiences with PAVR using different technologies. This new treatment modality is evolving very rapidly. There are currently 2 devices being used in clinical trials; several more devices have first-in-man results and others in preclinical development. It appears that PAVR will most likely become a viable option for selected patients in the near future. For these technologies to continue to improve and benefit patients, cross-specialty teamwork is vital. Treatment of severe AS will greatly evolve as these new and emerging technologies improve. Enhancement in device designs and increasing operator experience will make this technology safer and allow its application to a wider patient population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ahj.2008.10.003DOI Listing
February 2009

Cardiac perforation during patent foramen ovale closure sealed with an amplatzer PFO occluder.

J Invasive Cardiol 2008 Dec;20(12):665-8

Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute of New York, New York, NY 10075, USA.

Percutaneous patent foramen ovale (PFO) closure is increasingly performed for a variety of different conditions and is usually relatively straightforward, with a low adverse event rate and virtually no mortality. In cases with a long PFO tunnel, the "puncture technique" -- utilizing a transseptal puncture -- is performed to achieve better apposition of the septum primum to the septum secundum, and to avoid device deformity. Even though transseptal puncture can be safely performed by experienced operators, there is still a 1-2% risk of cardiac perforation. We report a novel technique to percutaneously close a cardiac perforation that occurred while using the puncture technique for PFO closure using an Amplatzer PFO Occluder. The PFO occluder successfully sealed the perforation, prevented development of cardiac tamponade and avoided the need for surgical intervention in a frail patient. This technique can be applied to other cardiac chamber perforations, especially if iatrogenic. This case illustrates the need to be thoroughly familiar with the cardiac anatomy and to avoid "instinctively" withdrawing the equipment once perforation occurs.
View Article and Find Full Text PDF

Download full-text PDF

Source
December 2008

Retrograde angioplasty for basilar artery stenosis: bypassing bilateral vertebral artery occlusions.

J Neurosurg 2009 Mar;110(3):427-30

Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA.

Basilar artery angioplasty with or without stenting is an emerging and promising treatment for vertebrobasilar insufficiency that is refractory to medical therapy. The usual approach is via a transfemoral route, with access directly through the vertebral artery (VA). An approach from the anterior circulation via the posterior communicating artery has been reported for optimal stent positioning and deployment across basilar apex aneurysms. No similar technique has been reported for treatment of midbasilar stenosis. The authors report a case of severe symptomatic basilar stenosis in which both VAs were occluded. The only option was to perform retrograde basilar angioplasty via the posterior communicating artery. This useful technique should be part of the armamentarium for the percutaneous treatment of symptomatic vertebrobasilar insufficiency for the occasional patient in whom occlusion or tortuosity precludes direct access to the VA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2008.7.JNS08436DOI Listing
March 2009

Carotid artery stenting in elderly patients: importance of case selection.

Catheter Cardiovasc Interv 2008 Sep;72(3):318-324

Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute, New York.

Objectives: This study was conducted to determine if carotid stenting (CS) could be safely performed in the elderly.

Background: Age has been shown to be a predictor of neurological complications during CS. We postulated that CS could be safely performed in elderly patients if certain anatomical and clinical markers such as excessive vascular tortuosity, heavy concentric calcification of the lesion, and decreased cerebral reserve were avoided.

Methods: From July 2003 to October 2007, 142 patients aged > or =50% or asymptomatic stenosis > or =70%. All patients underwent carotid and cerebral angiography to determine anatomic suitability and stent risk. Demographic and outcome data were entered into a database; other data were obtained retrospectively. Independent neurology evaluation was performed before and at 24 hr after the procedure.

Results: The mean age was 83.2 years, 62% were male, 25.5% were symptomatic, 8.5% had postcarotid endarterectomy restenosis, and 6.0% had contralateral internal carotid artery occlusion. There were no intracranial hemorrhages or periprocedural myocardial infarctions. One patient had amaurosis fugax. There were two minor and three major strokes in-hospital (3.3%). All patients had 30-day follow-up. One of the major strokes expired. Thus the overall 30-day stroke or death rate was 3.3% and major stroke or death rate was 2.0%. The 30-day stroke or death rate was 5.1% for symptomatic patients and 2.6% for asymptomatic patients.

Conclusion: CS can be performed safely in anatomically suitable elderly patients with low adverse event rates. CS should remain a revascularization option in appropriately selected elderly patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.21620DOI Listing
September 2008

[Percutaneous transcatheter valve therapy].

Rev Esp Cardiol 2008 Jun;61 Suppl 2:10-24

Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute of New York, New York, USA.

Aortic stenosis (AS) and mitral regurgitation (MR) are currently the commonest valvular pathologies in developed society. The current standard of treatment of severe AS and severe MR has been surgical aortic valve replacement (AVR) and mitral valve (MV) surgery. In 2002, the first human percutaneous AVR (PAVR) was performed and in 2005, results of percutaneous MV repair were also reported. The field of percutaneous transcatheter valve therapy is evolving very rapidly. There are 2 aortic percutaneous heart valves in clinical trials and several others with first-in-man data or in pre-clinical testing. Results seem promising and it appears that PAVR will most likely be a viable option for selected patients in a relatively short time. The future of AS treatment will evolve with the advent of devices which will be repositionable and retrievable, as well as integrating other materials engineered by nanotechnology and tissue engineering. There are several technologies being investigated in the field of MV repair, each attempting to mimic surgical technique. Compared with PAVR, percutaneous MV repair is a more complex process as many different pathological processes can result in MR. The current technologies will be suitable only for carefully selected patients with a specific etiology of MR. Most likely a combination of these technologies will be required for satisfactory MV repair although MV replacement may be what many of those patients require, and therefore percutaneous MV replacement will be an exciting alternative in the near future.
View Article and Find Full Text PDF

Download full-text PDF

Source
June 2008

First percutaneous transcatheter aortic valve-in-valve implant with three year follow-up.

Catheter Cardiovasc Interv 2008 Aug;72(2):143-8

Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute of New York, New York, USA.

Objectives: This study was conducted to report the clinical, hemodynamic, and iconographic outcomes of the longest survivor of the global CoreValve experience.

Background: Early results of percutaneous heart valve (PHV) implantation for severe symptomatic aortic stenosis (AS) have been encouraging, with mid term survival up to 2 years; however longer durability term is unknown. Although a PHV has been implanted in a degenerated surgical bioprosthesis, the feasibility of a PHV-in-PHV has not been demonstrated.

Methods: A patient with severe refractory heart failure due to severe aortic regurgitation (AR) and moderate AS, underwent CoreValve prosthesis implantation. The PHV was deployed too proximal into the left ventricular outflow tract, resulting in severe AR through the frame struts. Using the first PHV as a landmark, a second CoreValve was then deployed slightly distal to the first, with trivial residual paravalvular leak.

Results: The second CoreValve expanded well with proper function. Transvalvular gradient was 8 mmHg. Both coronary ostia were patent. New mild to moderate mitral regurgitation occurred due to impingement of the anterior mitral leaflet by the first PHV. NYHA functional class improved from IV to II, maintained over the past 3 years. Echocardiography at 3 years showed normal functioning CoreValve-in-CoreValve prostheses, without AR or paravalvular leaks. Transvalvular gradient was 10 mmHg. Cardiac CT showed stable valve-in-valve protheses with no migration.

Conclusion: The CoreValve prosthesis has maintained proper function up to 3 years, with no structural deterioration or migration. Treating mixed aortic valve disease with predominant AR is feasible. The concept as well as durability of the first PHV-in-PHV has also been demonstrated.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.21597DOI Listing
August 2008

Placement of a large transseptal cannula through an inferior vena cava filter for TandemHeart percutaneous left ventricular assist.

J Invasive Cardiol 2008 Jun;20(6):E197-9

Lenox Hill Heart and Vascular Institute, New York, New York 10075, USA.

We report a case of successful TandemHeart implantation for cardiogenic shock due to critical aortic stenosis using a 21 Fr transseptal cannula which was safely advanced through an existing inferior vena cava (IVC) filter under fluoroscopic guidance. This supported the patient through balloon valvuloplasty and subsequent definitive surgical valve replacement. This report demonstrates that the IVC filter can be safely crossed with a sheath as large as 21 Fr in size. In addition, patients with an existing IVC filter requiring a TandemHeart percutaneous ventricular assist device should not be denied this device for fear of dislodging the filter.
View Article and Find Full Text PDF

Download full-text PDF

Source
June 2008

Feasibility of patent foramen ovale closure with no-device left behind: first-in-man percutaneous suture closure.

Catheter Cardiovasc Interv 2008 Jun;71(7):921-6

Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute of New York, New York, USA.

Objectives: This study evaluated the feasibility of percutaneous patent foramen ovale (PFO) closure using a transcatheter suture (Superstitch), leaving no device behind.

Background: PFO has been implicated in cryptogenic strokes and migraine with auras. Percutaneous PFO closure, being less invasive than surgical closure, is increasingly performed. There are, however, early and long-term risks including device embolization, fracture, thrombosis, or infection, erosions into the free atrial wall and aorta, arrhythmias, and death. Furthermore, device implantation may complicate future percutaneous access to the left atrium. Partially reabsorbable devices and tissue welding to close PFO have recently been introduced. The first-in-man transcatheter suture closure of a PFO in an 18-year-old female with chronic migraine with aura and a well documented stroke is described.

Methods: The right femoral vein was cannulated under mild sedation and local anesthesia. Using intracardiac echocardiography imaging, bubble study demonstrated a right-to-left shunt through the PFO at rest. A Superstitch device was advanced across the PFO and sutures were delivered through the septum primum and secundum. The sutures were exteriorized and a knot was advanced to the right atrial septum and cut.

Results: Bubble study confirmed successful PFO suture closure. Transesophageal and transthoracic echocardiograms with bubble studies at 1 and 2 months, respectively showed complete closure with no right-to-left shunt even during Valsalva maneuver. At 6 months, the patient remained free of symptoms or migraine episodes.

Conclusion: Percutaneous transcatheter suture closure of a PFO can be successfully achieved with no residual shunt and leaving no device behind. Technological refinements are required for wider scale use.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.21550DOI Listing
June 2008

Percutaneous transcatheter left atrial appendage exclusion in atrial fibrillation.

J Invasive Cardiol 2008 Apr;20(4):E109-13

Lenox Hill Heart and Vascular Institute of New York, 130 East 77th Street, 9th Floor Blackhall, New York, NY 10075, USA.

Stroke is one of the leading causes of mortality, morbidity and serious disability in the developed world. Atrial fibrillation (AF), one of the most common cardiac arrhythmias, is a well-known predisposing factor for stroke, raising the risk significantly. Oral anticoagulation with warfarin is currently the most effective therapy for stroke risk reduction; however, this therapy increases the risk of bleeding and is often underutilized, contraindicated, or when administered, often subtherapeutic. It has been documented that the left atrial appendage (LAA) is the main source of left atrial thrombus, especially in non-rheumatic AF. Therefore, LAA exclusion may reduce the risk of stroke in AF, and retrospective surgical data have demonstrated a reduced risk of embolic events if surgical LAA exclusion was also performed during mitral valve replacement. Recently, several less invasive percutaneous transcatheter techniques of LAA exclusion - the PLAATO device, the Watchman device, and the Amplatzer Septal Occluder - have been employed with initially encouraging results. There is currently an ongoing randomized trial comparing percutaneous LAA exclusion to long-term oral anticoagulation therapy. Until such data are available, however, oral anticoagulation should remain the standard of care for stroke prevention in patients with AF.
View Article and Find Full Text PDF

Download full-text PDF

Source
April 2008

Carotid sheath rescue with a distal filter retrieval catheter.

Catheter Cardiovasc Interv 2008 Jun;71(7):987-90

Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute of New York, New York 10021, USA.

Sheath placement prior to carotid artery stenting is usually uncomplicated, and provides sufficient support for the procedure. In certain patients, especially those with unfavorable arch anatomy, tortuous vessels, and heavily calcified lesions, the sheath backs out into the aortic arch with compromise of wire and embolic protection device (EPD) position, and risk of "dragging" the EPD back through the lesion. A novel use of the distal filter retrieval catheter to "rescue" a prolapsed guide sheath is described. Use of the filter retrieval catheter as a "body" to retrack the sheath but not recapturing the deployed filter is a useful technique, since the equipment is already available. This avoided the need to pull a retrieved filter through a severe undilated carotid stenosis, reducing the amount of manipulations needed to reposition the sheath and thus reducing the risk of embolic events.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.21469DOI Listing
June 2008
-->