A previously healthy 60-year-old female was diagnosed with a secundum atrial septal defect measuring 23 x 12 mm on transesophageal echocardiogram.

In the setting of acute coronary syndrome, right-ventricular (RV) infarction, which has significant clinical implications, can occur in conjunction with inferior left-ventricular (LV) infarction. In rare cases, RV infarction is isolated. We describe a case of isolated RV infarction identified based on previously described electrocardiogram findings in the absence of hemodynamic or imaging evidence of RV dysfunction. This case highlights the fact that RV transmural ischemia can exist in the absence of the clinical syndrome associated with RV infarction, which we hypothesize is related to the proportion of RV myocardium involved in the infarct, or conversely, the amount of myocardium protected through various mechanisms.

As the use of surgically implanted sutureless aortic valves has increased over the past decade, we expect to encounter their failure increasingly in coming years. We describe a case of Perceval aortic valve failure with stent infolding and severe stenosis. This condition was treated with valve-in-valve transcatheter aortic valve implantation and complicated by aortic annular rupture at the site of infolding. This case is important because it outlines the limited experience with valve-in-valve transcatheter aortic valve implantation to treat failed sutureless valves and identifies sutureless valve infolding as a potential risk for annular rupture.

Abstract Objective To determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic. Design Multicentre randomised controlled trial. Setting 8 acute care hospitals in Canada. Participants 905 adults (≥40 years) who resided in areas with mobile phone coverage and were to be discharged from hospital after non-elective surgery were randomised either to virtual care and RAM (n=451) or to standard care (n=454). 903 participants (99.8%) completed the 31 day follow-up. Intervention Participants in the experimental group received a tablet computer and RAM technology that measured blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and body weight. For 30 days the participants took daily biophysical measurements and photographs of their wound and interacted with nurses virtually. Participants in the standard care group received post-hospital discharge management according to the centre’s usual care. Patients, healthcare providers, and data collectors were aware of patients’ group allocations. Outcome adjudicators were blinded to group allocation. Main outcome measures The primary outcome was days alive at home during 31 days of follow-up. The 12 secondary outcomes included acute hospital care, detection and correction of drug errors, and pain at 7, 15, and 30 days after randomisation. Results All 905 participants (mean age 63.1 years) were analysed in the groups to which they were randomised. Days alive at home during 31 days of follow-up were 29.7 in the virtual care group and 29.5 in the standard care group: relative risk 1.01 (95% confidence interval 0.99 to 1.02); absolute difference 0.2% (95% confidence interval −0.5% to 0.9%). 99 participants (22.0%) in the virtual care group and 124 (27.3%) in the standard care group required acute hospital care: relative risk 0.80 (0.64 to 1.01); absolute difference 5.3% (−0.3% to 10.9%). More participants in the virtual care group than standard care group had a drug error detected (134 (29.7%) v 25 (5.5%); absolute difference 24.2%, 19.5% to 28.9%) and a drug error corrected (absolute difference 24.4%, 19.9% to 28.9%). Fewer participants in the virtual care group than standard care group reported pain at 7, 15, and 30 days after randomisation: absolute differences 13.9% (7.4% to 20.4%), 11.9% (5.1% to 18.7%), and 9.6% (2.9% to 16.3%), respectively. Beneficial effects proved substantially larger in centres with a higher rate of care escalation. Conclusion Virtual care with RAM shows promise in improving outcomes important to patients and to optimal health system function. Trial registration ClinicalTrials.gov NCT04344665.

Background: After nonelective (i.e., semiurgent, urgent and emergent) surgeries, patients discharged from hospitals are at risk of readmissions, emergency department visits or death. During the coronavirus disease 2019 (COVID-19) pandemic, we are undertaking the Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM) trial to determine if virtual care with remote automated monitoring (RAM) compared with standard care will increase the number of days adult patients remain alive at home after being discharged following nonelective surgery. Methods: We are conducting a randomized controlled trial in which 900 adults who are being discharged after nonelective surgery from 8 Canadian hospitals are randomly assigned to receive virtual care with RAM or standard care. Outcome adjudicators are masked to group allocations. Patients in the experimental group learn how to use the study’s tablet computer and RAM technology, which will measure their vital signs. For 30 days, patients take daily biophysical measurements and complete a recovery survey. Patients interact with nurses via the cellular modem–enabled tablet, who escalate care to preassigned and available physicians if RAM measurements exceed predetermined thresholds, patients report symptoms, a medication error is identified or the nurses have concerns they cannot resolve. The primary outcome is number of days alive at home during the 30 days after randomization. Interpretation: This trial will inform management of patients after discharge following surgery in the COVID-19 pandemic and offer insights for management of patients who undergo nonelective surgery in a nonpandemic setting. Knowledge dissemination will be supported through an online multimedia resource centre, policy briefs, presentations, peer-reviewed journal publications and media engagement. Trial registration: ClinicalTrials.gov, no. NCT04344665

Background: This study examines the contemporary mediumand long-term outcomes of endovascular repair of aortic coarctation in the adult. Methods: We reviewed the clinical and imaging data of 56 consecutive adult patients with aortic coarctation who underwent endovascular repair at the Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada, from 2003 to 2018. Results: There were 20 (35.7%) female and 36 (64.3%) male patients (including 9 re-intervention cases) with a mean age of 33.6 +/- 13.6 years. Thirty-seven (66.1%) were treated with balloon-expandable covered stent and 12 (21.4%) were treated with balloon-expandable bare-metal stent. Pressure gradients decreased from baseline level of 27.99 +/- 12.75 (8-70) mm Hg to 5.33 +/- 4.42 (0-17.5) mm Hg following the procedure. There were 2 (3.6%) procedure related complications (aortic dissection [n = 1] and stent malposition [n = 1]). During a median (Q1 - Q3) follow up of 5.36 (2.28-7.58) years, 2 deaths (4.2%) and 9 (19%) re-interventions occurred, and the overall survival was 95.8%. Conclusion: Percutaneous coarctoplasty, with either covered or bare metal stents, is a safe and durable option for aortic coarctation repair with excellent long-term survival. (C) 2020 Elsevier B.V. All rights reserved.

One-third of all ischemic strokes are of unknown cause.1Collado F.M.S. Poulin M.F. Murphy J.J. Jneid H. Kavinsky C.J. Patent foramen ovale closure for stroke prevention and other disorders.J Am Heart Assoc. 2018; 7: 1-22Crossref Scopus (52) Google Scholar Patent foramen ovale (PFO) closure, for the prevention of stroke recurrence in patients with cryptogenic stroke (CS), has evolved from a putative therapy to one grounded in clinical trial evidence.1Collado F.M.S. Poulin M.F. Murphy J.J. Jneid H. Kavinsky C.J. Patent foramen ovale closure for stroke prevention and other disorders.J Am Heart Assoc. 2018; 7: 1-22Crossref Scopus (52) Google Scholar Earlier “negative” trials comparing the efficacy of PFO closure with medical therapy for preventing stroke recurrence had limitations. Those trials used older-generation devices,2Furlan A.J. Reisman M. Massaro J. et al.Closure or medical therapy for cryptogenic stroke with patent foramen ovale.N Engl J Med. 2012; 366: 991-999Crossref PubMed Scopus (806) Google Scholar had lower-than-expected event rates, or included patients with a transient ischemic attack as the index event.2Furlan A.J. Reisman M. Massaro J. et al.Closure or medical therapy for cryptogenic stroke with patent foramen ovale.N Engl J Med. 2012; 366: 991-999Crossref PubMed Scopus (806) Google Scholar,3Meier B. Kalesan B. Mattle H.P. et al.Percutaneous closure of patent foramen ovale in cryptogenic embolism.N Engl J Med. 2013; 368: 1083-1091Crossref PubMed Scopus (688) Google Scholar More recent clinical trials4Saver J.L. Carroll J.D. Thaler D.E. et al.Long-term outcomes of patent foramen ovale closure or medical therapy after stroke.N Engl J Med. 2017; 377: 1022-1032Crossref PubMed Scopus (578) Google Scholar, 5Søndergaard L. Kasner S.E. Rhodes J.F. et al.Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke.N Engl J Med. 2017; 377: 1033-1042Crossref PubMed Scopus (606) Google Scholar, 6Lee P.H. Song J.-K. Kim J.S. et al.Cryptogenic stroke and high-risk patent foramen ovale.J Am Coll Cardiol. 2018; 71: 2335-2342Crossref PubMed Scopus (274) Google Scholar and meta-analyses7Ahmad Y. Howard J.P. Arnold A. et al.Patent foramen ovale closure vs medical therapy for cryptogenic stroke: a meta-analysis of randomized controlled trials.Eur Heart J. 2018; 39: 1638-1649Crossref PubMed Scopus (79) Google Scholar confirm the efficacy of PFO closure in mitigating the risk of recurrent ischemic stroke compared with antiplatelet therapy alone in patients with recent CS. The choice of intraprocedural imaging during PFO closure varies across institutions and operators. Value-based approaches have been gaining traction across health care systems, linking costs to patient-centred clinical outcomes. The routine use of intracardiac echocardiography (ICE) in PFO closure may lend itself to a value-based quality-improvement initiative. Recent guidelines endorse routine intraprocedural use of either ICE, transesophageal echocardiography (TEE), or 3-dimensional TEE to guide PFO closure.8Silvestry F.E. Cohen M.S. Armsby L.B. et al.Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions.J Am Soc Echocardiogr. 2015; 28: 910-958Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar However, some operators have explored the use of fluoroscopy alone to guide PFO closure.9Mangieri A. Godino C. Montorfano M. et al.PFO closure with only fluoroscopic guidance: 7 years real-world single centre experience.Catheter Cardiovasc Interv. 2015; 86: 105-112Crossref PubMed Scopus (6) Google Scholar, 10Scacciatella P. Meynet I. Giorgi M. et al.Angiography vs transesophageal echocardiography–guided patent foramen ovale closure: a propensity score matched analysis of a two-center registry.Echocardiography. 2018; 35: 834-840Crossref PubMed Scopus (8) Google Scholar, 11Manolis A.S. Koulouris S. Rouska E. Pyrros J. Simplified percutaneous closure of patent foramen ovale and atrial septal defect with use of plain fluoroscopy: single operator experience in 110 consecutive patients.Indian Heart J. 2018; 70: 24-31Crossref PubMed Scopus (5) Google Scholar, 12Ulmi M. Praz F. Siontis G.C.M. et al.Propensity-score matched comparison of the Cera PFO Occluder with the Amplatzer PFO Occluder for percutaneous closure of patent foramen ovale without echocardiographic guidance.J Invasive Cardiol. 2017; 29: 280-284PubMed Google Scholar, 13Wahl A. Praz F. Stinimann J. et al.Safety and feasibility of percutaneous closure of patent foramen ovale without intra-procedural echocardiography in 825 patients.Swiss Med Wkly. 2008; 138: 567-572PubMed Google Scholar, 14Fateh-Moghadam S. Steeg M. Dietz R. Bocksch W. Is routine ultrasound guidance really necessary for closure of patent foramen ovale using the Amplatzer PFO Occluder?.Catheter Cardiovasc Interv. 2009; 73: 361-366Crossref PubMed Scopus (12) Google Scholar By relying on fluoroscopy alone to guide PFO closure, interventionists may overlook certain advantages of ICE. First, contrast angiography as a substitute is limited in its ability to detect residual right-to-left shunts. Recent randomized PFO closure trials that achieved a low rate of residual right-to-left shunts mandated intraprocedural echo guidance.4Saver J.L. Carroll J.D. Thaler D.E. et al.Long-term outcomes of patent foramen ovale closure or medical therapy after stroke.N Engl J Med. 2017; 377: 1022-1032Crossref PubMed Scopus (578) Google Scholar,5Søndergaard L. Kasner S.E. Rhodes J.F. et al.Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke.N Engl J Med. 2017; 377: 1033-1042Crossref PubMed Scopus (606) Google Scholar Patients undergoing fluoroscopy-only guided PFO closure may have a higher in1Collado F.M.S. Poulin M.F. Murphy J.J. Jneid H. Kavinsky C.J. Patent foramen ovale closure for stroke prevention and other disorders.J Am Heart Assoc. 2018; 7: 1-22Crossref Scopus (52) Google Scholar, 2Furlan A.J. Reisman M. Massaro J. et al.Closure or medical therapy for cryptogenic stroke with patent foramen ovale.N Engl J Med. 2012; 366: 991-999Crossref PubMed Scopus (806) Google Scholar, 3Meier B. Kalesan B. Mattle H.P. et al.Percutaneous closure of patent foramen ovale in cryptogenic embolism.N Engl J Med. 2013; 368: 1083-1091Crossref PubMed Scopus (688) Google Scholar, 4Saver J.L. Carroll J.D. Thaler D.E. et al.Long-term outcomes of patent foramen ovale closure or medical therapy after stroke.N Engl J Med. 2017; 377: 1022-1032Crossref PubMed Scopus (578) Google Scholar, 5Søndergaard L. Kasner S.E. Rhodes J.F. et al.Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke.N Engl J Med. 2017; 377: 1033-1042Crossref PubMed Scopus (606) Google Scholar, 6Lee P.H. Song J.-K. Kim J.S. et al.Cryptogenic stroke and high-risk patent foramen ovale.J Am Coll Cardiol. 2018; 71: 2335-2342Crossref PubMed Scopus (274) Google Scholar, 7Ahmad Y. Howard J.P. Arnold A. et al.Patent foramen ovale closure vs medical therapy for cryptogenic stroke: a meta-analysis of randomized controlled trials.Eur Heart J. 2018; 39: 1638-1649Crossref PubMed Scopus (79) Google Scholar, 8Silvestry F.E. Cohen M.S. Armsby L.B. et al.Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions.J Am Soc Echocardiogr. 2015; 28: 910-958Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar, 9Mangieri A. Godino C. Montorfano M. et al.PFO closure with only fluoroscopic guidance: 7 years real-world single centre experience.Catheter Cardiovasc Interv. 2015; 86: 105-112Crossref PubMed Scopus (6) Google Scholar, 10Scacciatella P. Meynet I. Giorgi M. et al.Angiography vs transesophageal echocardiography–guided patent foramen ovale closure: a propensity score matched analysis of a two-center registry.Echocardiography. 2018; 35: 834-840Crossref PubMed Scopus (8) Google Scholar, 11Manolis A.S. Koulouris S. Rouska E. Pyrros J. Simplified percutaneous closure of patent foramen ovale and atrial septal defect with use of plain fluoroscopy: single operator experience in 110 consecutive patients.Indian Heart J. 2018; 70: 24-31Crossref PubMed Scopus (5) Google Scholar, 12Ulmi M. Praz F. Siontis G.C.M. et al.Propensity-score matched comparison of the Cera PFO Occluder with the Amplatzer PFO Occluder for percutaneous closure of patent foramen ovale without echocardiographic guidance.J Invasive Cardiol. 2017; 29: 280-284PubMed Google Scholar, 13Wahl A. Praz F. Stinimann J. et al.Safety and feasibility of percutaneous closure of patent foramen ovale without intra-procedural echocardiography in 825 patients.Swiss Med Wkly. 2008; 138: 567-572PubMed Google Scholar, 14Fateh-Moghadam S. Steeg M. Dietz R. Bocksch W. Is routine ultrasound guidance really necessary for closure of patent foramen ovale using the Amplatzer PFO Occluder?.Catheter Cardiovasc Interv. 2009; 73: 361-366Crossref PubMed Scopus (12) Google Scholar, 15Rigatelli G. Pedon L. Zecchel R. et al.Long-term outcomes and complications of intracardiac echocardiography-assisted patent foramen ovale closure in 1,000 consecutive patients.J Interv Cardiol. 2016; 29: 530-538Crossref PubMed Scopus (29) Google Scholar, 16Earing M.G. Cabalka A.K. Seward J.B. et al.Intracardiac echocardiographic guidance during transcatheter device closure of atrial septal defect and patent foramen ovale.Mayo Clin Proc. 2004; 79: 24-34Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 17Barker M. Muthuppalaniappan A.M. Abrahamyan L. et al.Periprocedural outcomes of fluoroscopy-guided patent foramen ovale closure with selective use of intracardiac echocardiography.Can J Cardiol. 2020; 36: 1608-1615Abstract Full Text Full Text PDF Scopus (4) Google Scholarcidence of residual interatrial shunts requiring reintervention.10Scacciatella P. Meynet I. Giorgi M. et al.Angiography vs transesophageal echocardiography–guided patent foramen ovale closure: a propensity score matched analysis of a two-center registry.Echocardiography. 2018; 35: 834-840Crossref PubMed Scopus (8) Google Scholar Second, ICE allows operators to detect complications early and intervene accordingly. ICE facilitates the diagnosis of pericardial effusions before the occurrence of tamponade. The transverse pericardial sinus, at the point where the aortic root borders the atrial septum, is especially vulnerable to iatrogenic trauma during PFO intervention. Also, ICE allows intraprocedural detection of intracardiac air bubbles. Likewise, thrombus formation on sheaths, wires, and catheters can be detected promptly with the use of ICE. Third, interval changes, including atrial thrombus formation, can be detected if the baseline TEE was performed a long time before the PFO closure, especially in patients with deep vein thrombosis. Finally, the intraprocedural use of ICE facilitates the detection of additional high-risk PFO features if the baseline TEE was not comprehensive. The risks attributable to the use of ICE during PFO closure are minimal. ICE requires a second femoral venous access, and vascular access site complications occur in up to 1% of ICE-guided PFO closure procedures,15Rigatelli G. Pedon L. Zecchel R. et al.Long-term outcomes and complications of intracardiac echocardiography-assisted patent foramen ovale closure in 1,000 consecutive patients.J Interv Cardiol. 2016; 29: 530-538Crossref PubMed Scopus (29) Google Scholar potentially prolonging hospital stay. In addition, ICE catheter manipulation can occasionally trigger atrial or ventricular arrhythmias requiring treatment, including cardioversion.8Silvestry F.E. Cohen M.S. Armsby L.B. et al.Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions.J Am Soc Echocardiogr. 2015; 28: 910-958Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar,16Earing M.G. Cabalka A.K. Seward J.B. et al.Intracardiac echocardiographic guidance during transcatheter device closure of atrial septal defect and patent foramen ovale.Mayo Clin Proc. 2004; 79: 24-34Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Other rare complications include cardiac perforation and tamponade,8Silvestry F.E. Cohen M.S. Armsby L.B. et al.Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions.J Am Soc Echocardiogr. 2015; 28: 910-958Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar and dislodgment of recently placed pacemaker leads. Additional drawbacks include the higher procedural costs of ICE catheter use, longer procedure duration, and, possibly, higher infection risk arising from the use of resterilized ICE catheters (in the absence of robust resterilization processes). Therefore, operators must carefully balance the potential benefits of fluoroscopy-only guided PFO closure against the risks of abandoning routine ICE use. We have listed factors favouring each strategy in Figure 1. In this issue of the Canadian Journal of Cardiology, Barker et al. explore the feasibility of a minimalist approach to PFO closure using ICE selectively instead of routinely. They undertook a retrospective review, drawing on their institutional PFO closure experience, to ascertain the safety and short-term outcomes of fluoroscopy-only guided PFO closure.17Barker M. Muthuppalaniappan A.M. Abrahamyan L. et al.Periprocedural outcomes of fluoroscopy-guided patent foramen ovale closure with selective use of intracardiac echocardiography.Can J Cardiol. 2020; 36: 1608-1615Abstract Full Text Full Text PDF Scopus (4) Google Scholar They also systematized the indications for adopting an ICE-guided strategy.17Barker M. Muthuppalaniappan A.M. Abrahamyan L. et al.Periprocedural outcomes of fluoroscopy-guided patent foramen ovale closure with selective use of intracardiac echocardiography.Can J Cardiol. 2020; 36: 1608-1615Abstract Full Text Full Text PDF Scopus (4) Google Scholar They analysed data from 467 consecutive patients with CS over 11 years who underwent PFO closure with an Amplatzer device (out of 1035 patients subjected to this procedure over 18 years using 7 device types for various indications). Of these 467 patients, 381 underwent fluoroscopy-only guided closure, and 86 underwent combined fluoroscopy- and ICE-guided PFO closure. Remarkably, the authors were able to systematically decrease the proportion of ICE-guided PFO closures from 25.9% to 5.9% over the course of the study period. There were no significant differences between the 2 groups in the rates of same-day discharges or complications including arrhythmias, device embolization rates, and vascular or neurologic complications. The fluoroscopy-only guided PFO closure group had lower fluoroscopy and procedure time compared with the ICE-guided group. The authors were able to follow 91.6% of patients for a mean of 4 ± 5.9 months. Complete PFO closure was achieved in 94.6% of these patients with no significant difference in the rates of residual shunts between groups (fluoroscopy-guided: 5.8%; ICE-guided: 3.7%; P = 0.4). Other medium-term complications, including the rate of postprocedure atrial fibrillation and stroke, were similar between the 2 groups. This analysis is the first high-volume North American study to look at fluoroscopy-only guided PFO closure. Strengths of the study include its large sample size, extensive institutional experience, ability to demonstrate a progressive decline in the ICE utilization rates (indicating systematic adoption of fluoroscopy-only guided PFO closure with progressively increasing institutional experience), and the structured depiction of the indications for using ICE. Weaknesses include limitation of the analysis to a single PFO-occluder device type, lack of a systematic protocol to rule out residual interatrial shunts, difficulties in matching (given the small sample size in the ICE-guided group), and lack of quantitative depiction of the operator-level annual- and lifetime-procedural experience. Intraprocedural echocardiography utilization during PFO closure procedures varies widely. Some institutions rely entirely on fluoroscopy to guide their PFO closures,11Manolis A.S. Koulouris S. Rouska E. Pyrros J. Simplified percutaneous closure of patent foramen ovale and atrial septal defect with use of plain fluoroscopy: single operator experience in 110 consecutive patients.Indian Heart J. 2018; 70: 24-31Crossref PubMed Scopus (5) Google Scholar,13Wahl A. Praz F. Stinimann J. et al.Safety and feasibility of percutaneous closure of patent foramen ovale without intra-procedural echocardiography in 825 patients.Swiss Med Wkly. 2008; 138: 567-572PubMed Google Scholar,14Fateh-Moghadam S. Steeg M. Dietz R. Bocksch W. Is routine ultrasound guidance really necessary for closure of patent foramen ovale using the Amplatzer PFO Occluder?.Catheter Cardiovasc Interv. 2009; 73: 361-366Crossref PubMed Scopus (12) Google Scholar while others routinely use ICE or TEE for guidance. Although contemporary European PFO closure cohorts have reported good long-term outcomes while using fluoroscopy only in 43.0%-49.2% of closures,9Mangieri A. Godino C. Montorfano M. et al.PFO closure with only fluoroscopic guidance: 7 years real-world single centre experience.Catheter Cardiovasc Interv. 2015; 86: 105-112Crossref PubMed Scopus (6) Google Scholar,10Scacciatella P. Meynet I. Giorgi M. et al.Angiography vs transesophageal echocardiography–guided patent foramen ovale closure: a propensity score matched analysis of a two-center registry.Echocardiography. 2018; 35: 834-840Crossref PubMed Scopus (8) Google Scholar Barker et al. have successfully achieved similar results while limiting ICE guidance to 18% of their cohort.17Barker M. Muthuppalaniappan A.M. Abrahamyan L. et al.Periprocedural outcomes of fluoroscopy-guided patent foramen ovale closure with selective use of intracardiac echocardiography.Can J Cardiol. 2020; 36: 1608-1615Abstract Full Text Full Text PDF Scopus (4) Google Scholar Notably, toward the end of the study, the authors used ICE in fewer than 1 out of 16 PFO closures,17Barker M. Muthuppalaniappan A.M. Abrahamyan L. et al.Periprocedural outcomes of fluoroscopy-guided patent foramen ovale closure with selective use of intracardiac echocardiography.Can J Cardiol. 2020; 36: 1608-1615Abstract Full Text Full Text PDF Scopus (4) Google Scholar thereby calling into question the need for the guideline-recommended practice of routinely using ICE or TEE for all PFO closures.8Silvestry F.E. Cohen M.S. Armsby L.B. et al.Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions.J Am Soc Echocardiogr. 2015; 28: 910-958Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar The appeal of this minimalist approach lies in the lower procedural cost and shorter fluoroscopy and procedure time.9Mangieri A. Godino C. Montorfano M. et al.PFO closure with only fluoroscopic guidance: 7 years real-world single centre experience.Catheter Cardiovasc Interv. 2015; 86: 105-112Crossref PubMed Scopus (6) Google Scholar,17Barker M. Muthuppalaniappan A.M. Abrahamyan L. et al.Periprocedural outcomes of fluoroscopy-guided patent foramen ovale closure with selective use of intracardiac echocardiography.Can J Cardiol. 2020; 36: 1608-1615Abstract Full Text Full Text PDF Scopus (4) Google Scholar Reduction in total procedure time translates into improved catheterization lab efficiency, which is especially important in large-volume institutions. Barker et al. reported the use of fluoroscopy only to guide PFO closures with the Amplatzer PFO Occluder device.17Barker M. Muthuppalaniappan A.M. Abrahamyan L. et al.Periprocedural outcomes of fluoroscopy-guided patent foramen ovale closure with selective use of intracardiac echocardiography.Can J Cardiol. 2020; 36: 1608-1615Abstract Full Text Full Text PDF Scopus (4) Google Scholar This device was exclusively10Scacciatella P. Meynet I. Giorgi M. et al.Angiography vs transesophageal echocardiography–guided patent foramen ovale closure: a propensity score matched analysis of a two-center registry.Echocardiography. 2018; 35: 834-840Crossref PubMed Scopus (8) Google Scholar,11Manolis A.S. Koulouris S. Rouska E. Pyrros J. Simplified percutaneous closure of patent foramen ovale and atrial septal defect with use of plain fluoroscopy: single operator experience in 110 consecutive patients.Indian Heart J. 2018; 70: 24-31Crossref PubMed Scopus (5) Google Scholar or mostly9Mangieri A. Godino C. Montorfano M. et al.PFO closure with only fluoroscopic guidance: 7 years real-world single centre experience.Catheter Cardiovasc Interv. 2015; 86: 105-112Crossref PubMed Scopus (6) Google Scholar used across various observational registries analyzing the safety of fluoroscopy-guided PFO closure. Thus, the study findings cannot be generalized to other newer-generation devices. It is reassuring that the reported incidence of device embolization is low with fluoroscopy-guided PFO closure and is similar to that with ICE guidance. The main concern with fluoroscopy-guided PFO closure is the incidence of residual interatrial shunts. Notably, fluoroscopy-guided PFO closure was associated with a 16.8% incidence of severe residual shunts on follow-up, with a significant proportion of patients requiring reintervention, in a matched study.10Scacciatella P. Meynet I. Giorgi M. et al.Angiography vs transesophageal echocardiography–guided patent foramen ovale closure: a propensity score matched analysis of a two-center registry.Echocardiography. 2018; 35: 834-840Crossref PubMed Scopus (8) Google Scholar Unmatched studies reporting outcomes of fluoroscopy-guided PFO closure have indicated residual interatrial shunt rates of 0%-13%.11Manolis A.S. Koulouris S. Rouska E. Pyrros J. Simplified percutaneous closure of patent foramen ovale and atrial septal defect with use of plain fluoroscopy: single operator experience in 110 consecutive patients.Indian Heart J. 2018; 70: 24-31Crossref PubMed Scopus (5) Google Scholar,13Wahl A. Praz F. Stinimann J. et al.Safety and feasibility of percutaneous closure of patent foramen ovale without intra-procedural echocardiography in 825 patients.Swiss Med Wkly. 2008; 138: 567-572PubMed Google Scholar,14Fateh-Moghadam S. Steeg M. Dietz R. Bocksch W. Is routine ultrasound guidance really necessary for closure of patent foramen ovale using the Amplatzer PFO Occluder?.Catheter Cardiovasc Interv. 2009; 73: 361-366Crossref PubMed Scopus (12) Google Scholar Barker et al. reported a nonsignificant absolute difference of 2.1% in the residual shunt rates between fluoroscopy- and ICE-guided groups. Comparisons of the incidence of residual shunt after fluoroscopy- and ICE-guided PFO closure are complicated by differences in the diagnostic-workup imaging modalities used. Also, grading systems used for shunt quantification differ across studies. Standardization of protocols to detect and grade residual shunts would enable better comparison between groups and across studies. In addition, Barker et al. suggested that high-volume operators may be more adept at using fluoroscopy-only guidance for PFO closures. Operator- and institutional-level PFO closure volumes may affect procedural outcomes. Institutional experience with other atrial septal interventions may also influence results. Further studies are required to ascertain the level of operator and institutional experience required to make fluoroscopy guidance the default strategy for PFO closure. Barker et al. have demonstrated the potential safety of PFO closure with selective, rather than routine, use of ICE for intraprocedural imaging. High-volume structural programs may adopt fluoroscopy-only guided PFO closure with limited use of ICE as a value-based strategy. Concerns regarding a potentially higher incidence of residual shunts, necessitating future reinterventions, remain. Further research into the safety and effectiveness of a fluoroscopy-only guided PFO closure strategy, with stress on proving noninferiority in eliminating residual right-to-left shunts, is warranted. Meanwhile, programs contemplating a transition to fluoroscopy-only guided PFO closure should closely monitor any temporal changes in complication rates.

BackgroundTranscatheter aortic valve implantation (TAVI) is an effective alternative to surgical valve replacement in high-risk patients with severe aortic stenosis. Although measures of frailty have been used to attempt to predict outcomes in this population, few studies have demonstrated changes in these measures.MethodsWe performed a prospective, observational study of 171 patients undergoing TAVI, of whom 44 had maximal follow-up of 1 month and 50 had maximal follow-up of 1 year. Quality of life was assessed using the Minnesota Living With Heart Failure Questionnaire, Katz Index of Independence in Activities of Daily Living questionnaire, and patient perception of overall well-being. Frailty was measured using the 10-m walk test and handgrip strength testing.ResultsIn the overall cohort, participants demonstrated improvements in quality of life metrics, but deterioration in 10-m walk test and handgrip at 1 month. These trends continued at 1 year. However, patients in the lowest quintile of handgrip and 10-m walk test demonstrated a trend of improvements in these metrics during follow-up.ConclusionsDespite improvements in quality of life after TAVI, no improvements in frailty were observed in patients at 1 year.

Transcatheter aortic valve replacement has transitioned from an experimental procedure to an important alternative therapy for patients with symptomatic aortic stenosis and high surgical risk. We present a case outlining an approach to deal with the issue of “failure to cross” the aortic valve in transcatheter aortic valve replacement from the transfemoral retrograde approach.

Adult patients with repaired congenital heart disease are presenting with previously unseen types of residual lesions and consequences of prior repair. Patients with d-transposition of the great arteries repaired with atrial switch operations are returning with dysrhythmias and atrioventricular valve disease requiring intervention. We present the challenging case of a young adult with a residual shunt identified on preoperative three-dimensional transthoracic echocardiography, the precise anatomy of which was only characterized intraoperatively.

We hypothesized that an automated speech- recognition-inspired classification algorithm could differentiate between the heart sounds in subjects with and without pulmonary hypertension (PH) and outperform physicians. Heart sounds, electrocardiograms, and mean pulmonary artery pressures (mPAp) were recorded simultaneously. Heart sound recordings were digitized to train and test speech-recognition-inspired classification algorithms. We used mel-frequency cepstral coefficients to extract features from the heart sounds. Gaussian-mixture models classified the features as PH (mPAp ≥ 25 mmHg) or normal (mPAp < 25 mmHg). Physicians blinded to patient data listened to the same heart sound recordings and attempted a diagnosis. We studied 164 subjects: 86 with mPAp ≥ 25 mmHg (mPAp 41 ± 12 mmHg) and 78 with mPAp < 25 mmHg (mPAp 17 ± 5 mmHg) (p < 0.005). The correct diagnostic rate of the automated speech-recognition-inspired algorithm was 74% compared to 56% by physicians (p = 0.005). The false positive rate for the algorithm was 34% versus 50% (p = 0.04) for clinicians. The false negative rate for the algorithm was 23% and 68% (p = 0.0002) for physicians. We developed an automated speech-recognition-inspired classification algorithm for the acoustic diagnosis of PH that outperforms physicians that could be used to screen for PH and encourage earlier specialist referral.

Transcather aortic valve implantation (TAVI) is an established alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis and increased surgical risk. Frailty is a critical clinical metric that heart teams assess to select TAVI over SAVR. To date there has been limited data assessing frailty assessed sequentially over time in TAVI patients and the relationship of frailty to quality of life measurements.

We report a case of a 29‐year‐old man who developed exercised‐induced myocardial infarction 3 months post Melody valve implantation. We introduce the concept of ruling out dynamic coronary artery compression by simulating transcatheter pulmonary valve implant while increasing cardiac output and thus aortic dimensions in the catheterization laboratory. © 2014 Wiley Periodicals, Inc.

The acute effect of high‐intensity exercise combined with strength and endurance training on left ventricular (LV) systolic function in female rowers is not well known. The objective of this study was to evaluate the effects of 10‐weeks of endurance and strength training on maximal oxygen uptake (VO2max), endurance performance, strength, and LV morphology and systolic function in eight female rowers (mean age: 25 ± 9 years). LV systolic function was also assessed before and immediately after completing a high‐intensity endurance performance test (2000m of rowing). Ten‐weeks of combined strength and endurance training significantly improved VO2max (before vs. after; 2.7 ± 0.4 vs. 3.0 ± 0.3 L/min), endurance performance time (510 ± 41 vs. 491 ± 24 sec), leg press (163 ± 45 vs. 235 ± 86 kg) and bench press (40 ± 4 vs. 46 ± 5 kg) one repetition maximum strength. Combined training did not change end‐diastolic cavity area (19 ± 3 vs. 19 ± 4 cm2), end‐systolic cavity area (9 ± 2 vs. 8 ± 2 cm2), fractional area change (51 ± 6 vs. 55 ± 3%) or mass (160 ± 34 vs. 159 ± 17 g). High‐intensity exercise was associated with an increase in contractility and fractional area change from before to after training. In conclusion, 10 weeks of rowing and strength training in female rowers improves exercise capacity, endurance performance and muscle strength without altering LV morphology. In addition, combined strength and endurance training was not associated with an increase in LV systolic function but contractility and fractional area was significantly increased with high intensity exercise.Grant Funding Source: Supported by the Sport Science Association of Alberta

We describe the case of a 52‐year‐old woman presenting with non‐ST elevation myocardial infarction, atrial fibrillation, and a new diagnosis of hypertrophic cardiomyopathy. Transesophageal echocardiography following hemodynamic deterioration revealed completely restricted mitral leaflet motion with free mitral regurgitation, and severe left ventricular outflow tract (LVOT) obstruction. Surgical intervention was considered; however, repeat imaging following a period of clinical stability revealed resolution of the findings suggesting a transient ischemic etiology. The case is supported by clinical and echocardiographic images with movie clips, and a discussion of the likely pathology in the context of the underlying condition.

Procedural outcomes for transcatheter aortic valve implantation (TAVI) are well described. However, limited information exists regarding patient screening and selection. Thus, the purpose of the study was to review consecutive patients referred for TAVI from an inclusive-defined population. The Mazankowski Alberta Heart Institute TAVI program has maintained a prospective database on all referred patients. Patients are reviewed in outpatient clinic attended by a nurse, cardiologist, cardiac surgeon, and administrative assistant. After workup is complete, a TAVI Heart Team conference occurs to accept or reject each patient. Since November 2009, 276 patients (145 men and 131 women) have been referred with a steady increase in the number of referrals annually. Mean age was 82.2 years (men 81.6 and women 82.8), with 13% aged <70 years. Mean EuroSCORE was 13.8 and mean STS score was 5.7. Of the referred patients, 34% received TAVI, 17% were rejected, 12% underwent open AVR, 10% refused TAVI, and 27% are currently being assessed or followed. There were no differences in the mean EuroSCORE (13.4 vs 14.3; p = 0.64) or STS scores (5.2 vs 6.4; p = 0.13) of those accepted for TAVI versus those who were not. In conclusion, a team-based approach to assess this complex patient population is essential to ensure efficient and comprehensive evaluation, in turn determining appropriate care allocation. With expansion of clinical experience and the evidence supporting TAVI, the Heart Teams defined to assess this patient population will be burdened with increased clinical commitment and require appropriate support.

It is unknown if vigorous to maximal aerobic interval training (INT) is more effective than traditionally prescribed moderate-intensity continuous aerobic training (MCT) for improving peak oxygen uptake (Vo2) and the left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction. MEDLINE, PubMed, Scopus, and the Web of Science were searched using the following keywords: "heart failure," high-intensity interval exercise," "high-intensity interval training," "aerobic interval training," and "high-intensity aerobic interval training." Seven randomized trials were identified comparing the effects of INT and MCT on peak Vo2, 5 of which measured the LVEF at rest. The trials included clinically stable patients with heart failure with reduced ejection fraction with impaired left ventricular systolic function (mean LVEF 32%) who were relatively young (mean age 61 years) and predominantly men (82%). Weighted mean differences were calculated using a random-effects model. INT led to significantly higher increases in peak Vo2 compared with MCT (INT vs MCT, weighted mean difference 2.14 ml O2/kg/min, 95% confidence interval 0.66 to 3.63). Comparison of the effects of INT and MCT on the LVEF at rest was inconclusive (INT vs MCT, weighted mean difference 3.29%, 95% confidence interval -0.7% to 7.28%). In conclusion, in clinically stable patients with heart failure with reduced ejection fraction, INT is more effective than MCT for improving peak Vo2 but not the LVEF at rest.

Transcatheter aortic valve implantation (TAVI) has been recognized as an alternative treatment for high-risk surgical patients with symptomatic severe aortic stenosis (AS). Valve migration is a potentially life-threatening complication of TAVI that usually occurs during implantation. Late (>24 h) ([

BACKGROUND:Management of adults with congenital heart disease (ACHD) requires quaternary centres with cardiologists and cardiac surgeons who have expertise in the diagnosis and management of this patient population. We report on the feasibility of the management of ACHD patients using videoconferencing and streaming through 1 regional referral centre covering 4 western Canadian provinces, roughly 30% of Canada's land and population.METHODS:Videoconferencing sessions from January 2008 to December 2010 were systematically reviewed. Case presentations were classified as successful or unsuccessful. All patients were followed to assess whether the recommendations were acted upon. The hosting institution used the Alberta Health Services internet protocol network, while other connections used integrated service digital network. The videoconference equipment at the different sites includes Polycom HDX 9000 (Polycom, San Jose, CA), Tandberg Edge 95 (Tandberg, San Jose, CA), and Tandberg 990 (Tandberg).RESULTS:From January 2008 to December 2010 there were 26 sessions, 213 case presentations, and 177 patients discussed with an average 8.2 case presentations per session. Thirty-two case presentations were deferred, 10 of which were because of transmission errors and the remainder were because of unavailability of staff or images. Of the 177 recommendations, 124 procedures (91 surgical, 29 percutaneous, and 4 electrophysiological) were booked directly at the regional referral centre. Only 6 recommendations were not carried out (4 because of premature deaths, and 2 because of patient logistic issues).CONCLUSIONS:The results of this study illustrate that telehealth is a feasible medium for arriving at consensus recommendation in the management of ACHD patients living in a geographically diverse area.

Resistance training (RT) is a popular method of conditioning to enhance sport performance aswell as an effective form of exercise to attenuate the age-mediated decline in muscle strength and mass. Although the benefits of RT on skeletal muscle morphology and function are well established, its effect on left ventricular (LV) morphology remains equivocal. Some investigations have found that RT is associated with an obligatory increase in LV wall thickness and mass with minimal alteration in LV internal cavity dimension, an effect called concentric hypertrophy. However, others report that short- (<5 years) to long-term (>18 years) RT does not alter LV morphology, arguing that concentric hypertrophy is not an obligatory adaptation secondary to this form of exertion. This disparity between studies on whether RT consistently results in cardiac hypertrophy could be caused by: (i) acute cardiopulmonary mechanisms that minimise the increase in transmural pressure (i.e. ventricular pressure minus intrathoracic pressure) and LV wall stress during exercise; (ii) the underlying use of anabolic steroids by the athletes; or (iii) the specific type of RT performed. We propose that when LV geometry is altered after RT, the pattern is usually concentric hypertrophy in Olympic weightlifters. However, the pattern of eccentric hypertrophy (increased LV mass secondary to an increase in diastolic internal cavity dimension and wall thickness) is not uncommon in bodybuilders. Of particular interest, nearly 40% of all RT athletes have normal LV geometry, and these athletes are typically powerlifters. RT athletes who use anabolic steroids have been shown to have significantly higher LV mass compared with drug-free sport-matched athletes. This brief review will sort out some of the factors that may affect the acute and chronic outcome of RT on LV morphology. In addition, a conceptual framework is offered to help explain why cardiac hypertrophy is not always found in RT athletes.