The use of transcatheter aortic valve implantation (TAVI) has become the most popular technique of aortic valve intervention. Classically, TAVI is performed via femoral arterial access. However, some patients who have severe peripheral arterial disease do not have safely accessible femoral arteries. In such patients, the use of carotid access has been well described via the 'clamp-and-sew' technique. We describe a minimally invasive carotid access technique for TAVI deployment. The right common carotid is accessed by a 3 cm suprasternal incision. The carotid sheath is entered, and the surgeon obtains proximal and distal control of the carotid artery. The surgeon then makes two opposing purse strings over the anterior surface of the carotid artery. The Seldinger technique is used to obtain access to the carotid artery, followed by placement of the TAVI sheath. The valve is then deployed and echocardiographically confirmed. Upon removal of the TAVI sheath, the purse strings are tightened and sequentially tied. Haemostasis is achieved and skin is closed. This minimally invasive TAVI technique provides an option for patients with unfavourable peripheral access sites while offering the benefits of TAVI compared to open valve replacement.

Sinus of Valsalva aneurysm is a rare condition that can cause acute heart failure once it develops a fistula. A previously healthy 28-year-old man without history of intravenous drug use initially presents with an acute onset of heart failure symptoms. Transthoracic echocardiogram transesophageal echocardiogram revealed an aorto-atrial fistula causing significant left-to-right shunting. Blood cultures were negative for any infectious process. The patient initially required critical care with inotropic support and aggressive diuresis before going to the operating room for definitive repair. Intraoperative findings were consistent with the right sinus of Valsalva windsock deformity. Fistula formation from a ruptured sinus of Valsalva aneurysm is a rare cause of acute heart failure in young adults. However, all other causes should be ruled out, including endocarditis. In the setting of young, previously healthy adults, ruptured sinus of Valsalva is a rare but silent cause of acute-onset heart failure.

BACKGROUND:The benefit of implantable cardioverter-defibrillators (ICDs) and cardiovascular resynchronization therapy defibrillators (CRT-Ds) in patients supported with a HeartMate 3 left ventricular assist device (LVAD) remains uncertain. METHODS:An analysis was done of the Multicenter Study of MAGLEV Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3 (MOMENTUM 3) randomized clinical trial and the first 1000 patients in the Continued Access Protocol (CAP) trial. Patients were divided into 3 groups based on the presence of an ICD and/or CRT-D: No device (n = 153, 11%), ICD only (n = 699, 50.4%), and CRT-D (n = 535, 38.6%). We assessed the association of ICDs or CRT-Ds with overall mortality, ventricular arrhythmias (VAs), rehospitalization rates, quality of life, and the 6-minute walk test distance at 2 years' follow-up. RESULTS:Patients with an ICD or CRT-D had similar survival to those without (hazard ratio [HR], 1.3; 95% CI 0.8-2.1, P = .36) with no differences in rehospitalizations, quality of life or 6-minute walk test distance. VA occurred more frequently in patients with an ICD or CRT-D (HR, 2.4; 95% CI 1.3-4.3, P = .006). Compared with an ICD alone, patients with a CRT-D demonstrated similar survival (HR, 1.1; 95% CI 0.9-1.5, P = .36). However, they had increased rates of VA (HR, 1.3; 95% CI 1.0-1.7, P = .03). There were no differences in rate of rehospitalization between those with an ICD or CRT-D and those without (P = .19) or between those with an ICD and those with a CRT-D (P = .32). A propensity-matched sensitivity analysis confirmed these findings. CONCLUSIONS:In this post-hoc analysis of the MOMENTUM 3 trial, the presence of an ICD or CRT-D at the time of HM3 LVAD implantation was associated with an increased incidence of VA but was not associated with survival, quality of life, or functional capacity. TRIAL REGISTRATION:Momentum 3 portfolio, NCT02224755 (Pivotal) and NCT02892955 (CAP).

There are conflicting clinical data on whether the use of a distal perfusion catheter (DPC) is beneficial for reducing the risk of limb ischemia in peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. We investigated the hemodynamic effects of arterial cannula size, use of and size of a DPC, and ECMO flow (pump speed) on femoral artery hemodynamics in an adult peripheral VA-ECMO dynamic mock loop. The mock loop was tuned to heart failure conditions (cardiac output 3 L/min, arterial pressure 50 mm Hg, venous pressure 20 mm Hg). Three arterial cannulae (15Fr, 17Fr, 19Fr; right iliac) were each integrated into the loop with/without DPC (none, 5Fr, 8Fr; right superficial femoral artery [RSFA]), creating nine configurations tested. Hemodynamic pressures and flows were recorded over a range of pump speeds generating 0–3.5 L/min ECMO flow. The right femoral arteries demonstrated reduced flow, pressure, and pulsatility compared with the left across all cannula configurations and which worsened with increasing arterial cannula size and ECMO flow. Impaired right femoral hemodynamics were not improved with the use or size of DPC, suggesting that the increased resistance created by the presence of the arterial cannula and the DPC may be too great to overcome, thereby offsetting any potential flow benefits provided by the DPC.

Patients who undergo left ventricular assist device (LVAD) implantation may present with severe tricuspid regurgitation (TR), revealing underlying right heart failure. This study aims to evaluate the impact of concurrent tricuspid valve surgery (TVS) on LVAD implantation outcomes. Online electronic databases were systematically reviewed for studies including patients with advanced heart failure and TR treated by isolated LVAD implantation versus concomitant TVS and LVAD implantation. In-hospital outcomes were analyzed, and Kaplan-Meier (KM) curves presenting late survival by reconstruction of individual patient data. Sixteen studies were identified, comprising 2,206 patients who underwent either isolated LVAD or LVAD implant with concomitant TVS. There was no significant difference in early mortality between the two groups (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 0.85-1.65, p = 0.3, I2: 0%). The odds of right ventricular assist device (RVAD) implant were significantly higher in the LVAD + TVS group: (OR: 1.36 [95% CI: 1.0-1.86], p = 0.05). Analysis of late all-cause mortality showed a significantly higher risk of mortality in the LVAD + TVS group, hazard ratio (HR): 0.82 (0.69-0.98, p = 0.032) at each time-point. Tricuspid valve surgery at the same time as LVAD implant showed no difference in early operative mortality but jeopardized long-term survival. Future studies should aim to identify distinct patient subsets that could significantly benefit from TVS during the implantation of LVAD.

BACKGROUND:Sinus of Valsalva aneurysm is a rare condition that can cause acute heart failure once it develops a fistula. CASE SUMMARY:A previously healthy 28-year-old man without history of intravenous drug use initially presents with an acute onset of heart failure symptoms. Transthoracic echocardiogram transesophageal echocardiogram revealed an aorto-atrial fistula causing significant left-to-right shunting. Blood cultures were negative for any infectious process. The patient initially required critical care with inotropic support and aggressive diuresis before going to the operating room for definitive repair. Intraoperative findings were consistent with the right sinus of Valsalva windsock deformity. DISCUSSION:Fistula formation from a ruptured sinus of Valsalva aneurysm is a rare cause of acute heart failure in young adults. However, all other causes should be ruled out, including endocarditis. TAKE-HOME MESSAGE:In the setting of young, previously healthy adults, ruptured sinus of Valsalva is a rare but silent cause of acute-onset heart failure.

This case series evaluated the characteristics and outcomes of reoperative root replacement in patients with prior aortic valve replacement (AVR), aortic root replacement (ARR), or ascending or hemiarch replacement (AoR) from our single institution from 2014 to 2023. A total of 55 (prior surgery: 38 AVR, 5 ARR, and 12 AoR) patients were identified and indication for reoperation included valvular stenosis, endocarditis, aneurysm, and dissection. Perioperative mortality was 10.9% (6 patients) (inpatient complications: 2 stroke, 4 bleeding event, 2 renal failure, and 21 prolonged vent).

Importance:The advanced ambulatory heart failure (HF) population comprises patients who have progressed beyond the pillars of recommended stage C HF therapies but can still find meaningful life-years ahead. Although these patients are commonly encountered in practice, national databases selectively capture the small groups accepted for heart transplant listing or left ventricular assist devices. The epidemiology, trajectories, and therapies for other ambulatory patients with advanced HF are poorly understood. Observations:In December 2022, the National Heart, Lung and Blood Institute convened a team of experts to identify knowledge gaps and research priorities for the ambulatory population with limiting daily symptoms and transition toward refractory end-stage D HF, designated as stage C2D. This article summarizes the findings from that 3-day workshop. Workshop participants surveyed the initial challenges and knowledge gaps for (1) recognition of ambulatory C2D HF, (2) estimation of the magnitude of the affected population and identifiable subpopulations, and (3) physiologic phenotypes, such as low cardiac output, right HF, cardiorenal syndromes, congestive hepatopathy and frailty, which offer distinct targets for existing and emerging therapies. Social drivers of HF and patient preferences for quality/length of survival were highlighted as essential modifiers for personalization of therapies. Conclusions and Relevance:Ten key points summarized workshop findings, with target cohorts for study proposed as a crucial next step. This workshop summary is intended as a call for action to address knowledge gaps and develop new strategies to improve outcomes in the large ambulatory population with C2D HF.

BACKGROUND:Ventricular arrhythmias (VAs) are common in patients with left ventricular assist devices (LVADs), but their prognostic impact remains uncertain. Prior studies have yielded conflicting results regarding their association with mortality and morbidity. We aimed to evaluate the incidence and clinical outcomes associated with VAs in a large, multicenter LVAD cohort. METHODS:We analyzed 408 patients who underwent LVAD implantation across five centers between 2007 and 2015. VA was defined as sustained VAs lasting > 30 s or requiring ICD therapy. The effects of pre- and post-LVAD VA on clinical outcomes-including survival, hospitalizations, and ICD shocks-were assessed. RESULTS:Of 408 patients, 254 (62%) had a history of pre-LVAD VA. Compared to those without prior VA, patients with pre-LVAD VA were more likely to be male (85% vs. 75%, p = 0.02), receive amiodarone (44% vs. 31%, p = 0.01), and have larger left ventricular end-diastolic dimension (LVEDD) (7.1 vs. 6.8 cm, p = 0.01). Postimplant, the pre-VA group had a significantly higher incidence of VA (73% vs. 37%, p < 0.0001), atrial arrhythmias (63% vs. 42%, p < 0.0001), ICD shocks (41% vs. 32%, p = 0.001), and cardiac hospitalizations (median 0.20 vs. 0.08 events/year, p = 0.0003). However, Kaplan-Meier survival analysis showed no significant difference in overall mortality (log-rank p = 0.10). On multivariate Cox regression, pre-LVAD VA predicted post-LVAD VA, but LVEDD was the only independent predictor of mortality. CONCLUSIONS:In this multicenter cohort, pre-LVAD VAs were strongly associated with postimplant arrhythmic burden and increased morbidity, but not with long-term mortality. These findings highlight the importance of structural factors such as LVEDD over arrhythmia history in survival outcomes and underscore the need for individualized arrhythmia surveillance and management strategies in LVAD recipients with prior VAs.

BACKGROUND:Primary aortic thrombus (PAT) is a rare, life-threatening condition that can cause myocardial infarction, stroke, and acute limb or visceral ischemia. CASE SUMMARY:A 48-year-old woman was diagnosed with right-hand ischemia and non-ST-segment elevation myocardial infarction from coronary embolism attributable to a floating PAT in the ascending aorta. She underwent successful surgical resection of the PAT and was discharged on warfarin. DISCUSSION:More cases of PAT are being diagnosed because of improved cardiovascular imaging techniques. Coronary computed tomographic angiography can provide a detailed evaluation of the coronary arteries and the aorta in such patients. Management by a multidisciplinary team is needed to carefully select patients for initial surgical management vs medical therapy with anticoagulation alone. TAKE-HOME MESSAGES:Aortic thrombi are rare in the absence of underlying risk factors such as atherosclerosis, iatrogenic factors, trauma, dissection, aneurysms, aortitis, and hypercoagulable disorders. Surgical treatment should be considered early for proximal, large, free-floating PAT because of the embolic potential to multiple vascular beds, including the coronary circulation.