Introduction: Cardiac disease remains the largest single cause of maternal death. Whilst uncommon, left ventricular failure during pregnancy and delivery can be devastating to both mother and child. Echocardiography can play a significant role in rapidly establishing a diagnosis, guiding initial therapy and then monitoring response. Clinical vignettes: The history, presentation and management of three cases of peri-partum left ventricular failure is examined: stress cardiomyopathy in a 34 year old with twins, left ventricular dysfunction secondary to pre-eclampsia in a 22 year old with a singleton pregnancy and a true peri-partum cardiomyopathy in a 42 year old with IVF twins. The defining risk factors, presenting characteristics and echocardiographical findings for each pathology are highlighted. Conclusion: Echocardiography is playing an increasingly important role in the immediate assessment and management of left ventricular failure. This is especially true in the peri-partum woman, where establishing the correct therapy is both challenging and crucial due to the significant cardiovascular changes that occur around the time of delivery. To this end we believe that echocardiography should be rapidly available to guide the management of these patients by a multidisciplinary team made up of obstetricians, cardiologists, anaesthetists and intensive care physicians.

Percutaneous closure of a patent foramen ovale (PFO) reduces stroke in appropriately selected patients ([1][1]). PFO screening typically employs agitated saline injection into the brachiocephalic vein, which drains via the superior vena cava (SVC) to the right atrium. Bubbles bypassing the lungs are

OBJECTIVES:The objective of this study was to determine the safety and efficacy of intracardiac echocardiography (ICE) to guide percutaneous paravalvular leak (PVL) closure.BACKGROUND:PVL following surgical valve replacement occurs in 2%-15% of patients. Percutaneous treatment is an accepted management strategy in patients deemed to be too high risk for redo surgery. This is most commonly performed with transesophageal (TOE) guidance requiring general anesthesia that both potentially further increase the risk of intervention. ICE can be used to guide intervention, facilitating procedures to be performed under local anesthesia without esophageal intubation potentially making procedures shorter and safer and further enabling the treatment of patients that may have been turned down for intervention.METHODS:All patients that underwent ICE-guided percutaneous transcatheter PVL closure between 2006 and 2016 at the John Radcliffe Hospital, Oxford, United Kingdom were retrospectively analyzed.RESULTS:Twenty-one procedures were performed in 18 patients during the study period. Fourteen patients (77.8%) underwent successful ICE guided PVL closure. There were no ICE-related complications. Eleven patients (78.6%) reported symptomatic improvement of at least one New York Heart Association (NYHA) Class and the remaining 3 patients had no change. No patient demonstrated objective evidence of persistent hemolysis following successful closure. There was one death within 30 days of the procedure and 1 year survival was 71.4%.CONCLUSIONS:Percutaneous paravalvular leak closure guided by ICE without the requirement of general anesthesia is feasible, safe, and associated with acceptable procedural success rates.

Patent foramen ovale (PFO) and atrial septal defects (ASD) are common congenital cardiac defects in adults, which may cause complications in pregnancy such as paradoxical embolism. Closure of PFO/ASDs in pregnancy is rarely necessary, but has been suggested as a safe option in selected patients under expert hands. To review the outcomes and follow-up of patients who underwent percutaneous device closure of PFO/ASD during pregnancy at John Radcliffe Hospital since 2005. Retrospective review of all medical and obstetric notes of patients that fulfilled inclusion criteria. Helex® device was used in all patients. Procedures were performed with local anaesthesia under intracardiac echocardiography guidance (ICEG) and low frame rate fluoroscopy with a highly collimated beam. Twelve women were included, 3 (25%) with ASD, 9 (75%) with PFO. Average age was 31 [24-41]. None of the patients had clinical deep vein thrombosis (DVT) at diagnosis. Half of patients had a negative thrombophilia screen, and one resulted lupus anticoagulant positive. Indications for the procedure were: TIA (33.3%), stroke (33.3%), severe migraine (25%), myocardial infarction (8%). Successful PFO/ASD closure was achieved in all patients. Average radiation dose was 39 cGy/cm[b] [2.3–260], with estimated uterine/fetal dose of less than 0.001 mGy. Median gestation age was 19 weeks [10–31]. All women received aspirin 75 mg daily for 6 months after procedure. Of those, 25% had aspirin+ dypiridamol/clopidogrel, 17% aspirin+ prophylactic low molecular weight heparin (LMWH), 8% aspirin+ therapeutic LMWH. Follow up period was 6 years [1–10]. Eleven women (92%) had no recurrent symptoms; one patient had migraine. No medical nor obstetric complications were observed except preeclampsia in one patient. Overall, high rate of successful procedures and low rate of complications were seen. In conclusion, closure of PFO/ASDs in selected pregnant patients can be performed safely, if these women develop complications secondary to them.

This chapter covers pacemaker implantation. Pre-procedure considerations such as the operative conditions and steps for patient preparations are outlined. The implantation procedure is discussed in detail, with visual aids to show the incision and pocket placement, techniques to improve the success of the operation, and different types of venous access. Advantages and disadvantages of different routes are summarized. Lead implantation is covered, from positioning, securing, and electrical testing. Connecting the generator and wound closure is followed by a description of post-procedure care. Alternative device types and sites and are outlined, with indications for choice. Finally, special considerations in the young patient are described.

Percutaneous Management of Acquired Right Ventricular Outflow Tract Obstruction due to Giant Coronary Vein Graft Aneurysm

Rohan S. Wijesurendra, Katharine A. Sheppard, Stephen Westaby, Oliver Ormerod, and Saul G. Myerson* Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK; Department of Cardiology, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK; Department of Pathology, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK; and Department of Cardiothoracic Surgery, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK * Corresponding author. Tel: 144 1865 234597; Fax: 144 1865 740449. E-mail: saul.myerson@cardiov.ox.ac.uk

ObjectivesThis study aimed at assessing the feasibility and long‐term efficacy of left atrial appendage occlusion (LAAO) in a “real world” setting.BackgroundAlthough LAAO has recently emerged as an alternative to oral anticoagulants in patients with atrial fibrillation for the prevention of thromboembolic stroke, “real world” data about the procedure with different devices are lacking.MethodsEight centers in the United Kingdom contributed to a retrospective registry for LAAO procedures undertaken between July 2009 and November 2014.ResultsA total of 371 patients (72.9 ± 8.3 years old, 88.9% males) were enrolled. The overall procedure success was 92.5%, with major events in 3.5% of cases. The device choice was Watchman in 63% of cases, Amplatzer Cardiac Plug in 34.7%, Lariat in 1.7%, and Coherex WaveCrest in 0.6%. A significant improvement in procedure success (from 89.2% to 95.7%; P = 0.018) and reduction of acute major complications (from 6.5% to 0.5%; P = 0.001) were observed between procedures in the first and the second half of the recruitment time. An annual 90.1% relative risk reduction (RRR) for ischemic stroke, an 87.2% thromboembolic events RRR, and a 92.9% major bleeding RRR were observed, if compared with the predicted annual risks based on CHADS2, CHA2DS2‐Vasc, and HAS‐BLED scores, respectively, over a follow‐up period of 24.7 ± 16.07 months.ConclusionsLAAO can be performed safely in a real world setting with good implant success rates and procedural outcomes. The long‐term benefits of the procedure are reassuring in terms of both ischemic events and avoidance of severe bleeding associated with anticoagulation in this patient group. © 2016 Wiley Periodicals, Inc.

Background Stroke is a leading cause of disability, but in up to 40% of cases no cause is found. Although a patent foramen ovale (PFO) is an attractive mechanism to explain these cryptogenic strokes, using current imaging techniques, distinguishing between a causative rather than an incidental PFO remains elusive. We hypothesised that, in the presence of a PFO, atypical right atrial (RA) flow patterns would be linked to embolism risk by increasing the shunt of blood, and as such thrombus through the PFO. In order to investigate this we assessed RA flow patterns and interatrial shunt size in patients with a PFO and investigated whether these metrics predicted the incidence of paradoxical embolism. Methods 3 groups were recruited; 1) participants with a PFO but no embolism (n = 12), 2) patients with presumed paradoxical embolism (n = 20) and 3) participants without a PFO (n = 28). All underwent RA 4D flow assessment, and bubble transthoracic echocardiography to determine interatrial shunt size. Atypical RA flow was defined as any flow pattern that was not a classical vortex. Results Flow Patterns RA flow patterns were similar between the 2 groups with no embolic event irrespective of the presence of a PFO. In the PFO with embolism group, they were significantly different with a higher incidence of atypical RA flow (P = 0.0067, Figure 1B). Risk of embolism When considering all the subjects with a PFO (n = 32), the presence of an atypical flow pattern was 11.5 times more common in those who have had an embolic event (P = 0.002, Fisher’s exact test). To explore whether this effect was mediated by changing the degree of shunting, moderated multiple regression was performed. This showed that flow patterns were related to shunt grade (a pathway, β 34.0, p < 0.01), and that shunt grade was related to embolism incidence (b pathway, β 0.08, p < 0.01). As the a and b pathways were significant, mediation analysis was tested using 2,000 bootstrap resamples to generate a 95% confidence interval (bias corrected) of the indirect effect. This showed that the effect of an atypical flow pattern upon an embolic event is indeed mediated by increasing the shunt across the PFO (CI 0.45–18.42, Figure 2). As the direct effect of flow patterns on embolic risk becomes insignificant (c1 pathway, p = 0.06) this suggests full mediation. Conclusions Patients with a PFO and atypical RA flow pattern were 11.5 times more likely to have had an embolic event. This increased embolic risk seems to be mediated via increasing the shunt size across the PFO. As a result, not only will identification of the presence or absence of RA classical vortical flow in individuals presenting with a cryptogenic stroke help distinguish a causative PFO, but it may also identify patients with a PFO who are at elevated risk of future embolism.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Cardiovascular deaths remain the most common cause of pregnancy-related deaths.1 Pregnancy is a time of unique cardiovascular adaptation with maternal physiology altering through gestation to support the demands of the growing fetus. Several organs have particularly increased blood requirements during pregnancy, beside the uterus, including skin, kidneys and breasts. However, reports of the magnitude and timing of increases in cardiac output during normal pregnancy have been inconsistent. A clear understanding of how cardiac output and other haemodynamic parameters change in normal pregnancy might allow earlier and more accurate identification of maladapted cardiovascular physiology that characterises some complications in pregnancy and possibly allow attenuation of future sequelae. In particular, there has been interest in the impact of hypertensive disorders of pregnancy on cardiac function because they occur in up to 20% of pregnancies and are specifically associated with both changes in cardiac output during pregnancy, cardiac dysfunction2 and increased risks of cardiovascular diseases in later life for both mother and child.3In their Heart publication, Meah et al 4 have adopted a new methodological approach to describe changes in cardiac output during pregnancy, which has allowed them to report findings from a substantially larger dataset than previously possible. They have performed a systematic review of the literature and undertaken a series of meta-analyses on the accumulated findings of cardiac output and other haemodynamic data in healthy singleton pregnancies, from non-pregnancy through to post partum. To ensure an adequate sample size, they have had to draw on a heterogeneous source of data and include studies that report a range of modalities including echocardiography, impedance cardiography, suprasternal Doppler and inert gas rebreathing. Nevertheless, they found that this …

Background: Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery. Methods: All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up. Results: Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004–2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure ( P <0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 ( P <0.001) after a median follow-up of 110 (7–452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) ( P <0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P =0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P =0.037), New York Heart Association class (HR, 2.00; P =0.015) at follow-up and baseline creatinine (HR, 8.19; P =0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P =0.002). Conclusion: Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery.

Peripartum cardiomyopathy is a heart failure syndrome occurring late in pregnancy or during the early post-natal period. The pathophysiology of peripartum cardiomyopathy is not fully understood and various mechanisms have been postulated including an underlying inflammatory process. We here report four cases presenting with acute left ventricular systolic dysfunction. Three out of four of the patients presented with a left ventricular ejection fraction <30% and one with a left ventricular ejection fraction of 35%. All made a full clinical recovery following treatment with high-dose intravenous steroids. This case series adds to the growing body of evidence for the role for immunosuppressants in the management of peripartum cardiomyopathy.

BACKGROUND Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery. METHODS All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up. RESULTS Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004-2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure (P<0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 (P<0.001) after a median follow-up of 110 (7-452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) (P<0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P=0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P=0.037), New York Heart Association class (HR, 2.00; P=0.015) at follow-up and baseline creatinine (HR, 8.19; P=0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P=0.002). CONCLUSION Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery.

Alcohol septal ablation (ASA) in hypertrophic obstructive cardiomyopathy reduces left ventricular outflow tract gradients. A third of patients do not respond; inaccurate localisation of the iatrogenic infarct can be responsible. Transthoracic echocardiography (TTE) using myocardial contrast can be difficult in the laboratory environment. Intra-cardiac echocardiography (ICE) provides high-quality images. We aimed to assess ICE against TTE in ASA. The ability of ICE and TTE to assess three key domains (mitral valve (MV) anatomy and systolic anterior motion, visualisation of target septum, adjacent structures) was evaluated in 20 consecutive patients undergoing ASA. Two independent experts scored paired TTE and ICE images off line for each domain in both groups. The ability to see myocardial contrast following septal arterial injection was also assessed by the cardiologist performing ASA. In patients undergoing ASA, ICE was superior in viewing MV anatomy (P=0.02). TTE was superior in assessing adjacent structures (P=0.002). There was no difference in assessing target septum. Myocardial contrast: ICE did not clearly identify the area of contrast in 17/19 patients due to dense acoustic shadowing (8/19) and inadequate opacification of the myocardium (6/19). ICE only clearly localised contrast in 2/19 cases. ICE does not visualise myocardial contrast well and therefore cannot be used to guide ASA. TTE was substantially better at viewing myocardial contrast. There was no significant difference between ICE and TTE in the overall ability to comment on cardiac anatomy relevant to ASA.

Introduction Successful alcohol septal ablation (ASA) in hypertrophic obstructive cardiomyopathy (HOCM) reduces LVOT gradients. A third of patients do not respond; inaccurate location of the iatrogenic infarct can be responsible. Myocardial contrast studies following injection into a septal coronary artery guide ASA. Transthoracic echocardiography (TTE) is the current gold standard. TTE can be difficult in the lab environment. The ideal echocardiographic modality will see crucial anatomy relevant to ASA and delineate myocardial contrast well. We assessed ICE against TTE in ASA. Methods The ability of ICE and TTE to see relevant anatomy was assessed in two phases. Phase one recruited 25 successive patients undergoing PFO closure under ICE guidance. This was predominantly a feasibility study. Phase 2 recruited 20 successive HOCM patients undergoing ASA. The ability to assess myocardial contrast was assessed in phase 2. A scoring system to assess three key domains was used (see Table 1). Two independent experts scored paired, off-line TTE and ICE images, a score was allocated to each modality in each domain. Results Phase 1: ICE catheter manipulation to visualise the relevant anatomy was quick and safe. TTE was superior in viewing MV anatomy and SAM (score 1.4 vs. 0.4, p < 0.0001) but ICE visualised the target septum better (1.66 vs 1.08; p < 0.0001). There was no difference in ability to see adjacent structures. Phase 2: ICE was superior in viewing MV anatomy (1.88 vs 1.6; p = 0.02), superior catheter manipulation caused better scores in ICE. There was no difference in assessing target septum. TTE was superior in assessing adjacent structures (1.03 vs 0.63, p = 0.002). Myocardial Contrast injection was performed in 19/20 patients: ICE was able to visualise contrast satisfactorily in just 2/19. This was due to dense acoustic shadowing with inability to comment on surrounding myocardium (8/19), and inadequate opacification of the myocardium (6/19). Contrast localised to myocardium outside the field in 3/19 (RV cavity). This was not seen on ICE due to a narrower field of echo. TTE saw myocardial contrast location in all. Conclusions ICE cannot be used to guide ASA due to the inability to describe myocardial contrast distribution. ICE was better at seeing the motion of the MV, but TTE saw adjacent structures better. The ability of ICE to see SAM of the MV may lend itself to non-surgical septal reduction therapies that are not reliant on myocardial contrast.

Veiga-Gil, L.1; Klucniks, A.2; Ormerod, O.3; Foex, P.2; Dimitrov, P.2; Sinha, S.4 Author Information

Cardiovascular magnetic resonance using T1-mapping, T2-weighted and late gadolinium enhancement imaging provides a high diagnostic yield in patients presenting with acute chest pain, positive troponin and non-obstructive coronary arteries Vanessa M Ferreira, Erica Dall’Armellina, Stefan K Piechnik, Theodoros D Karamitsos, Jane M Francis, Robin Choudhury, Keith Channon, Rajesh Kharbanda, Colin Forfar, Oliver Ormerod, Bernard D Prendergast, Attila Kardos, Jim Newton, Matthias G Friedrich, Matthew D Robson, Stefan Neubauer