Background: Echocardiography has been debated as an adjunct for transcatheter aortic valve replacement (TAVR). The aim of this prospective study was to comparatively evaluate intraprocedural guidance using intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE).Methods: Fifty high-risk patients with severe aortic stenosis scheduled for TAVR were randomized to either guidance using ICE (group 1; n = 25) or monitoring using TEE (group 2; n = 25).Results: In contrast to TEE, ICE allowed continuous monitoring. The need for probe repositioning during the procedure was much lower in group 1 (0.1 +/- 0.3 vs 5.7 +/- 0.7 maneuvers, P < .001). Compared with TEE, the transcaval intracardiac echocardiographic view provided higher coaxiality with the ascending aorta expressed as the length of ascending aorta depicted (4.9 +/- 1.2 vs 6.1 +/- 1.2 cm, P = .003). Both coronary ostia were more frequently visualized in group 1 (18 vs 2 cases, P < .001). ICE-derived annular measurements were correlated closely with preinterventional readings on TEE (n = 25, r(2) = 0.90, P < .001). TEE underestimated intraprocedural pressure gradients in comparison with preinterventional measurements (mean difference, -10.2 +/- 11.1 mm Hg; n = 11, P = .012), but ICE did not (mean difference, -0.3 +/- 14.1 mm Hg; n = 25, P = .913). ICE and TEE detected newly grown thrombi (2 vs 1 case). Severe complications (e. g., annular dissection, pericardial effusion) were not observed.Conclusions: ICE, which is compatible with sedation and local anesthesia, can be considered an alternative to TEE for intraprocedural guidance during TAVR. It also seems to match the required work flow during TAVR better than TEE. (J Am Soc Echocardiogr 2011; 24: 966-75.)

Transcatheter therapies for the treatment of structural heart diseases (SHD) have expanded dramatically over the last years, thanks to the developments and improvements of devices and imaging techniques, along with the increasing expertise of operators. Imaging, in particular echocardiography, is pivotal during patient selection, procedural monitoring, and follow-up. The imaging assessment of patients undergoing transcatheter interventions places demands on imagers that differ from those of the routine evaluation of patients with SHD, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of SHD therapies, this document intends to update the previous consensus document and address new advancements in interventional imaging for access routes and treatment of patients with aortic stenosis and regurgitation, and mitral stenosis and regurgitation.

These are, to our knowledge, the first reported incidences in which ViV deployment of a SAPIEN 3 THV designed to avoid paravalvular leaks around the THV 2 also treated and obliterated a pre-existing paravalvular leak outside the sewing ring of surgical bioprostheses.

A therapeutic dilemma arises when infective endocarditis (IE) is complicated by a neurologic event. Postponement of surgery up to 4 weeks is recommended by the guidelines, however, this negatively impacts outcomes in many patients with an urgent indication for surgery due to uncontrolled infection, disease progression, or haemodynamic deterioration. The current literature is ambiguous regarding the safety of cardiopulmonary bypass in patients with recent neurologic injury. Nevertheless, most publications demonstrate a lower risk for secondary haemorrhagic conversion of uncomplicated ischaemic lesions than the risk for recurrent embolism under antibiotic treatment. Here, we discuss the current literature regarding neurologic stroke complicating IE with an indication for surgery.

The Coronary Artery Tree description and Lesion EvaluaTion (CatLet) score accommodating the variability in coronary anatomy is a recently developed and comprehensive angiographic scoring system aimed at assisting in risk‐stratification of patients with coronary artery disease. However, a validation of this angiographic scoring system is lacking.

Robotic totally endoscopic coronary artery bypass grafting (TECAB) was introduced in 1998 and has over a period of two decades gradually emerged from single-vessel revascularization to multivessel bypass grafting. Dedicated centers have continuously evolved and further developed this minimally invasive method of coronary bypass surgery. A literature review was conducted to assess intra- and postoperative outcomes of TECAB. PubMed returned 19 comprehensive articles on TECAB. Investigation was focused on perioperative outcome parameters, i.e.: operative time, conversion to larger incision, revision for bleeding, atrial fibrillation, stroke, acute renal failure, and mortality. Outcome from the analysis of 2,397 reported cases showed an average operative time of 291 ± 57 minutes (range 112 to 1,050), conversion rate to larger incisions at 11.5%, and perioperative mortality at 0.8%. Pooled data demonstrated 4.2% operative revision rate due to postoperative hemorrhage, 1.0% stroke incidence, 1.6% acute renal failure, and 13.3% de novo atrial fibrillation. The mean length of hospital stay measured 5.8 ± 1.7 days. Conversion rates and operative times decreased over time. According to data in the literature, coronary bypass surgery carried out in completely endoscopic fashion utilizing robotic assistance can require relatively extensive operative times and conversion rates are somewhat higher than in other robotic cardiac surgery. However, major postoperative events lie in an acceptable range. TECAB remains the surgical revascularization method with the least tissue trauma and represents an opportunity for coronary artery bypass grafting via port access. Rates of major complications are at least similar to conventional surgical access procedures.

An 88-year-old woman with severe symptomatic functional mitral regurgitation in spite of optimal medical therapy was referred for percutaneous mitral annuloplasty with the Cardioband system (Edwards Lifesciences, Irvine, California). Transesophageal echocardiogram revealed an ejection fraction of

Background: The SYNTAX score for decision makings or outcome predictions in coronary artery disease does not account for the variations in the coronary anatomy, which is a clear fallacy for patients with less typical anatomy than suggested by the SYNTAX score. The current study aimed to derive a new coronary angiographic scoring system accommodating the variability in the coronary anatomy. Methods: The 17-myocardial segment model and laws of competitive blood supply and flow conservation were utilized to derive this new scoring system. Results: We obtained 6 types of RCA dominance, 3 types of diagonal size and 3 types of left anterior descending artery (LAD) length, which together resulted in a total of 54 patterns of coronary artery circulation to account for the variability in the coronary anatomy among individuals. A Coronary Artery Tree description and Lesion EvaluaTion (CatLet) angiographic scoring system has been designed based on the above-mentioned reclassification scheme (htpp://www.catletscore.com, IE browser is required to run this calculator). Conclusions: This new CatLet angiographic scoring system accommodated the variability in the coronary anatomy and standardized the collection of the coronary angiographic data, which could facilitate the comparison and exchange of these data between different catheter labs. Its utility for predicting the clinical outcomes and standardizing the angiographic data collection will be investigated in a series of clinical trials enrolling "all-comers" with coronary artery disease (CAD).

Hypertrophic cardiomyopathy is the most common genetic cardiovascular disorder and is associated with symptoms of heart failure and increased risk of sudden cardiac death. The most common condition is obstruction of the left ventricular outflow tract. Surgical septal myectomy and alcohol septal ablation are the 2 accepted modes of septal reduction therapy and are indicated when there are advanced symptoms and a peak left ventricular outflow gradient ≥50 mmHg. Advantages of alcohol septal ablation are limited groin approach, reduction of obstruction of the left ventricular outflow tract and functional improvement, but there are higher chances for intracardiac device implantation and residual obstruction. Septal myectomy offers very low mortality, absolute and immediate resolution of obstruction of the left ventricular outflow tract and survival comparative to a matched general population with almost negligible residual obstruction. It is recommended that patients with obstructive hypertrophic cardiomyopathy should be treated at experienced centres.

Advanced percutaneous and surgical procedures in structural and congenital heart disease require precise pre-procedural planning and continuous quality control. Although current imaging modalities and post-processing software assists with peri-procedural guidance, their capabilities for spatial conceptualization remain limited in two- and three-dimensional representations. In contrast, 3D printing offers not only improved visualization for procedural planning, but provides substantial information on the accuracy of surgical reconstruction and device implantations. Peri-procedural 3D printing has the potential to set standards of quality assurance and individualized healthcare in cardiovascular medicine and surgery. Nowadays, a variety of clinical applications are available showing how accurate 3D computer reformatting and physical 3D printouts of native anatomy, embedded pathology, and implants are and how they may assist in the development of innovative therapies. Accurate imaging of pathology including target region for intervention, its anatomic features and spatial relation to the surrounding structures is critical for selecting optimal approach and evaluation of procedural results. This review describes clinical applications of 3D printing, outlines current limitations, and highlights future implications for quality control, advanced medical education and training.

A totally endoscopic version of coronary bypass surgery can on a routine basis only be carried out using robotic technology. Since its introduction in 1998, the procedure has evolved from single to multivessel totally endoscopic coronary artery bypass grafting (TECAB) (1). In most instances of multivessel TECAB, the left and right internal mammary artery (RIMA) are used as in situ bypasses and the left anterior descending artery (LAD) and higher obtuse marginal branches are grafted (2). These targets are readily accessed robotically and can be tackled even on the fully beating heart. For more distant targets, namely the distal circumflex (Cx) coronary artery and the right coronary artery (RCA) system, no specific techniques have been described yet. These coronary branches lie on the diaphragmatic and posterior surface of the heart and require movement of the heart into extreme positions which may compromise hemodynamics significantly if carried out without unloading. In addition, an in situ internal mammary artery bypass may not reach these targets without tension. Y-grafting is an option to achieve better reach. Cardioplegia may facilitate exposure of the RCA and the Cx in the completely endoscopic setting. We describe our technique of completely endoscopic bypass grafting of the posterior descending artery (PDA), a branch of the RCA, using the Y-graft technique. Cardioplegia is achieved by remote access heart lung machine perfusion and endoaortic balloon occlusion. The PDA is exposed on the arrested heart with a special insertion site of the robotic endostabilizer on the left lateral chest wall and lifting up the acute margin of the flaccid, arrested heart.

Transcatheter aortic valve replacement is a transformative technology for the treatment of severe aortic stenosis. It has allowed for the treatment of high-risk and inoperable aortic stenosis patients that would previously have not been able to undergo surgical aortic valve replacement. The safety and efficacy of transcatheter aortic valve replacement has been evaluated rigorously in multiple pivotal randomized clinical trials. Advancements in the technology with significant improvement in clinical outcomes and safety of the procedure have allowed for the extension to lower-risk groups. Future development will focus on continued refinement in the device and technique with expansion to low-risk patients and other clinical indications.

Left ventricular outflow obstruction after transcatheter mitral valve replacement is a life-threatening complication. We report a case of a 68-year old female with early degeneration of a transcatheter aortic valve and severely calcified mitral valve stenosis who was considered inoperable by a multidisciplinary heart team and referred for transcatheter aortic and mitral valve replacement. Our aim is to report the planning, procedural aspects, and management of device-related left-ventricular outflow tract obstruction after transcatheter double valve replacement.

Since hypertrophic obstructive cardiomyopathy complicated by intractable symptoms has heterogeneous phenotypic expressions, it is extremely important to tailor the therapy specifically for each patient. Therefore, a careful clinical evaluation including magnetic resonance and echocardiography should be performed prior to making decision about possible septal reduction therapy.[1]