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Background: Balloon uncrossable lesions are defined as lesions that cannot be crossed with a balloon after successful guidewire crossing. Methods: We analyzed the association between balloon uncrossable lesions and procedural outcomes of 8671 chronic total occlusions (CTOs) percutaneous coronary interventions (PCIs) performed between 2012 and 2022 at 41 centers. Results: The prevalence of balloon uncrossable lesions was 9.2%. The mean patient age was 64.2 ± 10 years and 80% were men. Patients with balloon uncrossable lesions were older (67.3 ± 9 vs. 63.9 ± 10, p < 0.001) and more likely to have prior coronary artery bypass graft surgery (40% vs. 25%, p < 0.001) and diabetes mellitus (50% vs. 42%, p < 0.001) compared with patients who had balloon crossable lesions. In-stent restenosis (23% vs. 16%. p < 0.001), moderate/severe calcification (68% vs. 40%, p < 0.001), and moderate/severe proximal vessel tortuosity (36% vs. 25%, p < 0.001) were more common in balloon uncrossable lesions. Procedure time (132 (90, 197) vs. 109 (71, 160) min, p < 0.001) was longer and the air kerma radiation dose (2.55 (1.41, 4.23) vs. 1.97 (1.10, 3.40) min, p < 0.001) was higher in balloon uncrossable lesions, while these lesions displayed lower technical (91% vs. 99%, p < 0.001) and procedural (88% vs. 96%, p < 0.001) success rates and higher major adverse cardiac event (MACE) rates (3.14% vs. 1.49%, p < 0.001). Several techniques were required for balloon uncrossable lesions. Conclusion: In a contemporary, multicenter registry, 9.2% of the successfully crossed CTOs were initially balloon uncrossable. Balloon uncrossable lesions exhibited lower technical and procedural success rates and a higher risk of complications compared with balloon crossable lesions.

Although performing a biopsy of the right ventricular septum is a routine procedure in many cardiac catheterization laboratories, the ability to direct a bioptome to a mass within the right or left side of the heart is extremely difficult with fluoroscopic or echocardiographic guidance. The first intracardiac echo (ICE) was performed in the early 1970s. Since that time, the use of ICE in the cardiac catheterization laboratory has aided in transseptal puncture, ablation of cardiac arrhythmias, mitral valvuloplasty, and the closure of atrial septal defects and patent foramen ovale. This case report describes the use of ICE to facilitate intracardiac biopsy of a right atrial mass.

Although performing a biopsy of the right ventricular septum is a routine procedure in many cardiac catheterization laboratories, the ability to direct a bioptome to a mass within the right or left side of the heart is extremely difficult with fluoroscopic or echocardiographic guidance. The first intracardiac echo (ICE) was performed in the early 1970s. Since that time, the use of ICE in the cardiac catheterization laboratory has aided in transseptal puncture, ablation of cardiac arrhythmias, mitral valvuloplasty, and the closure of atrial septal defects and patent foramen ovale. This case report describes the use of ICE to facilitate intracardiac biopsy of a right atrial mass.

ObjectivesThe purpose of this study was to understand the reason for variation in the sensitivity of different methods of detecting right-to-left shunts (RLS).BackgroundPatent foramen ovale (PFO) is implicated in the pathogenesis of cryptogenic stroke, decompression illness, and migraine headaches. Intravenous agitated saline injections with tomographic imaging (transthoracic, transesophageal, and intracardiac echocardiography) has been used for detecting intracardiac shunts. Some patients with a high clinical suspicion of PFO have inconclusive echocardiographic study results. Transcranial Doppler (TCD) is an alternative method for detecting RLS that is not dependent on tomographic imaging.MethodsThirty-eight consecutive patients who were undergoing PFO closure had simultaneous transcranial Doppler and intracardiac echocardiography performed. Agitated saline injections were performed at rest, with Valsalva maneuver, and with forced expiration into a manometer to 40 mm Hg before and after closure, as well as 3 or more months after closure. Right atrial pressures were measured in the periprocedural period, and RLS were graded according to standard methods during these maneuvers.ResultsRight atrial pressures were significantly higher with Valsalva maneuver compared with rest (before closure 21.6 +/- 11.9 mm Hg vs. 6.6 +/- 2.6 mm Hg, p < 0.001; after closure 28.4 +/- 13.9 mm Hg vs. 6.8 +/- 2.6 mm Hg, p < 0.001) and with manometer compared with Valsalva maneuver (before closure 38.7 +/- 6.6 mm Hg vs. 21.6 +/- 11.9 mm Hg, p < 0.001; after closure 44.0 +/- 9.5 mm Hg vs. 28.4 +/- 13.9 mm Hg, p < 0.001). Intracardiac echocardiography underestimated shunting in 34% of patients with Valsalva maneuver or manometer after closure compared with TCD.ConclusionsTranscranial Doppler with immediate feedback provided by forced expiration against a manometer to 40 mm Hg is more sensitive than echocardiographic imaging for the detection of RLS. These observations have signifi

ObjectivesThe purpose of this study was to understand the reason for variation in the sensitivity of different methods of detecting right-to-left shunts (RLS).BackgroundPatent foramen ovale (PFO) is implicated in the pathogenesis of cryptogenic stroke, decompression illness, and migraine headaches. Intravenous agitated saline injections with tomographic imaging (transthoracic, transesophageal, and intracardiac echocardiography) has been used for detecting intracardiac shunts. Some patients with a high clinical suspicion of PFO have inconclusive echocardiographic study results. Transcranial Doppler (TCD) is an alternative method for detecting RLS that is not dependent on tomographic imaging.MethodsThirty-eight consecutive patients who were undergoing PFO closure had simultaneous transcranial Doppler and intracardiac echocardiography performed. Agitated saline injections were performed at rest, with Valsalva maneuver, and with forced expiration into a manometer to 40 mm Hg before and after closure, as well as 3 or more months after closure. Right atrial pressures were measured in the periprocedural period, and RLS were graded according to standard methods during these maneuvers.ResultsRight atrial pressures were significantly higher with Valsalva maneuver compared with rest (before closure 21.6 +/- 11.9 mm Hg vs. 6.6 +/- 2.6 mm Hg, p < 0.001; after closure 28.4 +/- 13.9 mm Hg vs. 6.8 +/- 2.6 mm Hg, p < 0.001) and with manometer compared with Valsalva maneuver (before closure 38.7 +/- 6.6 mm Hg vs. 21.6 +/- 11.9 mm Hg, p < 0.001; after closure 44.0 +/- 9.5 mm Hg vs. 28.4 +/- 13.9 mm Hg, p < 0.001). Intracardiac echocardiography underestimated shunting in 34% of patients with Valsalva maneuver or manometer after closure compared with TCD.ConclusionsTranscranial Doppler with immediate feedback provided by forced expiration against a manometer to 40 mm Hg is more sensitive than echocardiographic imaging for the detection of RLS. These observations have signifi