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Despite TAVR emerging as the gold standard for a broad spectrum of patients, it is associated with serious complications. In this report we present a case, where a TAVR procedure led to a perforation at the aortomitral continuity, discuss the risk factors for the occurrence of perforations and how we decided to treat the patient., (© 2021 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: "Blind" pericardiocentesis is the standard procedure for emergency pericardial drainage when ultrasound guidance is unavailable. Under these circumstances, puncture site and needle direction are exclusively oriented according to certain anatomic landmarks. In the literature, different techniques for this "blind" method have been described. Goal of this retrospective study was to compare the potential success and complication rate of 13 simulated puncture directions., Methods: Simulated pericardiocentesis was performed in 150 CT scans from patients with moderate to severe pericardial effusions (greater than 1 cm distance between epicardium and pericardium). Thirteen different puncture techniques with varying puncture sites, direction of the puncture, and the angle were compared. A simulated pericardiocentesis was classified as "successful" when the effusion was reached. It was classified as "successful without a complication" when no adjacent structure was penetrated by the simulated puncture (lung, liver, internal thoracic artery, LAD, colon, and stomach). An attempt was declared as "unsuccessful" when the pericardial effusion was not reached at all, or the reached effusion measured less than 0.5 cm between the epicardium and pericardium at the location where the needle entered the pericardium., Results: A subxiphoidal puncture technique starting in Larrey's triangle (sternocostal triangle) and directed toward the left midclavicular point with a 30° inclination resulted in the highest success rate (131 of 150 cases = 87%). In parallel the lowest complication rate (7 of 150 = 5%) was found using this technique, as well. In contrast, pericardiocentesis performed using other puncture directions resulted in lower success (66%-85%) and higher complication rates (9%-31%)., Conclusion: This CT-based simulation study revealed that blind pericardiocentesis guided by anatomical landmarks only is best performed in a subxiphoid approach with a needle direction to the left midclavicular point with a 30° inclination. Nevertheless, injury of adjacent structures occurred frequently (5%) even when applying this puncture technique. Thus, blind pericardiocentesis can be performed with a high success rate and seems adequate to be performed under emergency conditions. However, planned procedures should be performed under image guidance., (© 2018 Wiley Periodicals, Inc.)

We describe the occurrence of a localized saccular pseudoaneurysm in a 69-year-old patient 2 weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction. The therapy of perforations requires prolonged balloon inflations, perfusion balloons, covered stents, or surgery. Coronary peudoaneurysm formations are rare; their therapy requires covered stents or surgery. Cathet. Cardiovasc. Intervent. 47:341-346, 1999., (Copyright 1999 Wiley-Liss, Inc.)

The purpose of this study was to assess safety and feasibility of intracoronary delivery of reviparin using a porous balloon following percutaneous transluminal coronary angioplasty. The 2.7 mm porous balloon used in this study had 35 holes arranged in a spiral pattern. Eighteen patients (male n = 10, female n = 8, age 63 +/- 9 years) undergoing successful PTCA in coronary arteries with a vessel diameter of 2.5 to 3.0 mm determined by online QCA (LAD = 11, RCX = 3, RCA = 4) were included. They received a bolus of 7,000 anti-Xa-IU reviparin followed by local delivery of 1,500 anti-Xa-IU in 4 ml with an injection pressure of 2 atm. The patients received additionally 10500 anti-Xa-units intravenously during the following 24 hours and a daily dose of 7000 anti-Xa-units reviparin subcutaneously for the following 28 days. Angiograms were obtained before and after PTCA, directly after local delivery, at 24 hours postintervention and after 6 months. The primary success rate was 100%. Quantitative coronary angiography showed a minimum luminal diameter of 0.42 +/- 0.14 mm before PTCA, 1.87 +/- 0.45 after PTCA, 1.67 +/- 0.43 after LDD, 1.63 +/- 0.46 after 24 hours, and 1.06 +/- 0.6 after 6 months. Angiographic follow-up was obtained in all patients. No major complications occurred during the 6-month follow-up period. The angiographic restenosis rate was 28% (5/18) at follow-up. This study demonstrates safety and feasibility of local intracoronary delivery of reviparin with a porous balloon following PTCA even in smaller diameter coronary arteries.

In patients with aortic valve stenosis, the quantification of stenosis is usually performed using fluid-filled catheters and a computerized calculation program. The aim of this study was to determine the accuracy of this technique in comparison to the manual planimetry of the area between the curves of a simultaneous registration, using a multitip micromanometer catheter. The study was performed in 19 patients, in whom left and right heart catheterization was warranted. Systolic left ventricular and aortic peak pressures were significantly overestimated using a fluid-filled catheter (206 +/- 35 vs. 199 +/- 37 mm Hg, P = 0.0003, and 148 +/- 18 vs. 143 +/- 21 mm Hg, P = 0.0052). However, peak-to-peak pressure gradients were identical comparing both techniques (58 +/- 31 vs. 56 +/- 32 mm Hg, r = 0.983). The mean pressure gradients and aortic valve areas based on simultaneous measurements of left ventricular and aortic pressures by micromanometer catheters were identical to the values determined by a computer-based program using fluid-filled catheters (54 +/- 21 vs. 52 +/- 21 mm Hg, r = 0.923, P < 0.05, and 0.75 +/- 0.25 vs. 0.77 +/- 0.25 cm2, r = 0.935). Thus, the conventional use of fluid-filled catheters and of a computerized calculation of aortic valve area is valid for quantification of aortic stenosis in patients with sinus rhythm and without significant aortic regurgitation.

Perfusion balloon catheters are designed to provide continuous transcatheter blood flow and thereby reduce myocardial ischemia during coronary angioplasty. To compare the transcatheter flow rates of active and passive (auto-) perfusion catheters, a well-controlled experimental study was performed in a circulation model that duplicates the phasic, predominantly diastolic flow pattern of the left coronary artery. Mean diastolic coronary driving pressure varied between 20 and 100 mm Hg. For the autoperfusion catheters, a strong relationship between transcatheter flow and diastolic coronary driving pressure was found. For example, a coronary driving pressure of 80 mm Hg provided a coronary flow of 30 ml/min (RX-Perfusion [RP], ACS), 28 ml/min (Speedflow [SF], Schneider), 20 ml/min (Lifestream [LS], ACS), and 19 ml/min (Flowtrack [FT], ACS). Reduction of driving pressure to 40 mm Hg decreased the absolute transcatheter flow, which was now 16 ml/min (RP), 13 ml/min (SF), and 10 ml/min (LS and FT). The relative catheter flow (the ratio of absolute flow to baseline coronary flow rate without a catheter in place), was independent of actual coronary driving pressure and ranged between 21% +/- 1% (RP) and 14% +/- 1% (FT and LS). For the active perfusion system (Coreflo, Leocor, a maximal transcatheter flow of 82 ml/min was found. Using this active perfusion system, the relative catheter flow increased with decreasing coronary driving pressure:80 --> 40 mm Hg: 56% --> 107%. For all catheters, the distal perfusion decreased between 30% (3.0 mm RP) and 50% (3.0 mm LS) by a 0.014-inch guidewire placed through the inner channel of the catheter. Because of the strong relationship between coronary driving pressure and transcatheter flow, the residual flow through all autoperfusion catheters becomes critical (<20 ml/min), when the coronary driving pressure drops below 50 mm Hg. By contrast, active perfusion systems are independent of the actual coronary driving pressure and are therefore advantageous for prolonged dilation in patients with low aortic pressure.

In this case report the first known case of a perforation of a side branch of the right coronary artery during diagnostic coronary angiography using 5 French Judkins catheters is described which occurred by selective intubation. Although catheter placement was controlled by contrast test injection the catheter occasionally intubated the conus artery super selectively just prior to the diagnostic injection. Thus, perforation of small side branches may be encountered especially by the use of 5 French Judkins catheters.

Formation of aneurysms in coronary arteries can be observed following percutaneous transluminal balloon angioplasty but has not been reported previously after coronary excimer laser angioplasty in humans. Stand alone coronary excimer laser angioplasty was performed in a 49-year-old man with a 75% left anterior descending artery stenotic lesion and exertional angina, documenting a good angiographic result postintervention. Control angiography 6 months after the procedure revealed an aneurysm distal to a 90% restenosis in the area of ablation.