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A virtual aortic annular plane that is built using the three hinge points, known as the hinge point-based annular plane (HPAP), is routinely used during transcatheter aortic valve replacement (TAVR). Abnormal aortic cusps (AAC) with unequal length and size influence the relationship of the HPAP to the aortic root axis significantly and pose challenges to valve deployment, leading to paravalvular leak and valve embolisation. Obtaining a centreline-based aortic annular plane in addition may help to understand valve deployment behaviour in AAC better.

Arterial cannulation in acute DeBakey type I dissection can be difficult. Moreover, the residual dissected aorta is susceptible to further adverse events in the future. Implanting a stent-graft into the descending aorta during the initial dissection repair ('frozen elephant trunk') has been demonstrated to promote favourable aortic remodelling, mitigating some of these longer-term complications. We describe a technique for cannulation of the ascending aorta in acute dissection that facilitates expeditious antegrade deployment of a frozen elephant trunk.

A 72 year old female with a past medical history of bicuspid aortic valve with severe aortic regurgitation status post placement of a 21 mm Magna Ease aortic valve replacement on 6/1/16, chronic atrial fibrillation, diabetes mellitus, and severe mitral regurgitation presented with symptoms of dyspnea upon exertion. Transesophageal echocardiogram (TEE) showed normal left ventricular function with severe mitral regurgitation, severe tricuspid regurgitation and severe pulmonary hypertension. Upon close interrogation of the tricuspid valve, there was evidence of fusion with a raphe present between the septal and anterior leaflets ("a bicuspid" tricuspid valve). The patient was referred for surgical evaluation where she was deemed to be at increased surgical risk and referred for percutaneous treatment for both severe mitral and severe tricuspid regurgitation. After an uncomplicated transseptal puncture, she underwent a placement of a single MitraClip XT clip to the A2/P2 portions of the mitral valve leaflets leaving mild residual mitral regurgitation by color Doppler. Attention was then taken towards the tricuspid valve where using TEE guidance, a MitraClip XT was positioned over the central aspect of the "bicuspid" tricuspid valve with the opened clip arms perpendicular leaflet coaptation. The MitraClip XT was advanced into the right ventricle and slowly retracted to grab both TV leaflets. There was mild, residual tricuspid regurgitation by color Doppler. The mean gradient across the tricuspid valve was 1 mmHg obtained at a heart rate of 52 bpm. This case describes the first known percutaneous treatment of severe tricuspid regurgitation from a "bicuspid" tricuspid valve with a MitraClip device. Abstract 1637 Figure.

ObjectiveCongenital renal arteriovenous fistulas (CRAVF) represent a distinct clinical entity with characteristic hemodynamic and angiographic features. Treatment is warranted given potential for growth with renal and hemodynamic compromise. We report our experience in a rare series of treated symptomatic CRAVFs.MethodsOver a 10-year period, patients treated for symptomatic CRAVFs (no history of predisposing renal pathology, instrumentation, neoplasm, or trauma) were retrospectively investigated for clinical presentation, imaging features, treatment outcomes, and complications. Technical success included delivery of embolic agent with complete obliteration of fistula. Clinical success included resolution of symptoms and freedom from recurrence and/or reintervention. Renal parenchymal loss was estimated by postembolization angiography and categorized as 0%, 50%.ResultsTwenty-five patients were referred with a presumptive diagnosis of intraparenchymal renal artery aneurysms. Of these, 10 had true intrarenal aneurysms, three had angiomyolipomas, and 12 had CRAVFs (mean age, 54; range, 29-71 years; eight women). Presenting symptoms included hematuria (eight gross, eight microscopic), refractory hypertension (diastolic blood pressure ≥90 mm Hg despite three or more medications; n = 6), flank pain (n = 8), high-output state (HOS; featuring tachycardia and jugular venous distention; n = 3), and flank bruit (n = 1). Defining angiographic features included a high-flow AVF fed by a single, enlarged intrarenal branch shunting into an aneurismal draining vein, occasionally featuring a calcified rim (four patients). All patients underwent transarterial embolization with coils (n = 5), coils and n-butylcyanoacrylate (n = 3), detachable balloons (n = 2), or Amplatzer plugs (n = 2). Technical success was 100%. Hematuria, tachycardia, jugular venous distension, pain, and bruit resolved in all. Hypertension improved in four of six patients (required less than three medications postembolization). Complications included postembolization syndrome in nine patients. Parenchymal loss was limited to

Mitral regurgitation is the most common valvular heart disease. The gold standard for patients not suitable for valve repair is a surgical valve replacement. A significant proportion of patients, however are not referred for surgery due to comorbidities, advanced age or severe LV dysfunction. Transcatheter mitral valve replacement may be a viable therapeutic option for these high risk patients. With improvements in technology and data on the durability of the transcatheter mitral valve, this technology has the potential to be used in a lower risk population. A number of transcatheter systems have emerged recently and are at different stages of investigation. In this review, we outline the key elements and challenges of the transcatheter mitral valve design as well as the status of devices that have reached First in Man status.

Objectives This study sought to evaluate the safety of percutaneous direct left ventricular access for interventional procedures. Background Experience with percutaneous access of the left ventricle (LV) for interventional procedures has been limited and associated with a high percentage of major complications. We report our clinical experience with percutaneous direct LV access for interventional procedures. Methods Between March 2008 and December 2010, there were 32 percutaneous transapical punctures in 28 consecutive patients (16 males, mean age 68.2 ± 10.8 years). The delivery sheath sizes ranged from 5- to 12-F. Results All transapical punctures were successfully performed, and safe closure of the access sites was achieved. Total procedural time was 153.6 ± 49.4 min for procedures converted from conventional approaches to a transapical approach, 129.5 ± 29.6 min for the transapical approach with trans-septal rail support, and 109.3 ± 41.4 min for the planned transapical approach. Fluoroscopy time was 61.3 ± 26.1 min, 29.7 ± 20.8 min, and 27.4 ± 21.4 min, respectively. Fluoroscopy time for closure of mitral paravalvular leaks was reduced by 35%, from 42.6 ± 29.9 min to 27.4 ± 15.6 min. Complications were observed in 2 patients (7.1%). Conclusions With meticulous planning, transapical puncture is safe. The transapical access provides a more direct approach to the LV targets for intervention and leads to a significant decrease in the procedural and fluoroscopy times. Device closure of the direct LV access site is a reliable and safe method of hemostasis. Placement of a closure device should be considered if sheaths larger than 5-F are used. Although we used this technique only for paravalvular leak and LV pseudoaneurysm closure, it may have application for other percutaneous structural heart interventions.

Aims: Reliable assessment of the aortic valvar apparatus (AVAp) is essential as it may facilitate consistent outcomes with percutaneous aortic valvar therapies. The commonly referenced aortic annulus is problematic since this measurement does not correspond to any actual anatomic structure. We aim to describe a reliable method of measuring relevant structures of the AVAp based on widely available computed tomography analyses. Methods and results: Retrospective analysis of computed tomograms of 75 patients with severe aortic stenosis (45 females, age 81.2 ± 7.8 years). Curved multiplaner reconstruction technique was used to measure average diameters of the 'Aortic Leaflets Basal Attachment Plane' (ALBAP), sinuses of Valsalva (SV), sinutubular junction (STJ), ascending aorta (AA), and distance from coronary arteries to the base of the cusps. Angulation between the AA and the left ventricle (LV) was measured in one plane that included the LV inflow long axis and the maximum visualization of the aortic root. Inter-rater reliability and absolute agreement among three raters were evaluated. Intra-class correlation coefficients for ALBAP, SV, STJ, and AA diameters were 0.90, 0.99, 0.95, and 0.94, respectively (P < 0.001) with 95 limits of agreement of the observed differences falling in the less than 1 mm range. Intra-class correlation coefficients were 0.82 for the angle and 0.61 and 0.78 for distances to the right and left coronary arteries (P < 0.001).Conclusion: This method showed a high degree of inter-rater reliability and absolute agreement for AVAp diameters. Agreement was lower for AA-LV angle and distance to coronary artery measurements, emphasizing the need for software improvements and standardized image acquisition protocols.

Objective: Pancreatectomy with portal and/or superior mesenteric vein resection remains a controversial procedure because of high complexity and morbidity. Neoadjuvant chemotherapy has been shown to increase resectability of these locally advanced lesions. We aimed to assess the utility and efficacy of direct percutaneous transhepatic portomesenteric venous stenting (THVS) with neoadjuvant chemotherapy in increasing surgical resectability of locally advanced pancreatic carcinoma. Methods: Forty pancreatic carcinoma patients with tumor thrombus involving the portal vein and superior mesenteric vein were identified. Patients underwent THVS followed by neoadjuvant chemotherapy. Whipple procedure was offered to responders. Results: THVS was attempted in all. The tumor thrombus could not be crossed in 2 patients (95% technical success rate). All patients underwent 3 cycles of neoadjuvant gemcitabine, paclitaxel, and capecitabine. Disease progression was noted in 16 patients and surgery was not offered. Twenty-two patients were explored with intent-to-perform a Whipple procedure. In 7 of these (32%), extensive disease precluding surgical resection was identified and the procedure was abandoned. Whipple procedure without vascular resection was performed successfully in 15 patients (68%). There were no perioperative deaths. Negative vascular margins were noted in 3 patients and negative peripancreatic lymph nodes in 5 patients. Median survival was 17 months (range, 5 to 70 mo). In the stented nonoperative group, median survival was 9 months (range, 3 to 19 mo). The stented and resected group achieved a statistically significant (P=0.0422) survival advantage. Conclusions: THVS in combination with neoadjuvant chemotherapy can increase tumor resectability and survival in a select group of locally advanced pancreatic cancer patients.

Our group has reported a high incidence of reactive hypoglycemia following Roux-en-Y gastric bypass (RYGB) with specific interest in postprandial insulin and the ratio of 1- to 2-h serum glucose levels. The purpose of this study is to compare the 6-month response to oral glucose challenge in patients undergoing RYGB, duodenal switch (DS), and vertical sleeve gastrectomy (VSG). Thirty-eight patients meeting the NIH criteria for bariatric surgery who have reached the 6-month postoperative mark are the basis of this report. Preoperatively and at 6 months follow-up, patients underwent blood draw to determine levels of fasting glucose, fasting insulin, HbA1c, C peptide, and 2 h oral liquid glucose challenge test (OGTT). HOMA-IR and 1 to 2 h ratios of glucose and fasting to 1 h ratio of insulin were calculated. All patients underwent a successful laparoscopic bariatric procedure (VSG =13, DS =13, and RYGB = 12). All operations reduced BMI, HgbA1c, fasting glucose, and fasting insulin. HOMA IR and glucose tolerance improved with all procedures. In response to OGTT at 6 months, there was a 20-fold increase in insulin at 1 h in RYGB, which was not seen in DS. At 6 months, 1-h insulin was markedly lower in DS (p

Background— Left ventricular pseudoaneurysm is a rare but serious complication from myocardial infarction and cardiac surgery. Although standard treatment is surgical intervention, percutaneous closure of left ventricular pseudoaneurysm has become an option for high-risk surgical candidates. Experience with percutaneous treatment is limited to a few single case reports. This is the first series of percutaneous treatment of the left ventricular pseudoaneurysms. Methods and Results— This is a retrospective analysis of 9 procedures of percutaneous repair of left ventricular pseudoaneurysm in 7 consecutive patients (ages 51 to 83 years, 6 men) completed in our Structural Heart Disease center from June 2008 to December 2010. All patients were considered as a high risk for surgery because of multiple comorbidities. Multiple imaging modalities were used before, during, and after the procedures to improve success and efficacy. The left ventricular pseudoaneurysms of all 7 patients were successfully repaired. Fluoroscopy time on average was 36.5±24.0 minutes (range, 12.4 to 75.7 minutes). All patients were followed up for a period ranging from 3 to 32 months after the procedure. Each patient improved by at least 1 New York Heart Association functional class, and 4 patients improved by 2 classes. Conclusions— Transcatheter closure of the left ventricular pseudoaneurysm is a feasible alternative for high-risk surgical candidates. The use of multiple imaging modalities is required for a detail planning and execution of the procedure.

This study sought to evaluate the safety of percutaneous direct left ventricular access for interventional procedures.Experience with percutaneous access of the left ventricle (LV) for interventional procedures has been limited and associated with a high percentage of major complications. We report our clinical experience with percutaneous direct LV access for interventional procedures.Between March 2008 and December 2010, there were 32 percutaneous transapical punctures in 28 consecutive patients (16 males, mean age 68.2 ± 10.8 years). The delivery sheath sizes ranged from 5- to 12-F.All transapical punctures were successfully performed, and safe closure of the access sites was achieved. Total procedural time was 153.6 ± 49.4 min for procedures converted from conventional approaches to a transapical approach, 129.5 ± 29.6 min for the transapical approach with trans-septal rail support, and 109.3 ± 41.4 min for the planned transapical approach. Fluoroscopy time was 61.3 ± 26.1 min, 29.7 ± 20.8 min, and 27.4 ± 21.4 min, respectively. Fluoroscopy time for closure of mitral paravalvular leaks was reduced by 35%, from 42.6 ± 29.9 min to 27.4 ± 15.6 min. Complications were observed in 2 patients (7.1%).With meticulous planning, transapical puncture is safe. The transapical access provides a more direct approach to the LV targets for intervention and leads to a significant decrease in the procedural and fluoroscopy times. Device closure of the direct LV access site is a reliable and safe method of hemostasis. Placement of a closure device should be considered if sheaths larger than 5-F are used. Although we used this technique only for paravalvular leak and LV pseudoaneurysm closure, it may have application for other percutaneous structural heart interventions.

Objectives The purpose of this study was to evaluate the feasibility and efficacy of the percutaneous device closure of a consecutive series of patients with periprosthetic paravalvular leaks referred to our structural heart disease center with congestive heart failure and hemolytic anemia. Background Clinically significant periprosthetic paravalvular leak is an uncommon but serious complication after surgical valve replacement. Percutaneous closure has been utilized as an alternative to surgical repair of this defect in high-risk surgical patients. Methods This is a retrospective review of 57 percutaneous paravalvular leak closures that were performed in 43 patients (67% male, mean age 69.4 ± 11.7 years) between April 2006 and September 2010. Integrated imaging modalities were used for the evaluation, planning, and guidance of the interventions. Results Closure was successful in 86% of leaks and in 86% of patients. Twenty-eight of 35 patients improved by at least 1 New York Heart Association functional class. The percentage of patients requiring blood transfusions and/or erythropoietin injections post-procedure decreased from 56% to 5%. Clinical success was achieved in 89% of the patients in whom procedure was successful. The survival rates for patients at 6, 12, and 18 months after paravalvular leak closures were 91.9%, 89.2%, and 86.5%, respectively. Freedom from cardiac-related death at 42 months post-procedure was 91.9%. Conclusions Percutaneous closure of symptomatic paravalvular leaks, facilitated by integrated imaging modalities has a high rate of acute and long-term success and appears to be effective in managing symptoms of heart failure and hemolytic anemia.