A Virtual Live Case of Bi/Trifurcation Percutaneous Coronary Intervention of the Left Main

On Day 2 of EuroPCR 2021, discussants from around the world took to their screens to join Jean Fajadet, PCR Vice-Chairman, and his panel, live from their studio in Paris, France. The aim was to understand how to adapt treatment strategy to the underlying anatomy in a case of left main bifurcation percutaneous coronary intervention.

A New Approach to Percutaneously Treat Chronic Coronary Total Occlusions: The ‘Minimalistic Hybrid Approach’ Algorithm

Vascular access-related complications are one of the most frequent issues following percutaneous interventions of chronic total occlusions (CTO) because of the traditional use of large introducer sheaths for more back-up catheter support, and the need for multiple access sites, often including femoral access. In current practice, many operators still approach the revascularisation of CTO through femoral access despite the demonstrated advantage of radial procedures, mostly in terms of incidence of bleeding complications. Recently, an alternative strategy to deal with CTO, with the aim to minimise the number of access-related complications without affecting the successful revascularisation rate, has been proposed: the ‘minimalistic hybrid approach’ algorithm. This approach consists of the use of classic ‘hybrid algorithm’ techniques, but also aims to minimise the number of access sites, the size of the catheters used, and the adoption of the femoral access.

Left Atrial Appendage Closure for Stroke Prevention

IMPLEMENTING an effective patient-selection approach, integrating device choice, procedural planning, and patient follow-up, have proven crucial to the success of left atrial appendage closure (LAAC) therapy for atrial fibrillation (AF). This was the focus of the EuroPCR 2021 ‘Structural Theatre’ session, which compared LAAC and direct oral anticoagulant (DOAC) treatment avenues for stroke prevention. In this session, Patrick Calvert, from Royal Papworth Hospital in Cambridge, UK, gave a presentation on patient selection, alongside Ole De Backer of Copenhagen University Hospital, Denmark, who discussed device selection and planning using CT imagery. Ivan Kuntjoro, from the National University Heart Centre of Singapore, briefly outlined left atria morphology, and Farell Hellig of Sunninghill Hospital, Johannesburg, South Africa, introduced procedural plans in a step-by-step approach while performing a live procedure. The session was concluded by Edgar Tay, UK Royal College of Physicians, who gave his insights on several of these topics and concluded the stream with how to optimise patient follow-up care.

Rare Right Ventricular Obstructing Myxoma: An Incidental Finding for a Common Symptom

Background: Palpitations are a common clinical manifestation within the general population and are often associated with conduction abnormalities within the heart. Structural causes account for only 3% of palpitations. As such, they are often investigated with cardiac event/Holter monitoring. Presented here is a case of palpitations secondary to intracardiac mass. Case summary: A 58-year-old female patient presented with palpitations. The electrocardiogram was unremarkable. Transthoracic echocardiography revealed a large, mobile mass visualised in the right ventricular outflow tract. Further investigations, including cardiac CT and cardiac MRI, confirmed a right ventricular myxoma, which was successfully surgically excised. There has been no evidence of recurrence or long-term morbidity. Discussion: Myxomas are extremely rare and most commonly present with signs of heart failure, thromboembolic events, or constitutional symptoms. Palpitations are a usual presentation of cardiac masses. Myxomas carry a high risk of sudden death through thromboembolic events or dysrhythmias, therefore immediate intervention is essential. From the findings, patients presenting with palpitations are recommended to undergo a transthoracic echocardiogram to identify the possibility of palpitations secondary to structural variants or abnormalities. Learning Points: If there are no haematological or biochemistry abnormalities, and no risk factors for palpitations were ascertained, patients presenting with palpitations should ideally have a transthoracic echocardiogram, in addition to Holter monitoring, to rule out a structural cause for their clinical manifestation. Structural abnormalities noticed on echocardiography are better characterised with cardiac MRI as it provides both structural and possible tissue characterisation.

Surgical Treatment of Greater Saphenous Vein Thrombosis Involving the Saphenofemoral Junction: An Albanian Experience

Superficial vein thrombosis (SVT) is less well-studied than deep vein thrombosis (DVT) because it has been considered less serious and is easily diagnosed following clinical symptomatology, and therefore requires mainly conservative treatment.1 The condition is common and is usually accompanied by clear inflammatory skin changes, and should be denoted as interchangeable with superficial vein thrombophlebitis.2

FATAL CARDIOVASCULAR COLLAPSE DURING TRANS-AORTIC TRANSCATHETER AORTIC VALVE REPLACEMENT FOLLOWING INTRA-PROCEDURAL RETROGRADE TRANSCATHETER HEART VALVE MIGRATION INTO THE LEFT VENTRICULAR OUTFLOW TRACT

Transcatheter heart valve retrograde migration after transcatheter aortic valve implantation is unusual. It can occur during the implantation of the aortic transcatheter heart valve, i.e., intra-procedural, or in the first few days following the intervention. Transcatheter valve embolisation and migration soon after deployment typically results from the implantation of a prothesis that was undersized for the annulus, an unreasonably low implantation, or the expulsion of the device following deployment by an excessive ventricular contraction. The presented case highlights the importance of the timing of the complication that has taken place, in this case, intra-procedural, which has become relevant to the research.

Percutaneous Coronary Intervention of a Diffusely Degenerated Saphenous Vein Graft: A Road Less Taken

Years after coronary artery bypass graft surgery, plaque formation or graft degeneration is a major concern. Saphenous vein grafts (SVG) are vulnerable to degeneration and occlusion, leading to poorer long-term disease because of atherosclerotic degeneration. The main mechanism responsible for SVG failure is neointimal hyperplasia and the occluded SVG is treated with percutaneous coronary intervention, mostly with the use of additional protection devices. Graft intervention for the diffuse degeneration of SVG can be performed with the use of suitable hardware without the distal protection device being required. The authors herein report the case of a 63-year-old female who presented with degenerated SVG to the left anterior descending artery with anastomotic stenosis, 6 years after coronary artery bypass graft surgery. She was successfully treated with three ultra-thin sirolimus-eluting stents in SVG to the left anterior descending artery, without the use of any embolic protection device.

Percutaneous Transcatheter Metabolic Interventions: The Next Frontier?

Obesity is a pandemic. The prevalence of obesity (BMI >30) and morbid obesity (BMI >40) among American adults is approximately 30% and 5%, respectively.1 The condition is strongly associated with medical comorbidities (e.g., heart disease, Type 2 diabetes mellitus, stroke, obstructive sleep apnoea, certain types of cancer, and osteoarthritis) and mortality, and has begun to overtake infectious diseases as the most significant contributor to illness worldwide. Furthermore, it is a leading preventable cause of death worldwide, with increasing prevalence in adults and children, and considered one of the most serious public health problems of the 21st century.2 Currently, there are three clinically viable treatment options for obesity: surgery, pharmacologic intervention, and intragastric balloon administration. However, these methods have varying success rates and are not free of complications. There remains a critical need for a minimally invasive intervention that can target this growing population.