Percutaneous closure of mitral paravalvular leaks: Focus on imaging and technique

Symptomatic prosthetic paravalvular leakage is a rare clinical condition occurring in up to 5% of patients after valve surgery. Symptoms include haemolytic anaemia, heart failure or both. Leaks tend to be more common in the mitral compared to the aortic position. Three dimensional transoesophageal echocardiography (3D TOE) is essential prior and during percutaneous leak closure. This imaging technique allows to qualify and quantify the leak and to judge feasibility of a percutaneous approach. It also enables the choice of the most appropriated closure device prior to intervention. During the procedure, 3D TOE guides adequate crossing of the leak and device deployment. It also fi nally allows assessment of the acute procedural result. Percutaneous closure should be considered as the fi rstchoice therapy if closure is judged feasible based on 3D TOE assessment. This procedure is currently performed in a limited number of patients by relatively few operators and is characterised by a long learning curve. Currently, literature data are scarce and reported acute procedural success is roughly around 70 to 80%. Intervention is mostly performed with vascular plugs or ventricular septum defect closure devices. Recently, dedicated implants have been made available. Their role has been limited to hybrid procedures from a transapical retrograde approach

743-5 Evaluation of the Accuracy of New Quantitative Image Processing Methods in Measuring the Size of Ventricular Septal Defects Directly on Three-dimensional Echocardiograms and Factors Influencing its Reliability

Volume-rendered 3-D echocardiography(3DE) can display the shape and size of various ventricular septal defects (VSD). Quantitation of VSD size directly from 3DE images has not been possible and measurements (M) could be performed only in 2DE slices derived from 3DE and required tedious efforts to obtain the correct 2DE slice orientation, Newly developed image processing (IP) algorithms permitdirect M on 3DE imagesbut the reliability of this method in sizing VSDs is unclear, Also, the effects of operator-dependent IP factors such as thresholding (TH) and opacification (OP) on quantitation are unknown. In this study, we examined the accuracy ofdirect 3DE quantificationof VSDs and the influence of TH and OP. We created 17 VSDs of various types and shapes in 9 pig hearts and acquired 2-D images with a transducer mounted on a parallel scanning device (216 image slices over 60mm distance). 3DE reconstructions were accomplished anden-face viewsof the VSDs were derived. Using the new quantitation tool, we measured the maximum and minimum diameters (Max D and Min D), directly on the 3DE image under optimal IP settings and compared them to independent direct M from the anatomic specimens. M were also performed with changes in TH and OP.ResultsThe VSD site, shape and size on 3DE corresponded well with anatomic specimens. Max D (Mean±SD) by anatomy was 10±4mm (range 4–16), and by 3DE was 10±4 (range 4–15); Min D by anatomy was 9±3 mm (range 4–15). and by 3DE was 8 ± 4 (range 5-19). The correlations between 3DE (y) and anatomy were: Max D: y=1.0x + 0.3, r = 0.88, P<0.001; Min D: y = 1.0x – 1.4, r = 0.89, P<0.001. Increased TH by 10 units led to overestimation of the VSD size by 6±18%, while TH decrease by 10 units resulted in 8±13% under-estimation. Increased OP by 10 and 20 units led to overestimation of VSD size by 11±29% and 17±23%.Conclusion3DE provides unique en-face views of VSDs unavailable by 2DE. VSD size can be measured directly on the 3D image. Inappropriate processing steps can result in unreliable data, however with optimal processing VSDs can be quantified accurately

Optimized Treatment of Refractory Hypercholesterolemia in Patients With Atherosclerotic Cardiovascular Disease or Heterozygous Familial Hypercholesterolemia With Alirocumab (OPTIMIZE).

Background Low-density lipoprotein cholesterol (LDL-C) is a major risk factor for atherosclerotic cardiovascular disease (ASCVD). In confirmatory trials, proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab substantially lowered LDL-C and reduced cardiovascular morbidity and mortality. However, the routine clinical use of alirocumab in Switzerland has not yet been studied. Methods In this prospective nation-wide cohort study, we aimed to investigate the patient profile and routine clinical efficacy and safety of alirocumab in 207 patients with ASCVD or heterozygous familial hypercholesterolemia and increased LDL-C despite maximally tolerated statin therapy. LDL-C was measured at baseline and after 3-months follow-up. Results Overall, mean age was 63 ± 11 years, 138 (67%) were men, and 168 (81%) had statin intolerance (SI). Patients with SI had a higher baseline LDL-C (4.3 ± 1.4 vs. 3.3 ± 1.4 mmol/l; p < 0.001) and less frequently ASCVD (71% vs. 95%; p = 0.002). After 3 months of treatment with alirocumab, LDL-C was reduced from 4.1 ± 1.5 to 2.0 ± 1.2 mmol/l (50.5%; p < 0.001). Mean absolute and relative reductions in LDL-C were similar in patients with vs. without SI (2.2 ± 1.2 vs. 1.9 ± 1.3 mmol/l; p = 0.24 and 49.0 vs. 56.6%; p = 0.11, respectively). In total, adverse events were recorded in 25 (12%) patients, with no new safety signals. Conclusions In routine clinical practice, alirocumab was predominantly used in patients with SI suggesting that the great majority of patients with insufficient LDL-C control who would be candidates for alirocumab are not receiving this therapeutic option in Switzerland. LDL-C lowering was potent and similar in patients with and without SI, replicating the favorable efficacy-safety profile of alirocumab from randomized trials