Enabling automated device size selection for transcatheter aortic valve implantation

The number of transcatheter aortic valve implantation (TAVI) procedures is expected to increase significantly in the coming years. Improving efficiency will become essential for experienced operators performing large TAVI volumes, while new operators will require training and may benefit from accurate support. In this work, we present a fast deep learning method that can predict aortic annulus perimeter and area automatically from aortic annular plane images. We propose a method combining two deep convolutional neural networks followed by a postprocessing step. The models were trained with 355 patients using modern deep learning techniques, and the method was evaluated on another 118 patients. The method was validated against an interoperator variability study of the same 118 patients. The differences between the manually obtained aortic annulus measurements and the automatic predictions were similar to the differences between two independent observers (paired diff. of 3.3 +/- 16.8 mm(2) vs. 1.3 +/- 21.1 mm(2) for the area and a paired diff. of 0.6 +/- 1.7 mm vs. 0.2 +/- 2.5 mm for the perimeter). The area and perimeter were used to retrieve the suggested prosthesis sizes for the Edwards Sapien 3 and the Medtronic Evolut device retrospectively. The automatically obtained device size selections accorded well with the device sizes selected by operator 1. The total analysis time from aortic annular plane to prosthesis size was below one second. This study showed that automated TAVI device size selection using the proposed method is fast, accurate, and reproducible. Comparison with the interobserver variability has shown the reliability of the strategy, and embedding this tool based on deep learning in the preoperative planning routine has the potential to increase the efficiency while ensuring accuracy

Multislice computer tomography (MSCT) for the optimisation of transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve replacement (TAVI) is a novel therapy that is increasingly used to treat patients with severe aortic stenosis at high risk for surgical valve replacement. Patient selection, procedural planning and evaluation all require a detailed analysis of patient anatomy. The role and added value of multislice computer tomography (MSCT) is described as a 3-D imaging modality that enables a comprehensive evaluation of the complex 3-D anatomy of the aortic root, planning of all potential transcatheter access routes and evaluation of prosthesis anatomy interactions post-implantation

Stent implantation in human coronary arteries. Clinical and angiographic aspects

Atherosclerotic cardiovascular disease remains one of the most important causes of morbidity and mortality in the industrialized world. Treatment is basically aimed at palliation and consists of either pharmacological intervention or revascularization. The frrst significant advances in the latter were largely surgical [!]. However, the pressing need for treatment with less invasive and potentially less expensive techniques, have stimulated the development of non-surgical revascularization techniques. Percutaneous transluminal coronary balloon angioplasty, which was first performed by Andreas Gruentzig in 1977, is one of the most successful examples and provided the stimulus for a rapid technological growth of interventional cardiology [2]. It is now widely accepted as a safe and effective treatment of obstructive coronary artery disease. However, the risk of abrupt vessel closure during or immediately after the intervention and the risk of late luminal renarrowing or restenosis continue to compromise its overall safety and efficacy [3,4]. To improve the immediate and long-term results of balloon angioplasty, a number of new technologies such as intracoronacy stenting, directional or rotational atherectomy and laser therapy have been developed and represent the leading edge in the battle against atherosclerosis [5-8]. The intracoronary stent has been shown to be effective in the treatment of acute or threatened vessel closure due to balloon angioplasty induced coronary dissection, alleviating the need for emergency bypass surgery [9]. Furthermore, it has been hypothesized that intracoronary stent implantation may reduce the incidence of restenosis by optimizing the immediate angiographic results which should lead to improved long-term clinical outcome

Case report: Concomitant MitraClip implantation for severe mitral regurgitation and plug closure of endocarditis induced fistula between aortic root and left atrium after transcatheter aortic valve implantation

Background: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) occurs in up to 1.5% of patients within the first year. The development of an aorto-atrial fistula (AAF) is a rare but problematic complication of IE, which can be confirmed with transoesophageal echocardiography (TOE). We present an exceptional case of occluding an aorto-left atrial fistula only diagnosed with intraprocedural TOE during a subsequent procedure of MitraClip implantation. Case summary: A 79-year-old symptomatic male patient with multiple comorbidities was referred due to severe mitral regurgitation (MR). He has had prior TAVI which was complicated with streptococcal IE for which he had received prolonged antibacterial therapy. Transthoracic echocardiography (TTE) revealed severe MR. The patient was accepted for a MitraClip procedure by the heart team. Intra-procedural TOE revealed also a significant continuous shunt through an AAF which was likely caused by the endocarditis. The strategy was therefore defined as to occlude the fistula with an Amplatzer Vascular Plug II 12 mm. The plug was released in the fistula leaving an insignificant residual shunt. After the transseptal puncture one MitraClip XTR was implanted, reducing the MR to mild. After the procedure, the patient's general clinical condition improved without signs of haemolysis. The pre-discharge TTE confirmed trace residual shunt, mild residual MR and mild paravalvular leakage. Discussion: Our case illustrates a complex transcatheter structural heart intervention with improvised procedural strategies based on the intra-procedural TOE findings. We conclude that the pre-procedural TOE needs to be comprehensive rather than exclusive, particularly in the context of bioprosthesis-related endocarditis

Incidence, predictors, and management of acute coronary occlusion after coronary angioplasty

Acute coronary occlusion occurs in 4.3% to 8.3% of patients during coronary angioplasty. Its occurrence is difficult to predict in an individual patient. At high risk are patients with unstable angina, intracoronary thrombus, extreme age, long complex lesions, and diffuse disease. "Standard" management including redilation (prolonged perfusion) thrombolytic treatment and emergency bypass surgery is only successful in approximately 50% of the patients and is associated with a high mortality and myocardial infarction rate of < 6% and 30%, respectively. Bail-out stent implantation appears to emerge as an effective alternative in suitable patients and might reduce mortality, the apparent progression to myocardial infarction, or might decrease the need for emergency bypass. New techniques including directional atherectomy, rotational ablation, or the excimer laser are associated with a similar frequency of acute occlusion. Immediate access to a surgical back-up facility remains necessary to treat refractory acute occlusions