IABP

There’s always a good reason to review the physiology and reasons for placement of an Intra Aortic Balloon Pump (IABP).  We come across these a couple of times a month in our cardiac patients.  They’re a great temporary measure to stabilizing and treating the patient.

Contemporary Clinical Niche for Intra-Aortic Balloon Counterpulsation in Perioperative Cardiovascular Practice: An Evidence-Based Review for the Cardiovascular Anesthesiologist. JCVA, February 2017. Volume 31, Issue 1, Pages 309–320.

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From JCVA, Feb 2017.

One of the best explanations that I have ever seen for the IABP is from Dr. Rishi Kumar.  He’s a board certified anesthesiologist and is ICU fellowship trained and is pursuing a cardiac anesthesia fellowship as well.  This lovely human is no joke.  I’ve read his blog and his instagram posts, and he’s a wonderful teacher and mentor to those he reaches.  Please click his link for an entry regarding IABPs on his blog.

RKMD.com: Intra-Aortic Balloon Pump, Arterial Line, and EKG Waveforms. April 2018.

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iabp-ekg-arterial-line-waveforms-aligned-600x559

 

TEE for placement of IABP

Anesthesia & Analgesia, July 2011. Vol 113, No. 1.

  • Want the tip 1-2 cm from left subclavian artery (LSCA)
  • X-plane aortic arch down to descending aorta to see the left subclavian artery
  • Visible during systole when the IABP balloon is deflated

Good visualization of the LSCA

A Novel Technique for Intra-aortic Balloon Positioning in the Intensive Care Unit.  J Extra Corpor Technol. 2012 Sep; 44(3): 160–162.

 

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Mitraclip and TEE for MR

IMG_0056

 

European Heart Journal – Cardiovascular Imaging (2013) 14, 935–949.  Peri-interventional echo assessment for the MitraClip procedure. 

Everest Clinical Trial results PPT

Open Heart 2014;1:e000056. Two-year outcomes after percutaneous mitral valve repair with the MitraClip system: durability of the procedure and predictors of outcome.

ASE Echo 2016: Percutaneous approaches to MR. UofMichigan PPT.

2015: The role of 3D TEE in the MitraClip procedure – UofColorado PPT

Abbott TTE checklist for MitraClip

EuroValve Congress 2015: MR in the MitraClip Era

2012: Echo in mitral valve intervention. 

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Abbott MitraClip device and delivery system package insert

Neth Heart J (2017) 25:125–130. MitraClip step by step; how to simplify the procedure.

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Transseptal Puncture technique with TEE

JACC Cardiovascular Imaging: July 2012. Role of echo in percutaneous mitral valve interventions. 

MitraClip Cases with TEE: Mayo Clinic.

 

Left Atrial Occlusion Devices

Our hospital is starting to do more left atrial occlusion devices for people who have afib and aren’t able to tolerate blood thinners. Currently, two types are offered by our cardiologists: Watchman procedure (endocardial) vs Lariat procedure (epicardial).

Lariat

It look and acts similar to a lariat or lasso.  An external guide wire with a magnet at its tip is introduced outside the heart towards the left atrial appendage (LAA). Another wire with a magnet at its tip is introduced from a groin vein and it traverses the interatrial septum to sit at the most distal point inside the LAA. The magnets “connect” and the lariat is introduced along the external guide wire and essentially lassos the LAA.

Lariat procedure
Watchman

A large occlusion device is inserted via a groin vein and traverses the interatrial septum into the proximal (base or largest opening) left atrial appendage. The device gets deployed and successfully occludes the LAA.

Watchman

PPT on Watchman from Boston Scientific

Is one better than the other?

Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications.  Pillarisetti J, et al. Heart Rhythm. 2015.

CONCLUSION: The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.

Anesthesia

For these cases, we typically have a good flowing peripheral IV and intubate these patients for general anesthesia. There’s a fair amount of TEE required for placement and verification of correct positioning of the device. Both procedures require transseptal access. Watch for hypotension as there is a risk for pericardial effusion.

TEE for Lariat

TEE for Lariat


TEE for Watchman

Watchman TEE

Echo Essentials for Endoluminal LAA Closure: April 2014 Cardiac Interventions Today

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation: J Vis Exp. 2012; (60): 3671

Anesthesia and Transesophageal Echocardiography for WATCHMAN Device Implantation: December 2016Volume 30, Issue 6, Pages 1685–1692.

f4-large
From JACC: Cardiovascular Interventions
PDF Article

Percutaneous Left Atrial Appendage Closure
Procedural Techniques and Outcomes

3D Echo inside the Cath Lab – A must in LAA Closure. London, 2016.

ECHONOMY:Tools for Echocardiographic Calculations

YouTube: LEFT ATRIAL APPENDAGE CLOSURE PROCEDURE : Role of Transesophageal Echocardiography

YouTube: TCTAP 2015 SHD Live Case Session: LAA Closure

YouTube: How to image the inter-atrial septum using 3D-TEE “RATLe-90 maneuver”

YouTube: TOE in LA Appendage Assessment by Jason Sharp

**ASEcho.org 2017**

WATCHMAN:
 
Baseline TEE:
·       Full Scripps TEE protocol
·       Measure the LAA at the following views:
o   0°, 45°, 90°, 135°
·       Report the LAA maximal orifice, as well as the LAA dimensions at each angle using the following Xcelera drop-downs under “Left Atrium”:
 
·       Comment on presence or absence of atrial thrombus or “smoke”
·       Optional: Comment on LAA shape (ie: cauliflower, chicken wing, windsock, cactus)
 

 

Intra-Procedural TEE:
·       Comment on presence or absence of atrial thrombus

·       Report the LAA maximal orifice using the following Xcelera drop-down under “Left Atrium”:

·       Enter LAA device size and implantation date under the “History” section in Xcelera
·       Comment on the presence or absence of a residual leak using the following Xcelera drop-down under “Left Atrium”:
 
·       If a residual leak is present, comment on the size (mm) of the leak using the following Xcelera drop-down under “Left Atrium”:
 
·       Iatrogenic ASD with direction of shunting
·       Comment on any post-procedure pericardial effusion (compare to baseline)

 

 
Post-Procedure Discharge TTE (pt. in hospital):
·       LIMITED 2D TTE to rule out pericardial effusion (unless order specifies otherwise)
·       Spectral Doppler for respirophasic flow changes if an effusion is present

 

 
45-Day, 6 Month, 1 year and 2 year F/U TEEs:
·       Comment on presence or absence of atrial thrombus
·       Comment on the presence or absence of a residual leak using the following Xcelera drop-down under “Left Atrium”:
 
·       If a residual leak is present, comment on the size (mm) of the leak using the following Xcelera drop-down under “Left Atrium”:
 
·       Carry over LAA device size and implantation date under the “History” section in Xcelera

·       Comment on Iatrogenic ASD with direction of shunting, if still present

Left atrial occlusion devices

Our hospital is starting to do more left atrial occlusion devices for people who have afib and aren’t able to tolerate blood thinners. Currently, two types are offered by our cardiologists: Watchman procedure (endocardial) vs Lariat procedure (epicardial).

Lariat

It look and acts similar to a lariat or lasso.  An external guide wire with a magnet at its tip is introduced outside the heart towards the left atrial appendage (LAA). Another wire with a magnet at its tip is introduced from a groin vein and it traverses the interatrial septum to sit at the most distal point inside the LAA. The magnets “connect” and the lariat is introduced along the external guide wire and essentially lassos the LAA.

Lariat procedure
Watchman

A large occlusion device is inserted via a groin vein and traverses the interatrial septum into the proximal (base or largest opening) left atrial appendage. The device gets deployed and successfully occludes the LAA.

Watchman

PPT on Watchman from Boston Scientific

Is one better than the other?

Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications.  Pillarisetti J, et al. Heart Rhythm. 2015.

CONCLUSION: The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.

Anesthesia

For these cases, we typically have a good flowing peripheral IV and intubate these patients for general anesthesia. There’s a fair amount of TEE required for placement and verification of correct positioning of the device. Both procedures require transseptal access. Watch for hypotension as there is a risk for pericardial effusion.

TEE for Lariat

TEE for Lariat


TEE for Watchman

Watchman TEE

Echo Essentials for Endoluminal LAA Closure: April 2014 Cardiac Interventions Today

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation: J Vis Exp. 2012; (60): 3671

Anesthesia and Transesophageal Echocardiography for WATCHMAN Device Implantation: December 2016Volume 30, Issue 6, Pages 1685–1692.

f4-large
From JACC: Cardiovascular Interventions
PDF Article

Percutaneous Left Atrial Appendage Closure
Procedural Techniques and Outcomes

3D Echo inside the Cath Lab – A must in LAA Closure. London, 2016.

ECHONOMY:Tools for Echocardiographic Calculations

YouTube: LEFT ATRIAL APPENDAGE CLOSURE PROCEDURE : Role of Transesophageal Echocardiography

YouTube: TCTAP 2015 SHD Live Case Session: LAA Closure

YouTube: How to image the inter-atrial septum using 3D-TEE “RATLe-90 maneuver”

YouTube: TOE in LA Appendage Assessment by Jason Sharp

 

How Should We Manage PAR After TAVI?

invasivecardiology

Stefan Toggweiler, MD

Evidence indicates that postprocedural moderate or severe paravalvular regurgitation (PAR) reduces life expectancy in such a way that it may even nullify the beneficial effect of TAVI.
Due to improved implantation techniques, knowledge, and materials, the rates of moderate or severe PAR have dropped to less than 5%-10% in most recently published trials and registries, but mild PAR still occurs quite frequently. Many interventional cardiologists now aim for the “perfect” result, and even mild PAR seems to justify postdilatation of a transcatheter valve. However, we should keep in mind that postdilatation carries the risks of annular injury, valve displacement, and embolization of calcific debris.
In our study published in the month’s JIC, we investigated the natural course of PAR after implantation of the self-expandable CoreValve. Patients underwent transesophageal echocardiography after 30 days and 1 year. In most patients, PAR improved. Very small jets disappeared, and larger…

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IABP and pVADs: Clinical Effectiveness Versus Cost

invasivecardiology

By Atman P. Shah, MD, FACC, FSCAI
Clinical Director, Section of Cardiology
Co-Director, Cardiac Catheterization Laboratory
Associate Professor of Medicine
The University of Chicago

Interventional cardiologists are increasingly able to take care of complex coronary artery disease in a population of patients that would have be been deemed too high-risk a decade ago. However, many of these patients have poor left ventricular function and may need to undergo prolonged ischemic times during percutaneous revascularization. There are a number of support devices available for interventional cardiologists to use, and given that every single patient is different, it is up to the operator to personalize therapy within the construct of available data. But, the available data are not entirely clear and do not seem to clearly favor one device over another. Given the changing economics of health care, if there is no clear winning device, should cost influence a physician’s decision? The…

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