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Atlas of Cardiac
Catheterization and
Interventional
Cardiology
EDITED BY

Mauro Moscucci, MD, MBA

Chairman, Department of Medicine, Sinai
Hospital of Baltimore
Baltimore, Maryland
Adjunct Professor of Medicine, University of
Michigan Health System
Physician Consultant, Joint Commission
Resources
Baltimore, Maryland

ASSOCIATE EDITORS

Mauricio G. Cohen, MD, FACC,

FSCAI
Professor of Medicine
Cardiovascular Division, Department of Medicine
University of Miami Miller School of Medicine
Director, Cardiac Catheterization Laboratory
University of Miami Hospital and Clinics
Miami, Florida
Stanley J. Chetcuti, MD
Professor of Medicine
Eric J. Topol Professor of CVM
Director Cardiac Catheterization Laboratory
Co-Director Structural Heart Service
Division of Cardiovascular Medicine
Department of Internal Medicine
University of Michigan
Ann Arbor, Michigan
Acquisitions Editor: Sharon Zinner
Product Development Editor: Ashley Fischer
Editorial Coordinator: Louise Bierig
Editorial Assistant: Nicole Dunn
Marketing Manager: Rachel Mante Leung
Production Project Manager: Marian Bellus
Design Coordinator: Holly McLaughlin
Manufacturing Coordinator: Beth Welsh
Prepress Vendor: TNQ Technologies

Copyright © 2019 Wolters Kluwer

All rights reserved. This book is protected by copyright. No part of

this book may be reproduced or transmitted in any form or by any
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Printed in China

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eISBN: 978-1-975116-19-4

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Publisher.
This work is provided “as is,” and the publisher disclaims any and all
warranties, express or implied, including any warranties as to
accuracy, comprehensiveness, or currency of the content of this
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This work is no substitute for individual patient assessment based

upon healthcare professionals’ examination of each patient and
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Dedication

To my many mentors and colleagues, and particularly

to Kenneth Borow,
John Carroll, Donald Baim, and William Grossman,
recognizing their charismatic vision
and support that put me on this pathway.

And to my wife Adriana for her continuous

understanding, love, and support.
Her willingness to continue to adapt her life to the
many months of night
and weekend work that were required to create this
Atlas will be unforgettable.
Preface

The evolution of photography and more recently of

medical imaging has been one of the major advances
of this past century. An image can tell a story, even
without caption, and there is nothing more powerful
than images when introducing new technology, new
techniques, and new processes.
In 2010, I had the privilege to be asked by
Wolters Kluwer to take over the eighth edition of
“Grossman and Baim’s Cardiac Catheterization,
Angiography, and Intervention”. That new edition,
capitalizing on the outstanding work from prior
editions, had an additional emphasis on cardiac
imaging. Yet, it looked like there was still an
opportunity for a book fully dedicated to images.
Thus, following further discussion with the Wolters
Kluwer team, the idea for this Atlas was developed.
The purpose of this Atlas is to provide a visual
overview of cardiac catheterization and interventional
cardiology. Given the emphasis on imaging, the
opening chapter is on integrated imaging modalities
in the cardiac catheterization laboratory. We hope
that our readers will enjoy the unique cases
illustrated in this chapter. The remaining chapters
can be divided into 2 main groups. Chapters 2-15 are
focused on basic elements of cardiac catheterization
and interventional cardiology including complications,
vascular access, pressure measurements, pitfalls in
the evaluation of hemodynamic data, pericardial
disease, pediatric cardiac catheterization, coronary,
peripheral, and pulmonary angiography, coronary
anomalies, evaluation of myocardial blood flow, and
intravascular ultrasounds. Chapters 15-25 cover key
areas of interventional cardiology, from percutaneous
transluminal coronary angioplasty (PTCA) to
advanced epicardial access.
Our readers will notice that the chapters have 2
basic formats: (1) a clinical, case-based structure
with images and (2) a primarily image-based
structure. Given the diversity of topics, we felt that
this flexible approach could provide the most value to
our readers. In addition, the chapters on PTCA and
coronary stenting focus on basic concepts,
equipment characteristics, basic techniques, and
clinical trials, rather than on clinical cases. The
decision of how to structure these chapters was
based on the fact that general training in
interventional cardiology not always incorporates
formal training about the history, the development,
and engineering of interventional devices.
This book and the stories told through images
would have not been possible without the work of
the many pioneers who contributed to the
development of cardiac catheterization and
interventional cardiology. Our gratitude to them will
continue to be immeasurable.

Mauro Moscucci. MD, MBA

Baltimore, Maryland
Acknowledgments

First and foremost, I would like to thank the many

mentors who I was fortunate to have through my
career in cardiology and interventional cardiology,
including Dr. Kenneth Borow, Dr. John Carroll, Dr.
Donald Baim, and Dr. William Grossman for their
charismatic mentorship and guidance during my
initial training in cardiology at the University of
Chicago, and my 2 years of training at the Beth
Israel Hospital in Boston in the early 1990s. Their
continued friendship and support over the following
decades have been inspiring. I would also like to
thank Julie Goolsby, who as acquisition editor for
Wolters Kluwer supported my initial proposal, and
Sharon Zinner, who in her role as senior acquisition
editor continued to provide an incredible support
while we were developing the Atlas. In addition, I
would like to thank Ashley Fischer, for her
outstanding assistance and patience as the product
development editor, and Louise Bierig, for her
support as development editor. The incredible
support of the Wolters Kluwer team was what that
made this Atlas becoming true. Finally, I am
extremely grateful to my associate editors, Dr.
Stanley Chetcuti and Dr. Mauricio Cohen, and to all
the authors and many colleagues and friends who
have contributed to this Atlas.
Contents

chapter 1 Integrated Imaging Modalities in

the Cardiac Catheterization
Laboratory
MICHAEL S. KIM, MD, AND ROBERT A. QUAIFE, MD

chapter 2 Complications of Percutaneous

Coronary Intervention
MAURO MOSCUCCI, MD, MBA

chapter 3 Percutaneous Vascular Access:

Transfemoral, Transseptal, Apical,
and Transcaval Approach
MICHAEL DAVID DYAL, MD, FACC AND CLAUDIA A.
MARTINEZ, MD

chapter 4 Radial Artery Approach

CARLOS ENRIQUE ALFONSO, MD, TEJAS PATEL, MD,
DM, FACC, FSCAI, FESC, AND MAURICIO G. COHEN,
MD, FACC, FSCAI

chapter 5 Cutdown Approach: Femoral,

Axillary, Direct Aortic, and
Transapical
 ROSS MICHAEL REUL, MD, PHILIP L. AUYANG, MD,
AND MICHAEL JOSEPH REARDON, MD

chapter 6 Catheterization in Childhood and

Adult Congenital Heart Disease
ADA C. STEFANESCU SCHMIDT, MD, MSC, SAMUEL
L. CASELLA, MD, MPH, MICHAEL J. LANDZBERG, MD,
AND DIEGO PORRAS, MD

chapter 7 Pressure Measurements

MAURO MOSCUCCI, MD, MBA, AND CALIN V. MANIU,
MD

chapter 8 Hemodynamics of Tamponade,

Constrictive, and Restrictive
Physiology
YOGESH N. V. REDDY, MBBS, MAURO MOSCUCCI,
MD, MBA, AND BARRY A BORLAUG, MD

chapter 9 Pitfalls in the Evaluation of

Hemodynamic Data
MAURO MOSCUCCI, MD, MBA

chapter 10 Coronary Angiography and Cardiac

Ventriculography
ROBERT N. PIANA, MD, AARON KUGELMASS, MD,
AND MAURO MOSCUCCI, MD, MBA

chapter 11 Coronary Anomalies

MAURO MOSCUCCI, MD, MBA
chapter 12 Pulmonary Angiography
KYUNG J. CHO, MD

chapter 13 Angiography of the Aorta and

Peripheral Arteries
HECTOR TAMEZ, MD, THOMAS M. TU, MD, RUBY LO,
MD, AND DUANE S. PINTO, MD, MPH

chapter 14 Myocardial and Coronary Blood

Flow and Metabolism
MATHEW LIAKOS, MD, KIRAN V. REDDY, MD, FACC,
AND ALLEN JEREMIAS, MD, MSC

chapter 15 Intravascular Imaging

MASAYASU IKUTOMI, MD, PHD, YASUHIRO HONDA,
MD, FAHA, FACC, PETER J. FITZGERALD, MD, PHD,
FACC, AND PAUL G. YOCK, MD

chapter 16 Endomyocardial Biopsy

MAURO MOSCUCCI, MD, MBA

chapter 17 Percutaneous Circulatory Support:

Intra-Aortic Balloon
Counterpulsation, Impella,
Tandem Heart, and Extracorporeal
Bypass
CARLOS D. DAVILA, MD, MICHELE ESPOSITO, MD,
AND NAVIN K. KAPUR, MD

chapter 18 Percutaneous Transluminal

Coronary Angioplasty
 MAURO MOSCUCCI, MD, MBA

chapter 19 Atherectomy, Thrombectomy, and

Distal Protection Devices
KARIM M. AL-AZIZI, MD AND AARON KUGELMASS,
MD

chapter 20 Coronary Stenting

MAURO MOSCUCCI, MD, MBA

chapter 21 Percutaneous Interventions for

Valvular Heart Disease
HONG JUN (FRANCISCO) YUN, MD AND STANLEY J.
CHETCUTI, MD

chapter 22 Interventions for Adult Structural

Heart Disease
HONG JUN (FRANCISCO) YUN, MD AND STANLEY J.
CHETCUTI, MD

chapter 23 Peripheral Interventions

JAYENDRAKUMAR S. PATEL, MD, SAMIR R. KAPADIA,
MD, AND MEHDI H. SHISHEHBOR, DO, MPH, PHD

chapter 24 Thoracic Aortic Endovascular

Repair
ARNOUD KAMMAN, MD, KAREN M. KIM, MD, DAVID
M. WILLIAMS, MD, AND HIMANSHU J. PATEL, MD

chapter 25 Percutaneous Epicardial

Techniques
JUAN F. VILES-GONZALEZ, MD, FACC, FAHA, FHRS
AND ANDR D’AVILA, MD

Index
Contributors

Karim M. Al-Azizi, MD
Structural Heart Disease Fellow
Department of Interventional Cardiology
The Heart Hospital–Baylor Scott & White
Plano, Texas

Carlos Enrique Alfonso, MD

Assistant Professor of Medicine
Cardiovascular Division
University of Miami Miller School of Medicine
University of Miami Hospital & Clinics
Miami, Florida

Philip L Auyang, MD
Resident Physician
Houston Methodist DeBakey Heart and Vascular
Center
Houston, Texas

Barry A. Borlaug, MD
Associate Professor
Department of Cardiovascular Diseases
Mayo Clinic
Rochester, Minnesota

Samuel L. Casella, MD, MPH

Clinical Fellow
Department of Pediatrics
Harvard Medical School
Massachusetts Hall
Cambridge, Massachusetts
Department of Cardiology
Boston Children’s Hospital
Boston, Massachusetts

Stanley J. Chetcuti, MD
Professor of Medicine
Eric J. Topol Professor of CVM
Director Cardiac Catheterization Laboratory
Co-Director Structural Heart Service
Division of Cardiovascular Medicine
Department of Internal Medicine
University of Michigan
Ann Arbor, Michigan

Kyung J. Cho, MD
Emeritus Professor of Radiology
University of Michigan Health System
Department of Radiology
Division of Interventional Radiology
Ann Arbor, Michigan

Mauricio G. Cohen, MD, FACC, FSCAI

Professor of Medicine
Cardiovascular Division, Department of Medicine
University of Miami Miller School of Medicine
Director, Cardiac Catheterization Laboratory
University of Miami Hospital and Clinics
Miami, Florida

André D’Avila, MD
Director
Cardiac Arrhythmia Service Hospital
SOS Cardio
Florianopolis, SC, Brazil

Carlos D. Davila, MD
General Cardiology Fellow
The Cardiovascular Center
Tufts Medical Center
Boston, Massachusetts

Michael David Dyal, MD

Interventional Cardiology Fellow
Department of Medicine
University of Miami
Miami, Florida
Michele Esposito, MD
Cardiovascular Disease Fellow
The Cardiovascular Center
Tufts Medical Center
Boston, Massachusetts

Peter J. Fitzgerald, MD, PhD, FACC

Professor Emeritus, Medicine & Engineering
Director, Stanford Center for Cardiovascular
Innovation
Division of Cardiovascular Medicine
Stanford University School of Medicine
Stanford, California

Yasuhiro Honda, MD, FAHA, FACC

Clinical Professor of Medicine
Director, Stanford Cardiovascular Core Analysis
Laboratory
Division of Cardiovascular Medicine
Stanford University School of Medicine
Stanford, California

Masayasu Ikutomi, MD, PhD

Division of Cardiovascular Medicine
Stanford University School of Medicine
Stanford, California

Allen Jeremias, MD, MSc

Director of Interventional Cardiology Research
Department of Cardiology
St. Francis Hospital
Roslyn, New York

Arnoud Kamman, MD
Surgical Resident
Department of Surgery
Ikazia Hospital Rotterdam
Rotterdam, the Netherlands

Samir R. Kapadia, MD
Professor of Medicine
Section Head, Interventional Cardiology
Director, Sones Cardiac Catheterization Laboratory
Cleveland, Ohio

Navin K. Kapur, MD
Associate Professor
Department of Medicine and Cardiology
Tufts Medical Center
Boston, Massachusetts

Karen M. Kim, MD
Department of Cardiac Surgery
Frankel Cardiovascular Center
University of Michigan
Ann Arbor, Michigan
Michael S. Kim, MD
Medical Director
Structural Heart & Valve Disease Program
Cardiovascular Institute of North Colorado
Banner Health
Greeley, Colorado

Aaron Kugelmass, MD
Professor
Department of Medicine
Univeristy of Massachusetts Medical School-Baystate
Medical Director
Heart and Vascular Program
Chief of Cardiology
Baystate Health System
Springfield, Massachusetts

Michael J. Landzberg, MD
Associate Professor of Medicine
Harvard Medical School
Boston, Massachusetts
Immediate-Past Director, Boston Adult Congenital
Heart (BACH) Group
Department of Cardiology, Department of Medicine
Boston Children’s Hospital and Brigham and Women’s
Hospital
Boston, Massachusetts
Matthew Liakos, MD
Stony Brook University Medical Center
Stony Brook, New York

Ruby Lo, MD
Assistant Professor
Vascular and Endovascular Surgery
Brown University
Providence, Rhode Island
Boston, Massachusetts

Calin V. Maniu, MD
Director
STEMI Program Lifebridge Health
Baltimore, Maryland

Claudia A. Martinez, MD
Associate Professor
Department of Medicine
University of Miami
Miami, Florida

Mauro Moscucci, MD, MBA

Chairman, Department of Medicine
Sinai Hospital of Baltimore
Baltimore, Maryland
Adjunct Professor of Medicine, University of Michigan
Health System
Physician Consultant
Joint Commission Resources
Baltimore, Maryland

Himanshu J. Patel, MD
Joe D. Morris Collegiate Professor
Section Head
Department of Cardiac Surgery
University of Michigan
Ann Arbor, Michigan

Jayendrakumar S. Patel, MD
Fellow
Department of Interventional Cardiology
Heart and Vascular Institute, Cleveland Clinic
Cleveland, Ohio

Tejas Patel, MD, DM, FACC, FSCAI, FESC

Professor
Department of Cardiology
Sheth V.S. General Hospital
Chairman & Chief Interventional Cardiologist
Apex Heart Institute
Ahmedabad, India

Robert N. Piana, MD
Professor of Medicine
Director, Adult Congenital Interventional Cardiology
Division of Cardiovascular Medicine
Vanderbilt University Medical Center
Nashville, Tennessee

Duane S. Pinto, MD, MPH

Harvard Medical Faculty Physicians (HMFP)
Beth Israel Deaconess Medical Center
Boston, Massachusetts

Diego Porras, MD
Assistant Professor
Department of Pediatrics
Harvard Medical School
Department of Cardiology
Boston Children’s Hospital
Boston, Massachusetts

Robert A. Quaife, MD
Professor of Medicine and Radiology Director
Advanced Cardiac Imaging University of Colorado
Anschutz Medical Campus Aurora
Division of Cardiology
University of Colorado Denver
Aurora, Colorado

Michael Joseph Reardon, MD

Professor of Cardiothoracic Surgery
Allison Family Distinguished Chair of Cardiovascular
Research
Department of Cardiovascular Surgery Associates
Houston Methodist Physician Specialty Group
Houston, Texas

Kiran V. Reddy, MD, FACC

Interventional Cardiologist
Division of Cardiology
St Francis Hospital
Roslyn, New York

Yogesh N.V. Reddy, MBBS, MSc

Advanced Heart Disease Failure Fellow
Division of Cardiovascular Diseases
Mayo Clinic
Rochester, Minnesota

Ross Michael Reul, MD

Attending Surgeon of Cardiovascular Surgery
Associates
Department of Cardiovascular Surgery Associates
Houston Methodist Physician Specialty Group
Houston, Texas

Ada C. Stefanescu Schmidt, MD, MSc

Clinical and Research Fellow
Adult Congenital Heart Disease
Boston Children’s Hospital
Harvard Adult Congenital Heart Disease Fellowship
Department of Cardiology
Boston, Massachusetts

Mehdi H. Shishehbor, DO, MPH, PhD

Clinical Assistant Professor of Medicine
Department of Cardiovascular Medicine
Director, Interventional Cardiovascular Center,
University Hospitals
Heart & Vascular Institute
Cleveland Clinic
Cleveland, Ohio

Hector Tamez, MD
Co-director of Chronic Total Occlusion Projection
Instructor of Medicine
Division of Cardiology
Department of Medicine
Beth Israel Deaconess Medical Center
Boston, Massachusetts

Thomas M. Tu, MD
Director, Cardiac Catheterization Lab
Baptist Health Louisville
Interventional Cardiology
Department of Medicine
Baptist Hospital Medical Group
Louisville, Kentucky

Juan F. Viles-Gonzalez, MD, FACC, FAHA, FHRS

Associate Professor
Director, Cardiac Electrophysiology
Tulane University School of Medicine
Heart and Vascular Institute
New Orleans, Louisiana

David M. Williams, MD
Kyung J. Cho Professor of Radiology
Department of Radiology
Frankel Cardiovascular Center
University of Michigan
Ann Arbor, Michigan

Paul G. Yock, MD
Martha Meier Weiland Professor of Bioengineering
and Medicine
Founding Director, Stanford Byers Center for
Biodesign
Stanford, California

Hong Jun (Francisco) Yun, MD

Interventional Cardiology Fellow
Division of Cardiovascular Medicine
Department of Internal Medicine
University of Michigan
Ann Arbor, Michigan
chapter 1
Integrated Imaging
Modalities in the Cardiac
Catheterization Laboratory
MICHAEL S. KIM, MD, and ROBERT A. QUAIFE,
MD

INTRODUCTION
Over the last decade, there has been an exponential
growth in the number of transcatheter therapies
designed to treat both congenital and acquired
structural heart disease (SHD) pathologies. Along
with this growth have come major advances in image
guidance including three-dimensional
transesophageal echocardiography (3D TEE), cardiac
computed tomographic angiography (CCTA), and
magnetic resonance imaging and angiography
(MRI/MRA). In contemporary practice, catheter-
based treatments of various structural heart and
valve diseases have become increasingly reliant on
accurate preprocedural imaging assessment and
intraprocedural guidance to maximize outcomes and
minimize complications.1 For example, CCTA has
become the “gold standard” in aortic annulus
analysis in preplanning for transcatheter aortic valve
replacement (TAVR) procedures.2,3 Similarly, 3D TEE
has become a mainstay in both preprocedure
evaluation and intraprocedural guidance for
transcatheter mitral valve repair with the MitraClip
device.4,5
A major challenge facing all SHD interventionalists
and imaging specialists, however, centers on the
importance of integrating efficiently multiple imaging
modalities so as to prevent “sensory imaging
overload.” Oftentimes, many operators also struggle
with “mentally translating” two-dimensional (2D)
imaging sequences (eg, CCTA, 2D echocardiography)
into accurate and useful 3D spatial images in their
own minds to both effectively preplan and efficiently
perform complex SHD procedures. To overcome
these barriers, imaging manufacturers are actively
developing new software tools that are designed to
take the complexities of multimodality imaging
integration out of the hands of the operators, while
simultaneously giving back to the operator a
simplified and efficient mechanism by which to
manipulate and analyze the processed images.6-8
This chapter, through several clinical examples,
will highlight how both high-quality preprocedure
imaging and intraprocedural imaging using novel
multimodality image integration tools can be
effectively used to guide complex SHD interventions.

CASE 1 Right Ventricular to Left Atrium

Fistula Repair
A 55-year-old male with a history of an endocardial cushion defect
that was surgically repaired at age 7 years with a patch at the
septum primum and inlet ventricular septal defect (VSD) was
referred to evaluate and treat a residual right ventricular (RV) to
left atrial (LA) fistula. He had a recent biventricular
pacemaker/internal cardiac defibrillator (ICD) placed for
asymptomatic complete heart block in the setting of left ventricular
(LV) dysfunction. After device implantation, he began complaining
of new visual symptoms (intermittent vision loss in his left eye)
concerning for transient ischemic attacks (TIAs); a brain MRI could
not be obtained owing the presence of his ICD. A transthoracic
echocardiogram (TTE) was performed demonstrating a residual
defect/fistula between the RV and LA with at least moderate right
to left shunting following injection of agitated saline contrast
(FIGURE 1.1; Video 1.1). Given the concern that the patient
would be at risk for forming small thrombi on his ICD leads that
both may have and could in the future embolize paradoxically, the
decision was made to proceed with transcatheter closure of the
residual fistula.

Video 1-1

As part of his preprocedure evaluation, the patient underwent a

CCTA to better elucidate the size and location of the fistula
(FIGURE 1.2; Video 1.2). The CCTA demonstrated a clear
communication between the RV and LA with a tract diameter of
approximately 5 to 7 mm (depending on timing within the cardiac
cycle) and a length of approximately 6 mm. Intraprocedure 3D TEE
was used as image guidance (FIGURE 1.3). Using an antegrade
approach (transvenous access with transseptal puncture and defect
crossing from the LA), the patient underwent an uncomplicated
fistula closure using a 6 × 6 Amplatzer Duct Occluder II device
(FIGURE 1.4). Postprocedure TEE and TTE demonstrated no
residual flow across the device. The patient was discharged on
postprocedure day 1 and remains in good condition.

Video 1-2
FIGURE 1.1 TTE agitated saline contrast (“bubble”) study through a
peripheral vein demonstrating a communication between the RV and
LA (arrow) with right to left shunting.
 FIGURE 1.2 Multiplanar re-
construction of the CCTA demonstrating the fistula between the RV
and LA (arrows) in orthogonal planes. The fistula was dynamic in
nature and measured approximately 7 mm in diameter and 6 mm in
length during ventricular systole.
 FIGURE 1.3 Intraprocedure TEE. A and B, 4 chamber and LV
outflow tract view showing color flow between the LA and RV. C and
D, Location of the transseptal puncture inferior (C) and posterior (D).
E and F, Orientation of the steerable guide catheter directly into the
location of the fistula from the LA. G and H, Occluder device across
the fistula with absence of flow by color Doppler indicating complete
closure.

FIGURE 1.4 Fluoroscopic images of RV to LA fistula closure. A, With

the steerable guide catheter (arrowheads, positioned guide catheter)
pointed into the LA side of the fistula, a Magic Torque wire is
advanced across the defect and out the LV outflow tract across the
aortic valve into the ascending aorta (Ao). B, A 5 French diagnostic
catheter is advanced over the wire into the ascending Ao, and the
wire is removed. C, Amplatzer Duct Occluder II device (arrow,
showing deployed device) is fully deployed across the fistula. D, Final
angiography demonstrating stable placement of the occluder device.
CASE 2 Prosthetic Mitral Paravalvular Leak
Repair
A 70-year-old female with a history of rheumatic heart disease
underwent surgical mitral valve replacement with a 29 mm porcine
bioprosthesis. Although her immediate postoperative course was
uneventful, she presented several weeks after surgery with
decompensated heart failure symptoms (New York Heart
Association Class III-IV). A TTE and TEE confirmed the presence of
a severe paravalvular leak located on the posterior aspect of the
sewing ring. There was also evidence of mild hemolysis. A
cardiothoracic surgeon was consulted who felt that a reoperation
would put the patient at excessive risk given her current clinical
state, and thus she was referred for transcatheter paravalvular leak
(PVL) repair.
The patient underwent a preprocedure CCTA to evaluate the
size and extent of the posterior PVL as well as assess for any
additional defects (FIGURE 1.5). The CCTA clearly demonstrated
the presence of a large, crescentic defect located on the posterior
aspect of the bioprosthetic valve sewing ring. The defect measured
approximately 10 mm in diameter at its widest segment and
approximately 24 mm in total length. Intraprocedure 3D TEE
coupled with novel live echo-fluoro image integration technology
(EchoNavigator—Philips Healthcare, The Netherlands) was used for
image guidance (FIGURE 1.6; Video 1.3). Using an
antegrade approach, the patient underwent an uncomplicated PVL
closure with implantation of a 14 and 12 mm Amplatzer Vascular
Plug II device (St Jude Medical, Inc., St Paul, MN) across the large
posterior PVL, resulting in complete eradication of the PVL
(FIGURE 1.7; Video 1.4). The patient was discharged on
postprocedure day 2 and remains in excellent clinical condition
with NYHA Class I symptoms and no evidence of hemolysis.
Video 1-3

Video 1-4
 FIGURE 1.5 CCTA of posterior mitral paravalvular leak. A-C, 2D
multiplanar reconstruction of the mitral annulus demonstrating a
large paravalvular leak located on the posterior aspect of the sewing
ring (arrows). D, 3D en face view of the prosthetic mitral valve
localizing the size and extent of the posterior paravalvular leak
(arrow) immediately opposite to the Ao.
 FIGURE 1.6 Intraprocedural TEE with live echo-fluoro image
integration technology (EchoNavigator) to guide transcatheter mitral
paravalvular leak repair. A, LV outflow tract view demonstrating
severe paravalvular regurgitation located posteriorly on the sewing
ring. B, 3D en face view of the prosthetic mitral valve demonstrating
a crescentic defect located on the posterior aspect (6 o’clock) on the
sewing ring (arrow). C, 3D en face view with color Doppler showing a
crescentic leak originating from approximately 4 o’clock to 7 o’clock
(arrowheads). D, Live echo-fluoro image integration technology with
the PVL labeled with the red dot (arrows). The steerable guide
catheter is located medial to the location of the PVL. E, Live echo-
fluoro image integration showing that torqueing the steerable guide
catheter posteriorly and slightly advancing it further into the LA aligns
it directly above the location of the PVL.
 FIGURE 1.7 Intraprocedural TEE with live echo-fluoro image
integration demonstrating eradication of the mitral paravalvular leak.
A, Fluoroscopy showing 2 Amplatzer Vascular Plug II devices across
the sewing ring (arrow) in the area of the paravalvular leak. B, 3D
TEE view demonstrating the posterior location of the 2 vascular plug
 devices (arrowheads). C and D, Live echo-fluoro image integration
technology demonstrating location of the vascular plug devices
(arrowheads) and complete eradication of paravalvular leak with
absence of color flow across the sewing ring (arrows).

CASE 3 Left Ventricular Apical

Pseudoaneurysm Repair
A 75-year-old female with severe, symptomatic aortic stenosis who
was deemed prohibitive risk for surgical aortic valve replacement
owing to frailty, severe lung disease, and prior pericardiectomy in
the 1980s for chronic pericarditis was referred for TAVR. She also
had a history of severe peripheral arterial disease (PAD) with
bilateral femoral-popliteal bypass surgery in the past. Given her
severe PAD, she underwent attempted TAVR via a transapical
approach. The procedure was aborted owing to severe bleeding
during placement of the pledgeted sutures in the LV apex. The
patient fortunately had an uneventful postoperative course. The
procedure plan was then changed to attempt TAVR using a self-
expanding transcatheter heart valve via a subclavian approach
once she had recovered from her index procedure. A repeat CCTA
performed to evaluate the suitability of using her left subclavian
artery for access incidentally also detected the presence of a large,
LV apical pseudoaneurysm (PSA) that had developed in the interim
postoperative recovery period (FIGURE 1.8). The neck of the PSA
measured 3 mm with the PSA body measuring 12 mm × 25 mm.
Given the size of the PSA and the inherent risk of rupture, the
decision was made to attempt transcatheter repair of the PSA
concomitantly with the planned TAVR procedure.
 FIGURE 1.8 CCTA demonstrating the evolution of LV apical PSA. A,
Baseline CCTA before attempted transapical TAVR. B, Repeat C CTA
demonstrating the interval development of a new LV apical PSA
(arrow, aneurysm chamber). C and D, Measurements of the PSA with
a neck diameter of 3 mm and body dimensions of 12 mm × 25 mm.

Successful and uncomplicated TAVR via left subclavian access

was performed, and a 29 mm Medtronic CoreValve transcatheter
heart valve (Medtronic, Minneapolis, MN) was implanted. LV
angiography performed post-TAVR confirmed the presence of a
large LV apical PSA (FIGURE 1.9; Video 1.5). 3D TEE was
then used as adjunctive imaging during the PSA repair (FIGURE
1.10). The patient underwent successful PSA repair using a 6 × 6
Amplatzer Duct Occluder II device (St Jude Medical, Inc., St Paul,
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