Vaikom Mahadevan | University of California, San Francisco (original) (raw)

Papers by Vaikom Mahadevan

Journal of the American College of Cardiology

Circulation, 2020

Introduction: Patent ductus arteriosus (PDA) is often recognized and treated with percutaneous cl... more Introduction: Patent ductus arteriosus (PDA) is often recognized and treated with percutaneous closure in adults. However, the impact on cardiac reverse remodeling following PDA closure in adults is not clear. We performed a meta-analysis to characterize the extent of cardiac remodeling following percutaneous PDA closure in adults. Methods: MEDLINE and EMBASE were systematically searched for original studies that reported echocardiographic variables at baseline, immediately post-procedure (within 24 hours), and at follow-up (>1 month) in adults undergoing percutaneous PDA closure. Additionally, we included echocardiographic data from a cohort of patients >18 years of age that underwent percutaneous PDA closure between 01/2015 and 12/2019 at our centre. For parameters with sufficient data for pooling, weighted averages were calculated, and pooled differences were presented as weighted mean differences. Heterogeneity was assessed using the I 2 statistic. Results: After screening...

JACC: Cardiovascular Interventions, 2018

Circulation, 2020

Introduction: Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic ... more Introduction: Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement in patients with predicted poor surgical outcomes due to end stage liver disease (ESLD) or end stage renal disease (ESRD), though there remains minimal data regarding outcomes and treatment strategy in this population. This study evaluates in-hospital, 30-day, and 1-year outcomes after TAVR in a cohort of patients with ESLD and/or ESRD compared to a cohort without these comorbidities. Methods: We retrospectively compared 317 consecutive patients (N=37 ESLD and ESRD, N=286 without ESLD or ESRD) age >18 who underwent transfemoral or transssubclavian TAVR at University of California San Francisco Medical Center from August 1 st , 2014 to April 1 st , 2020. Results: The ESLD and ESRD group had younger patients (69.8±11.5 vs 79.1±9.8, p<0.01), a higher incidence of diabetes mellitus (54.8% vs 28.3%, p<0.01), and higher STS-PROM scores (7.8±6.5 vs 4.7±3.9, p<0.01)...

Current Treatment Options in Cardiovascular Medicine, 2020

Purpose of review This article highlights our current understanding of bicuspid aortic valve (BAV... more Purpose of review This article highlights our current understanding of bicuspid aortic valve (BAV) syndrome and how genetics, pathology, imaging features, and clinical symptoms direct the clinical management, surveillance, and intervention of those with BAV. Recent findings While randomized data and guidelines are lacking, transcatheter therapies are routinely used for BAV stenosis in medical centers throughout the world. Guidelines suggest that younger patients age less than 50 years undergo surgical aortic valve replacement (AVR) with a mechanical valve and the elderly 9 70 years of age receive a bioprosthetic valve. For the age group 50-70 years, either option should be considered. Decision on type of intervention depends on specific features such as presence of stenosis or regurgitation, if there is any associated aortopathy, comorbid illnesses, contraindications, and patient preference. We have learned that the decision to intervene and mode of intervention is best achieved by a multidisciplinary valve team. Summary Despite improvement in our understanding of BAV and the advancement of novel therapies particularly for BAV stenosis, much is still to be learned about the optimal treatment of BAV disease in the current era.

Seminars in Roentgenology, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

JACC: Cardiovascular Interventions, 2018

BACKGROUND Worldwide, several studies have been conducted about the association between hypertens... more BACKGROUND Worldwide, several studies have been conducted about the association between hypertension in childhood and adolescence and socio-demographic factors: lifestyle, family history and anthropometry. OBJECTIVE This study aims to identify the prevalence of prehypertension and related variables in young adults.

Interventional Cardiology, 2018

Background Cardiac output (CO) measurement guides management of various medical conditions, inclu... more Background Cardiac output (CO) measurement guides management of various medical conditions, including but not limited to various adult congenital heart diseases (ACHD), and pulmonary hypertension. It is mandatory to calculate patients’ oxygen consumption (VO2), to measure CO. Ideally VO2 consumption can be measured by using a facemask apparatus; however, due to complexity in their routine use, various formulae derives assumed VO2 are incorporated to obtain CO values. The most commonly used formula in catheter laboratories treating adult patients was reported by LaFarge and Miettinen (1970). However, it was based on data from paediatric population, and their use in adult population is not validated. Moreover, these individual formulae were compared with true VO2 consumption; however, limited information exploring agreement between these formulae is available. Such a comparison is very important, as individual catheter laboratories use these formulae at their discretion to derive cardiac output, influencing patients’ management. Materials and methods We sought to compare cardiac output measurement based upon four commonly used formulas, (1) LaFarge and Miettenen, (2) Dehmer, Firth and Hills, (3) Bergstra, Van Dijk, Jillege, and (4) Seckeler, Hirsch, Beekman Methodology, in 112 ACHD patients who underwent diagnostic catheterization at the Manchester Royal Infirmary, UK between 1st January 2015 to 31st March 2017. Their CO derived by using 4 different formulae were compared using a one way repeated measures ANOVA test. Results CO measured by various formulae is reported here with: LaFarge and Miettenen 4.31±1.43 L/min; Dehmer, Firth and Hills – 4.91±1.50 L/min; Bergstra, Van Dijk, Jillege, – 6.1±2.22 L/min; and Seckeler, Hirsch, Beekman Methodology – 2.96±0.88 L/min. LaFarge and Miettenen formula derived CO was lowest in comparison to all other formulae and was significantly lower than Dehmer as well as Bergstra formulae (p<0.0001 for each), whereas non-significantly lower than the Seckeler et al formula. Conclusion There is no agreement between the assumed VO2 derived cardiac output measurements, including the most commonly used LaFarge formula, when compared in a cohort of ACHD patients. Using such assumed formulae derived CO may be misleading and such values should be interpreted carefully. Every cardiologist should be cognizant of these limitations. Facemask apparatus should be routinely used in catheter laboratories to obtain true VO2, especially, when such a value is likely to influence major management decisions. Abstract 61 Figure 1

Cardiac Rhythm Management, 2018

Background Advances in clinical management have improved life expectancy in the ACHD population; ... more Background Advances in clinical management have improved life expectancy in the ACHD population; as a result, implantable cardiac devices remain in situ for longer periods than ever before. These patients pose unique challenges, including; young age at implant, multiple device procedures during their lifetime, complex venous and cardiac anatomy, and co-morbidities which may predispose to infection. In the non-ACHD population, there is useful long-term research which helps to guide clinical decision-making; however, small numbers and incomplete outcome data has lead to limited comparability against ACHD patients. Aims This study aimed to examine 20 years of pacing experience in a large ACHD centre, using novel data-mining techniques to generate comprehensive lead survival data. Methodology A retrospective analysis was performed of pacing and defibrillator leads implanted between June 1996 and December 2016 in a 173 patient ACHD cohort. Automated text searching algorithms with manual review of over 1 00 000 pieces of clinical correspondence was used to maximise identification of outcomes. Lead-specific complications, non-elective removal and overall lead survival were compared for surgical and transvenous leads in patients with complex and non-complex ACHD anatomy. Results 340 leads with complete implant and follow-up data were identified of which 53% were in patients with complex ACHD anatomy and 15% were in patients with tricuspid valve abnormalities. Median lead survival time was 13.6 years in transvenous leads and 15.9 years in surgical leads (p=n .s.) Transvenous leads were associated with a higher risk of major infection than were surgically-implanted leads (11.5% vs 0% p<0.05) while surgical leads had a higher rate of pacing failure or lead damage (25.9% vs 8.0% p<0.001). Complication rates were not affected by complex ACHD anatomy or abnormal tricuspid valve function. Conclusion In this large cohort of patients with ACHD, lead survival appears to be reasonable regardless of whether a transvenous or surgical approach is used. A higher incidence of infection in transvenous leads is offset by a higher electrical failure rate in surgical leads. Further work examining large cohorts is required to determine optimal pacing strategies tailored to patient-specific anatomical challenges. Abstract 23 Figure 1 Time to lead failure/non-elective removal Abstract 23 Table 1

Journal of the American College of Cardiology, 2018

Background: Hemodynamically significant atrial septal defect (ASD) causes increase in the RV prel... more Background: Hemodynamically significant atrial septal defect (ASD) causes increase in the RV preloading condition with its detrimental effect of RV dilatation. Transcatheter closure of secundum type ASD causes a sudden change of the RV loading condition. The purpose of this study is to assess the RV myocardial deformation changes caused by percutaneous ASD closure in older adults Methods: This is a retrospective study to evaluate RV myocardial deformation changes in patients who underwent transcatheter closure of ASD. RV global longitudinal strain and strain rate (SR) were assessed, utilizing Tomtec imaging software, through speckle-tracking technology, before and 1-2 months after percutaneous closure. Repeated measure analysis was used to compare the strain parameters, p < 0.05 was considered statistically significant. Results: RV myocardial deformation indices were studied in 18 patients (8 Male, 10 Female) aged 52 years ± 17 before and 1-2 months (45 days ± 18) after percutaneous ASD device closure. There was a significant decrease in the RV global longitudinal strain post intervention-22.1 (± 5.1) vs-15.9 (± 3.4); coef. (95% Conf. Interval) =-6.2 (-8.6 to-3.7) p < 0.005. The RV longitudinal SR was not influenced by intervention 1.0/sec (± 0.4) vs 0.9/sec (± 0.2); coef. (95% Conf. Interval) =-0.14 (-0.32 to 0.034) p = 0.115. In this cohort of older adults at time of intervention (52 years ± 17), there was still a significant decrease in RV internal dimensions post-intervention. RVEDA (right ventricular end-diastolic area (cm2) decreased significantly post intervention (31.7 ± 7.9) vs (24.9 ± 5.3); coef. (95% Conf. Interval)-6 (-9 to-3), p <0.005. RV basal internal diameter (mm) decreased significantly post intervention (48.3 ± 6.4) vs (42.0 ± 6.7); coef. (95% Conf. Interval)-5(-8 to-3), p < 0.005 Conclusion: RV myocardial deformation measured by global longitudinal strain, being dependent on RV preloading condition, decreased significantly post percutaneous ASD device closure. Percutaneous ASD closure can provide significant reduction in RV internal dimensions despite older age at intervention.

Journal of the American College of Cardiology, 2018

Background: Ebstein anomaly is a congenital malformation of the tricuspid valve (TV) with right v... more Background: Ebstein anomaly is a congenital malformation of the tricuspid valve (TV) with right ventricular(RV) myopathy. There is wide range of presentation from patients who are asymptomatic to various degree of RV failure. Case: We present a 32 year old male who presents with palpitations and shortness of breath. He presented with wide complex tachycardia and SBP in the 80's. Because of vital signs instability at presentation, electrical cardioversion was applied with successful conversion to sinus rhythm. Physical examination (PE) after restoring sinus rhythm was significant hypoxia with Sao2 88% resistant to oxygen therapy, regular HR, split S1 with normal mitral component and accentuated tricuspid component (click-like sound), normal S2 with very faint pulmonic component, a soft 2/6 holo-systolic murmur best heard at the left parasternal border. TTE showed severely dilated RA, apical displacement of the TV with tethered septal leaflet and elongated anterior leaflet in a sail-like deformity. To further evaluate for the possibility of interatrial communication, TEE was performed and revealed a large size secundum type atrial septal defect (ASD) (18 mm) with bidirectional shunting. Decision-making: The proposed interventions include surgical repair of the TV with concomitant closure of the ASD, versus transcatheter closure of the ASD. Transcatheter closure of the ASD was attempted, however it was poorly tolerated with a significant drop in blood pressure during balloon test occlusion. Conclusion: This case represents typical PE findings in an adult patient with Ebstein anomaly. It also reflects the common association of WPW syndrome and ASD in patients with Ebstein anomaly. The decision to perform transcather closure of ASD in Ebstein anomaly can be challenging and mandates careful hemodynamic evaluation with balloon test occlusion. In patients, who do not tolerate balloon test occlusion, a different strategy should be considered including; surgical TV repair with concomitant surgical closure of ASD, either complete or partial closure. Bidirectional cavopulmonary anastomosis (bidirectional Glenn, BDG) can be considered in cases of severe RV dysfunction at time of TV repair.

Journal of the American College of Cardiology, 2019

BACKGROUND Transcatheter aortic and pulmonary valves have been used to treat stenosis or regurgit... more BACKGROUND Transcatheter aortic and pulmonary valves have been used to treat stenosis or regurgitation after prior surgical tricuspid valve (TV) replacement or repair. Little is known about intermediate-term valve-related outcomes after transcatheter tricuspid valve replacement (TTVR), including valve function, thrombus, and endocarditis. OBJECTIVES The authors sought to evaluate mid-term outcomes in a large cohort of patients who underwent TTVR after surgical TV repair or replacement, with a focus on valve-related outcomes. METHODS Patients who underwent TTVR after prior surgical TV replacement or repair were collected through an international registry. Time-related outcomes were modeled and risk factors assessed. RESULTS Data were collected for 306 patients who underwent TTVR from 2008 through 2017 at 80 centers; 52 patients (17%) had a prior history of endocarditis. Patients were followed for a median of 15.9 months after implantation (0.1 to 90 months), with 64% of patients estimated to be alive without TV reintervention or a valve-related event at 3 years. The cumulative 3-year incidence of death, reintervention, and valve-related adverse outcomes (endocarditis, thrombosis, or significant dysfunction) were 17%, 12%, and 8%, respectively. Endocarditis was diagnosed in 8 patients 2 to 29 months after TTVR, for an annualized incidence rate of 1.5% per patient-year (95% confidence interval: 0.45% to 2.5%). An additional 8 patients were diagnosed with clinically relevant valve thrombosis, 3 in the short term, 2 within 2 months, and 3 beyond 6 months. Only 2 of these 8 patients received anticoagulant therapy before thrombus detection (p ¼ 0.13 vs. patients without thrombus). Prior endocarditis was not a risk factor for reintervention, endocarditis, or valve thrombosis, and there was no difference in valve-related outcomes according to TTVR valve type. CONCLUSIONS TV dysfunction, endocarditis, and leaflet thrombosis were uncommon after TTVR. Patients with prior endocarditis were not at higher risk for endocarditis or other adverse outcomes after TTVR, and endocarditis occurred with similar frequency in different valve types. Though rare, leaflet thrombosis is an important adverse outcome, and further study is necessary to determine the appropriate level of prophylactic therapy after TTVR.

Journal of the American College of Cardiology, 2017

Background: Patients with pulmonary atresia with intact ventricular septum (PA/IVS) are prone to ... more Background: Patients with pulmonary atresia with intact ventricular septum (PA/IVS) are prone to development of coronary artery sinusoidal connections with the right ventricular (RV) cavity. Case: 25 year-old female with a history of PA/IVS physiology status post Fontan palliation, presented with pressure like chest pain of gradual onset, exacerbated with activity. Her vital signs were stable, EKG showed no ischemic changes, troponins were negative. Cardiac catheterization revealed a single coronary origin from the left aortic sinus; it divided to left anterior descending artery (LAD) and a diminutive circumflex artery. There was no forward flow form the aorta to the right coronary artery (RCA). The distal part of the LAD was connected to the RV cavity through three sinusoidal connections; two of them were stenotic and one was draining to the RV. Decision-Making: The patient was also found to have a small non-restrictive VSD, however she was still falling in the hemodynamic territory of PA/IVS with formation of sinusoidal connections to the RV. The diastolic pressure in the RV was lower than the aortic diastolic pressure with a potential risk for coronary steal phenomena in diastole. For concerns about the complications of closing the coronary sinusoidal connection, the decision was made to pursue with medical management including B.Blockers and nitrates. Conclusions: Coronary-ventricular connections carry a risk for coronary steal with subsequent ischemia in patients with PA/IVS.

Journal of the American College of Cardiology, 2017

Background: Fontan surgery provides palliation for single ventricle patients. A late complication... more Background: Fontan surgery provides palliation for single ventricle patients. A late complication is the development of atrial tachyarrhythmias (AT). This study aims to establish incidence and identify predictors of AT in Fontan patients with long-term follow-up. Methods: Retrospective review of medical records from 2 tertiary academic institutions identified 113 Fontan patients ≥ 18 years. Results: Mean age was 31 ± 7years, 54% females; 37% atriopulmonary (AP) Fontan, 31% lateral tunnel (LT), and 32% extracardiac (EC). Mean follow-up was 31± 7 yrs and time since Fontan surgery was 23± 6 yrs. We estimated that by age 35 yrs over half will have AT. Incidence of AT was 57% in AP, 27% in LT and 16% in EC groups at follow-up. Patients with AT more likely had AP Fontan (57% vs. 22%, p<0.0001) and New York Heart association (NYHA) class II/III (46%vs.25%, p=0.04) than those without. Kaplan-Meier curve shows that median time to AT was dependent on gender and age at the time of Fontan surgery (Figure). Multivariate Cox regression analysis showed no effect of Fontan type, NYHA class, but confirmed female gender (hazard ratio (HR) 0.4; p=0.008) and increasing age at Fontan surgery as independent predictors of reduced HR (0.8; p<0.001). Conclusions: There is a significant, increased atrial tachyarrhythmia burden in adult Fontan patients that is dependent on gender and age at Fontan surgery. These patients continue to pose significant challenges as adults and long-term close follow with defined management strategies is crucial.

Journal of the American College of Cardiology, 2017

Background: Device closure of the left atrial appendage (LAA) is widely used for patients unsuita... more Background: Device closure of the left atrial appendage (LAA) is widely used for patients unsuitable for anticoagulation. The Lariat device (SentreHEART, Redwood City, CA) is a percutaneous suture based device currently approved for percutaneous LAA ligation. While greater than 90% of patients who undergo the Lariat procedure have no residual flow in the LAA, a small proportion can have significant (3-5 mm) leaks. The thromboembolic risk of a residual leak remains unclear. The aim of this study was to evaluate the safety and efficacy of the Amplatzer vascular plug (AVPII, St. Jude Medical, St. Paul, MN) in the closure of residual LAA leak after LAA ligation using the Lariat device. Methods: Here we report the outcomes of four patients with significant residual leaks who underwent device closure. Four patients, all male, mean age 75 ± 10.6 years with residual LAA leak diameter ranging between 3.5 to 6mm as assessed by transesophageal echocardiogram (TEE), underwent device closure using the AVPII. Transseptal access was obtained through a femoral venous approach using a NTG RF transseptal needle (Baylis Medical, Montreal, Canada). Contrast injection into the left atrium with a 5F straight pigtail catheter confirmed the residual LAA leak. A 6F multipurpose guide catheter was positioned in the LAA leak over a glide wire followed by deployment of an AVPII device (6 or 8mm). Results: All cases resulted in complete cessation of residual LAA flow after device deployment as confirmed by TEE and angiography. Three patients required one AVPII device and one patient required two 8mm AVPII devices. There were no procedural complications. At a median follow-up period of 369 days, anticoagulation was discontinued in two of four patients (the other two remain on anticoagulation pending further ablation). One patient reverted to sinus rhythm from persistent atrial fibrillation following residual leak closure. Conclusions: Percutaneous management of LAA leak following Lariat closure using the AVPII device is safe, efficacious, and potentially permits discontinuation of anticoagulation mitigating bleeding risk. It should be considered in patients with a residual LAA leak.

Journal of the American College of Cardiology, 2017

Background: Elevated body mass index (BMI) is increasingly affecting adults with congenital heart... more Background: Elevated body mass index (BMI) is increasingly affecting adults with congenital heart disease. The effect of an increased BMI with respect to clinical variables has not been evaluated in adult Fontan patients. Methods: Retrospective review of medical records from 2 tertiary academic institutions identified 68 Fontan patients ≥ 18 years for whom BMI data was available. Results: Mean BMI was 24±4 kg/m 2 with 6% being underweight (BMI <18.5), 54% normal (18.5-<25), 31% overweight (25-<30) and 9% obese (≥ 30). Patients with BMI ≥ 25 kg/m 2 were significantly older (34 ± 9 vs. 31 ± 7 yrs, p=0.03), had higher Fontan (16 ± 3 vs.14 ± 6 mm Hg, p=0.04) and pulmonary capillary wedge pressures (PCWP, 12 ± 3 vs. 9 ± 3 mm Hg, p=0.03) and lower peak oxygen consumption (VO 2 , 18±5 vs. 22±4 ml/Kg/min, p=0.005), minute ventilation (Ve, 44 ± 10 vs. 58 ± 21 L/min, p=0.03) and Ve/Vco2, (33 ± 7 vs. 36 ± 4, p=0.03) on cardiopulmonary exercise testing (CPET). There were no differences in gender, Fontan type, ventricular type and function, arrhythmia burden, New York Heart Association status, other echocardiographic, hemodynamic or CPET variables. Linear regression graph showed a linear correlation between BMI and the significant clinical variables (Figure). Conclusions: Overweight/obesity is highly prevalent in adult Fontan patients. Higher BMI is associated with poor hemodynamics and aerobic capacity. This might correlate with worse health outcomes in this patient population, although further study is needed to determine this.

The International Journal of Cardiovascular Imaging, 2017

used off-label as an MRI blood pool contrast agent offers an attractive alternative to gadofosves... more used off-label as an MRI blood pool contrast agent offers an attractive alternative to gadofosveset trisodium in patients with renal failure, with excellent 4D flow image quality and good correlation of volumetric measurements compared to the CMR reference (SSFP).

International journal of cardiology, Jan 15, 2017

Computed tomography angiography (CTA) is the test of choice for pre-procedure imaging of transcat... more Computed tomography angiography (CTA) is the test of choice for pre-procedure imaging of transcatheter aortic valve replacement (TAVR) candidates. The iodinated contrast required, however, increases the risk of renal dysfunction in patients with pre-existing renal failure. Ferumoxytol is a magnetic resonance imaging (MRI) contrast agent that can be used with renal failure. Its long vascular resonance time allows gated MRA sequences that approach CTA in image quality. We present respiratory and cardiac gated MRA enabled by ferumoxytol that can be post-processed in an analogous fashion to CTA. Seven patients with renal failure presenting for TAVR were imaged with respiratory and cardiac gated MRA at 3T using ferumoxtyol for contrast. Aortic annulus, root and peripheral access dimensions were calculated in a fashion identical to that used for CTA. Of these, 6 patients underwent a TAVR procedure and 5 had intraoperative valve assessment with transesophageal echocardiograph (TEE) using s...

Expert Review of Cardiovascular Therapy, 2016

Introduction: Patent foramen ovale (PFO) is a common congenital cardiac abnormality and that has ... more Introduction: Patent foramen ovale (PFO) is a common congenital cardiac abnormality and that has been associated with several disease processes including transient ischemic attacks (TIA), stroke, migraine headaches with aura, decompression sickness, platypnea-orthodeoxia syndrome, and shunt induced cyanosis. Controversy exists regarding closure of PFO as a therapeutic treatment modality for these disease processes. This review addresses the contemporary clinical indications for PFO closure. Areas covered: We conducted a comprehensive literature search of contemporary research studies focusing on randomized trials and meta-analyses comparing medical therapy and device closure of PFOs for the treatment of PFO associated clinical syndromes. We synthesized this literature into a review addressing indications for PFO closure in stroke, TIA, migraine headaches with aura, decompression sickness, platypnea-orthodeoxia syndrome, and shunt induced cyanosis. Expert commentary: Because in many PFO associated conditions it can be difficult to determine the degree to which the PFO is a causative factor in the disease process, we recommend a comprehensive diagnostic evaluation to exclude other obvious etiologies of PFO associated conditions before implicating the PFO and proceeding with closure. However in the properly selected patient population there is growing clinical experience and experimental evidence suggesting that closure of PFO is a safe and effective treatment modality.

Open heart, 2016

Transcatheter aortic valve replacement (TAVR) has been established as an alternative therapy for ... more Transcatheter aortic valve replacement (TAVR) has been established as an alternative therapy for patients with severe aortic stenosis who are unfit for the surgical aortic valve replacements. Pre and periprocedural imaging for the TAVR procedure is the key to procedural success. Currently transesophageal echocardiography (TOE), including real-time three-dimensional (RT-3D) imaging TOE, has been used for peri-interventional monitoring and guidance for TAVR. We describe our initial experience with real-time three-dimensional intracardiac echocardiography (RT-3DICE), imaging technology for the use in the TAVR procedure. We used RT-3DICE using an ACUSON SC2000 2.0v (Siemens Medical Solution), and a 10F AcuNav V catheter (Siemens-Acuson, Inc, Mountain View, California, USA) in addition to preoperative multislice CT (MSCT) in total of five patients undergoing TAVR procedure. Aortic annulus and sinus of valsalva diameters were measured using RT-3DICE. Aortic valve measurements obtained usi...

Journal of the American College of Cardiology

Circulation, 2020

Introduction: Patent ductus arteriosus (PDA) is often recognized and treated with percutaneous cl... more Introduction: Patent ductus arteriosus (PDA) is often recognized and treated with percutaneous closure in adults. However, the impact on cardiac reverse remodeling following PDA closure in adults is not clear. We performed a meta-analysis to characterize the extent of cardiac remodeling following percutaneous PDA closure in adults. Methods: MEDLINE and EMBASE were systematically searched for original studies that reported echocardiographic variables at baseline, immediately post-procedure (within 24 hours), and at follow-up (>1 month) in adults undergoing percutaneous PDA closure. Additionally, we included echocardiographic data from a cohort of patients >18 years of age that underwent percutaneous PDA closure between 01/2015 and 12/2019 at our centre. For parameters with sufficient data for pooling, weighted averages were calculated, and pooled differences were presented as weighted mean differences. Heterogeneity was assessed using the I 2 statistic. Results: After screening...

JACC: Cardiovascular Interventions, 2018

Circulation, 2020

Introduction: Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic ... more Introduction: Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement in patients with predicted poor surgical outcomes due to end stage liver disease (ESLD) or end stage renal disease (ESRD), though there remains minimal data regarding outcomes and treatment strategy in this population. This study evaluates in-hospital, 30-day, and 1-year outcomes after TAVR in a cohort of patients with ESLD and/or ESRD compared to a cohort without these comorbidities. Methods: We retrospectively compared 317 consecutive patients (N=37 ESLD and ESRD, N=286 without ESLD or ESRD) age >18 who underwent transfemoral or transssubclavian TAVR at University of California San Francisco Medical Center from August 1 st , 2014 to April 1 st , 2020. Results: The ESLD and ESRD group had younger patients (69.8±11.5 vs 79.1±9.8, p<0.01), a higher incidence of diabetes mellitus (54.8% vs 28.3%, p<0.01), and higher STS-PROM scores (7.8±6.5 vs 4.7±3.9, p<0.01)...

Current Treatment Options in Cardiovascular Medicine, 2020

Purpose of review This article highlights our current understanding of bicuspid aortic valve (BAV... more Purpose of review This article highlights our current understanding of bicuspid aortic valve (BAV) syndrome and how genetics, pathology, imaging features, and clinical symptoms direct the clinical management, surveillance, and intervention of those with BAV. Recent findings While randomized data and guidelines are lacking, transcatheter therapies are routinely used for BAV stenosis in medical centers throughout the world. Guidelines suggest that younger patients age less than 50 years undergo surgical aortic valve replacement (AVR) with a mechanical valve and the elderly 9 70 years of age receive a bioprosthetic valve. For the age group 50-70 years, either option should be considered. Decision on type of intervention depends on specific features such as presence of stenosis or regurgitation, if there is any associated aortopathy, comorbid illnesses, contraindications, and patient preference. We have learned that the decision to intervene and mode of intervention is best achieved by a multidisciplinary valve team. Summary Despite improvement in our understanding of BAV and the advancement of novel therapies particularly for BAV stenosis, much is still to be learned about the optimal treatment of BAV disease in the current era.

Seminars in Roentgenology, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

JACC: Cardiovascular Interventions, 2018

BACKGROUND Worldwide, several studies have been conducted about the association between hypertens... more BACKGROUND Worldwide, several studies have been conducted about the association between hypertension in childhood and adolescence and socio-demographic factors: lifestyle, family history and anthropometry. OBJECTIVE This study aims to identify the prevalence of prehypertension and related variables in young adults.

Interventional Cardiology, 2018

Background Cardiac output (CO) measurement guides management of various medical conditions, inclu... more Background Cardiac output (CO) measurement guides management of various medical conditions, including but not limited to various adult congenital heart diseases (ACHD), and pulmonary hypertension. It is mandatory to calculate patients’ oxygen consumption (VO2), to measure CO. Ideally VO2 consumption can be measured by using a facemask apparatus; however, due to complexity in their routine use, various formulae derives assumed VO2 are incorporated to obtain CO values. The most commonly used formula in catheter laboratories treating adult patients was reported by LaFarge and Miettinen (1970). However, it was based on data from paediatric population, and their use in adult population is not validated. Moreover, these individual formulae were compared with true VO2 consumption; however, limited information exploring agreement between these formulae is available. Such a comparison is very important, as individual catheter laboratories use these formulae at their discretion to derive cardiac output, influencing patients’ management. Materials and methods We sought to compare cardiac output measurement based upon four commonly used formulas, (1) LaFarge and Miettenen, (2) Dehmer, Firth and Hills, (3) Bergstra, Van Dijk, Jillege, and (4) Seckeler, Hirsch, Beekman Methodology, in 112 ACHD patients who underwent diagnostic catheterization at the Manchester Royal Infirmary, UK between 1st January 2015 to 31st March 2017. Their CO derived by using 4 different formulae were compared using a one way repeated measures ANOVA test. Results CO measured by various formulae is reported here with: LaFarge and Miettenen 4.31±1.43 L/min; Dehmer, Firth and Hills – 4.91±1.50 L/min; Bergstra, Van Dijk, Jillege, – 6.1±2.22 L/min; and Seckeler, Hirsch, Beekman Methodology – 2.96±0.88 L/min. LaFarge and Miettenen formula derived CO was lowest in comparison to all other formulae and was significantly lower than Dehmer as well as Bergstra formulae (p<0.0001 for each), whereas non-significantly lower than the Seckeler et al formula. Conclusion There is no agreement between the assumed VO2 derived cardiac output measurements, including the most commonly used LaFarge formula, when compared in a cohort of ACHD patients. Using such assumed formulae derived CO may be misleading and such values should be interpreted carefully. Every cardiologist should be cognizant of these limitations. Facemask apparatus should be routinely used in catheter laboratories to obtain true VO2, especially, when such a value is likely to influence major management decisions. Abstract 61 Figure 1

Cardiac Rhythm Management, 2018

Background Advances in clinical management have improved life expectancy in the ACHD population; ... more Background Advances in clinical management have improved life expectancy in the ACHD population; as a result, implantable cardiac devices remain in situ for longer periods than ever before. These patients pose unique challenges, including; young age at implant, multiple device procedures during their lifetime, complex venous and cardiac anatomy, and co-morbidities which may predispose to infection. In the non-ACHD population, there is useful long-term research which helps to guide clinical decision-making; however, small numbers and incomplete outcome data has lead to limited comparability against ACHD patients. Aims This study aimed to examine 20 years of pacing experience in a large ACHD centre, using novel data-mining techniques to generate comprehensive lead survival data. Methodology A retrospective analysis was performed of pacing and defibrillator leads implanted between June 1996 and December 2016 in a 173 patient ACHD cohort. Automated text searching algorithms with manual review of over 1 00 000 pieces of clinical correspondence was used to maximise identification of outcomes. Lead-specific complications, non-elective removal and overall lead survival were compared for surgical and transvenous leads in patients with complex and non-complex ACHD anatomy. Results 340 leads with complete implant and follow-up data were identified of which 53% were in patients with complex ACHD anatomy and 15% were in patients with tricuspid valve abnormalities. Median lead survival time was 13.6 years in transvenous leads and 15.9 years in surgical leads (p=n .s.) Transvenous leads were associated with a higher risk of major infection than were surgically-implanted leads (11.5% vs 0% p<0.05) while surgical leads had a higher rate of pacing failure or lead damage (25.9% vs 8.0% p<0.001). Complication rates were not affected by complex ACHD anatomy or abnormal tricuspid valve function. Conclusion In this large cohort of patients with ACHD, lead survival appears to be reasonable regardless of whether a transvenous or surgical approach is used. A higher incidence of infection in transvenous leads is offset by a higher electrical failure rate in surgical leads. Further work examining large cohorts is required to determine optimal pacing strategies tailored to patient-specific anatomical challenges. Abstract 23 Figure 1 Time to lead failure/non-elective removal Abstract 23 Table 1

Journal of the American College of Cardiology, 2018

Background: Hemodynamically significant atrial septal defect (ASD) causes increase in the RV prel... more Background: Hemodynamically significant atrial septal defect (ASD) causes increase in the RV preloading condition with its detrimental effect of RV dilatation. Transcatheter closure of secundum type ASD causes a sudden change of the RV loading condition. The purpose of this study is to assess the RV myocardial deformation changes caused by percutaneous ASD closure in older adults Methods: This is a retrospective study to evaluate RV myocardial deformation changes in patients who underwent transcatheter closure of ASD. RV global longitudinal strain and strain rate (SR) were assessed, utilizing Tomtec imaging software, through speckle-tracking technology, before and 1-2 months after percutaneous closure. Repeated measure analysis was used to compare the strain parameters, p < 0.05 was considered statistically significant. Results: RV myocardial deformation indices were studied in 18 patients (8 Male, 10 Female) aged 52 years ± 17 before and 1-2 months (45 days ± 18) after percutaneous ASD device closure. There was a significant decrease in the RV global longitudinal strain post intervention-22.1 (± 5.1) vs-15.9 (± 3.4); coef. (95% Conf. Interval) =-6.2 (-8.6 to-3.7) p < 0.005. The RV longitudinal SR was not influenced by intervention 1.0/sec (± 0.4) vs 0.9/sec (± 0.2); coef. (95% Conf. Interval) =-0.14 (-0.32 to 0.034) p = 0.115. In this cohort of older adults at time of intervention (52 years ± 17), there was still a significant decrease in RV internal dimensions post-intervention. RVEDA (right ventricular end-diastolic area (cm2) decreased significantly post intervention (31.7 ± 7.9) vs (24.9 ± 5.3); coef. (95% Conf. Interval)-6 (-9 to-3), p <0.005. RV basal internal diameter (mm) decreased significantly post intervention (48.3 ± 6.4) vs (42.0 ± 6.7); coef. (95% Conf. Interval)-5(-8 to-3), p < 0.005 Conclusion: RV myocardial deformation measured by global longitudinal strain, being dependent on RV preloading condition, decreased significantly post percutaneous ASD device closure. Percutaneous ASD closure can provide significant reduction in RV internal dimensions despite older age at intervention.

Journal of the American College of Cardiology, 2018

Background: Ebstein anomaly is a congenital malformation of the tricuspid valve (TV) with right v... more Background: Ebstein anomaly is a congenital malformation of the tricuspid valve (TV) with right ventricular(RV) myopathy. There is wide range of presentation from patients who are asymptomatic to various degree of RV failure. Case: We present a 32 year old male who presents with palpitations and shortness of breath. He presented with wide complex tachycardia and SBP in the 80's. Because of vital signs instability at presentation, electrical cardioversion was applied with successful conversion to sinus rhythm. Physical examination (PE) after restoring sinus rhythm was significant hypoxia with Sao2 88% resistant to oxygen therapy, regular HR, split S1 with normal mitral component and accentuated tricuspid component (click-like sound), normal S2 with very faint pulmonic component, a soft 2/6 holo-systolic murmur best heard at the left parasternal border. TTE showed severely dilated RA, apical displacement of the TV with tethered septal leaflet and elongated anterior leaflet in a sail-like deformity. To further evaluate for the possibility of interatrial communication, TEE was performed and revealed a large size secundum type atrial septal defect (ASD) (18 mm) with bidirectional shunting. Decision-making: The proposed interventions include surgical repair of the TV with concomitant closure of the ASD, versus transcatheter closure of the ASD. Transcatheter closure of the ASD was attempted, however it was poorly tolerated with a significant drop in blood pressure during balloon test occlusion. Conclusion: This case represents typical PE findings in an adult patient with Ebstein anomaly. It also reflects the common association of WPW syndrome and ASD in patients with Ebstein anomaly. The decision to perform transcather closure of ASD in Ebstein anomaly can be challenging and mandates careful hemodynamic evaluation with balloon test occlusion. In patients, who do not tolerate balloon test occlusion, a different strategy should be considered including; surgical TV repair with concomitant surgical closure of ASD, either complete or partial closure. Bidirectional cavopulmonary anastomosis (bidirectional Glenn, BDG) can be considered in cases of severe RV dysfunction at time of TV repair.

Journal of the American College of Cardiology, 2019

BACKGROUND Transcatheter aortic and pulmonary valves have been used to treat stenosis or regurgit... more BACKGROUND Transcatheter aortic and pulmonary valves have been used to treat stenosis or regurgitation after prior surgical tricuspid valve (TV) replacement or repair. Little is known about intermediate-term valve-related outcomes after transcatheter tricuspid valve replacement (TTVR), including valve function, thrombus, and endocarditis. OBJECTIVES The authors sought to evaluate mid-term outcomes in a large cohort of patients who underwent TTVR after surgical TV repair or replacement, with a focus on valve-related outcomes. METHODS Patients who underwent TTVR after prior surgical TV replacement or repair were collected through an international registry. Time-related outcomes were modeled and risk factors assessed. RESULTS Data were collected for 306 patients who underwent TTVR from 2008 through 2017 at 80 centers; 52 patients (17%) had a prior history of endocarditis. Patients were followed for a median of 15.9 months after implantation (0.1 to 90 months), with 64% of patients estimated to be alive without TV reintervention or a valve-related event at 3 years. The cumulative 3-year incidence of death, reintervention, and valve-related adverse outcomes (endocarditis, thrombosis, or significant dysfunction) were 17%, 12%, and 8%, respectively. Endocarditis was diagnosed in 8 patients 2 to 29 months after TTVR, for an annualized incidence rate of 1.5% per patient-year (95% confidence interval: 0.45% to 2.5%). An additional 8 patients were diagnosed with clinically relevant valve thrombosis, 3 in the short term, 2 within 2 months, and 3 beyond 6 months. Only 2 of these 8 patients received anticoagulant therapy before thrombus detection (p ¼ 0.13 vs. patients without thrombus). Prior endocarditis was not a risk factor for reintervention, endocarditis, or valve thrombosis, and there was no difference in valve-related outcomes according to TTVR valve type. CONCLUSIONS TV dysfunction, endocarditis, and leaflet thrombosis were uncommon after TTVR. Patients with prior endocarditis were not at higher risk for endocarditis or other adverse outcomes after TTVR, and endocarditis occurred with similar frequency in different valve types. Though rare, leaflet thrombosis is an important adverse outcome, and further study is necessary to determine the appropriate level of prophylactic therapy after TTVR.

Journal of the American College of Cardiology, 2017

Background: Patients with pulmonary atresia with intact ventricular septum (PA/IVS) are prone to ... more Background: Patients with pulmonary atresia with intact ventricular septum (PA/IVS) are prone to development of coronary artery sinusoidal connections with the right ventricular (RV) cavity. Case: 25 year-old female with a history of PA/IVS physiology status post Fontan palliation, presented with pressure like chest pain of gradual onset, exacerbated with activity. Her vital signs were stable, EKG showed no ischemic changes, troponins were negative. Cardiac catheterization revealed a single coronary origin from the left aortic sinus; it divided to left anterior descending artery (LAD) and a diminutive circumflex artery. There was no forward flow form the aorta to the right coronary artery (RCA). The distal part of the LAD was connected to the RV cavity through three sinusoidal connections; two of them were stenotic and one was draining to the RV. Decision-Making: The patient was also found to have a small non-restrictive VSD, however she was still falling in the hemodynamic territory of PA/IVS with formation of sinusoidal connections to the RV. The diastolic pressure in the RV was lower than the aortic diastolic pressure with a potential risk for coronary steal phenomena in diastole. For concerns about the complications of closing the coronary sinusoidal connection, the decision was made to pursue with medical management including B.Blockers and nitrates. Conclusions: Coronary-ventricular connections carry a risk for coronary steal with subsequent ischemia in patients with PA/IVS.

Journal of the American College of Cardiology, 2017

Background: Fontan surgery provides palliation for single ventricle patients. A late complication... more Background: Fontan surgery provides palliation for single ventricle patients. A late complication is the development of atrial tachyarrhythmias (AT). This study aims to establish incidence and identify predictors of AT in Fontan patients with long-term follow-up. Methods: Retrospective review of medical records from 2 tertiary academic institutions identified 113 Fontan patients ≥ 18 years. Results: Mean age was 31 ± 7years, 54% females; 37% atriopulmonary (AP) Fontan, 31% lateral tunnel (LT), and 32% extracardiac (EC). Mean follow-up was 31± 7 yrs and time since Fontan surgery was 23± 6 yrs. We estimated that by age 35 yrs over half will have AT. Incidence of AT was 57% in AP, 27% in LT and 16% in EC groups at follow-up. Patients with AT more likely had AP Fontan (57% vs. 22%, p<0.0001) and New York Heart association (NYHA) class II/III (46%vs.25%, p=0.04) than those without. Kaplan-Meier curve shows that median time to AT was dependent on gender and age at the time of Fontan surgery (Figure). Multivariate Cox regression analysis showed no effect of Fontan type, NYHA class, but confirmed female gender (hazard ratio (HR) 0.4; p=0.008) and increasing age at Fontan surgery as independent predictors of reduced HR (0.8; p<0.001). Conclusions: There is a significant, increased atrial tachyarrhythmia burden in adult Fontan patients that is dependent on gender and age at Fontan surgery. These patients continue to pose significant challenges as adults and long-term close follow with defined management strategies is crucial.

Journal of the American College of Cardiology, 2017

Background: Device closure of the left atrial appendage (LAA) is widely used for patients unsuita... more Background: Device closure of the left atrial appendage (LAA) is widely used for patients unsuitable for anticoagulation. The Lariat device (SentreHEART, Redwood City, CA) is a percutaneous suture based device currently approved for percutaneous LAA ligation. While greater than 90% of patients who undergo the Lariat procedure have no residual flow in the LAA, a small proportion can have significant (3-5 mm) leaks. The thromboembolic risk of a residual leak remains unclear. The aim of this study was to evaluate the safety and efficacy of the Amplatzer vascular plug (AVPII, St. Jude Medical, St. Paul, MN) in the closure of residual LAA leak after LAA ligation using the Lariat device. Methods: Here we report the outcomes of four patients with significant residual leaks who underwent device closure. Four patients, all male, mean age 75 ± 10.6 years with residual LAA leak diameter ranging between 3.5 to 6mm as assessed by transesophageal echocardiogram (TEE), underwent device closure using the AVPII. Transseptal access was obtained through a femoral venous approach using a NTG RF transseptal needle (Baylis Medical, Montreal, Canada). Contrast injection into the left atrium with a 5F straight pigtail catheter confirmed the residual LAA leak. A 6F multipurpose guide catheter was positioned in the LAA leak over a glide wire followed by deployment of an AVPII device (6 or 8mm). Results: All cases resulted in complete cessation of residual LAA flow after device deployment as confirmed by TEE and angiography. Three patients required one AVPII device and one patient required two 8mm AVPII devices. There were no procedural complications. At a median follow-up period of 369 days, anticoagulation was discontinued in two of four patients (the other two remain on anticoagulation pending further ablation). One patient reverted to sinus rhythm from persistent atrial fibrillation following residual leak closure. Conclusions: Percutaneous management of LAA leak following Lariat closure using the AVPII device is safe, efficacious, and potentially permits discontinuation of anticoagulation mitigating bleeding risk. It should be considered in patients with a residual LAA leak.

Journal of the American College of Cardiology, 2017

Background: Elevated body mass index (BMI) is increasingly affecting adults with congenital heart... more Background: Elevated body mass index (BMI) is increasingly affecting adults with congenital heart disease. The effect of an increased BMI with respect to clinical variables has not been evaluated in adult Fontan patients. Methods: Retrospective review of medical records from 2 tertiary academic institutions identified 68 Fontan patients ≥ 18 years for whom BMI data was available. Results: Mean BMI was 24±4 kg/m 2 with 6% being underweight (BMI <18.5), 54% normal (18.5-<25), 31% overweight (25-<30) and 9% obese (≥ 30). Patients with BMI ≥ 25 kg/m 2 were significantly older (34 ± 9 vs. 31 ± 7 yrs, p=0.03), had higher Fontan (16 ± 3 vs.14 ± 6 mm Hg, p=0.04) and pulmonary capillary wedge pressures (PCWP, 12 ± 3 vs. 9 ± 3 mm Hg, p=0.03) and lower peak oxygen consumption (VO 2 , 18±5 vs. 22±4 ml/Kg/min, p=0.005), minute ventilation (Ve, 44 ± 10 vs. 58 ± 21 L/min, p=0.03) and Ve/Vco2, (33 ± 7 vs. 36 ± 4, p=0.03) on cardiopulmonary exercise testing (CPET). There were no differences in gender, Fontan type, ventricular type and function, arrhythmia burden, New York Heart Association status, other echocardiographic, hemodynamic or CPET variables. Linear regression graph showed a linear correlation between BMI and the significant clinical variables (Figure). Conclusions: Overweight/obesity is highly prevalent in adult Fontan patients. Higher BMI is associated with poor hemodynamics and aerobic capacity. This might correlate with worse health outcomes in this patient population, although further study is needed to determine this.

The International Journal of Cardiovascular Imaging, 2017

used off-label as an MRI blood pool contrast agent offers an attractive alternative to gadofosves... more used off-label as an MRI blood pool contrast agent offers an attractive alternative to gadofosveset trisodium in patients with renal failure, with excellent 4D flow image quality and good correlation of volumetric measurements compared to the CMR reference (SSFP).

International journal of cardiology, Jan 15, 2017

Computed tomography angiography (CTA) is the test of choice for pre-procedure imaging of transcat... more Computed tomography angiography (CTA) is the test of choice for pre-procedure imaging of transcatheter aortic valve replacement (TAVR) candidates. The iodinated contrast required, however, increases the risk of renal dysfunction in patients with pre-existing renal failure. Ferumoxytol is a magnetic resonance imaging (MRI) contrast agent that can be used with renal failure. Its long vascular resonance time allows gated MRA sequences that approach CTA in image quality. We present respiratory and cardiac gated MRA enabled by ferumoxytol that can be post-processed in an analogous fashion to CTA. Seven patients with renal failure presenting for TAVR were imaged with respiratory and cardiac gated MRA at 3T using ferumoxtyol for contrast. Aortic annulus, root and peripheral access dimensions were calculated in a fashion identical to that used for CTA. Of these, 6 patients underwent a TAVR procedure and 5 had intraoperative valve assessment with transesophageal echocardiograph (TEE) using s...

Expert Review of Cardiovascular Therapy, 2016

Introduction: Patent foramen ovale (PFO) is a common congenital cardiac abnormality and that has ... more Introduction: Patent foramen ovale (PFO) is a common congenital cardiac abnormality and that has been associated with several disease processes including transient ischemic attacks (TIA), stroke, migraine headaches with aura, decompression sickness, platypnea-orthodeoxia syndrome, and shunt induced cyanosis. Controversy exists regarding closure of PFO as a therapeutic treatment modality for these disease processes. This review addresses the contemporary clinical indications for PFO closure. Areas covered: We conducted a comprehensive literature search of contemporary research studies focusing on randomized trials and meta-analyses comparing medical therapy and device closure of PFOs for the treatment of PFO associated clinical syndromes. We synthesized this literature into a review addressing indications for PFO closure in stroke, TIA, migraine headaches with aura, decompression sickness, platypnea-orthodeoxia syndrome, and shunt induced cyanosis. Expert commentary: Because in many PFO associated conditions it can be difficult to determine the degree to which the PFO is a causative factor in the disease process, we recommend a comprehensive diagnostic evaluation to exclude other obvious etiologies of PFO associated conditions before implicating the PFO and proceeding with closure. However in the properly selected patient population there is growing clinical experience and experimental evidence suggesting that closure of PFO is a safe and effective treatment modality.

Open heart, 2016

Transcatheter aortic valve replacement (TAVR) has been established as an alternative therapy for ... more Transcatheter aortic valve replacement (TAVR) has been established as an alternative therapy for patients with severe aortic stenosis who are unfit for the surgical aortic valve replacements. Pre and periprocedural imaging for the TAVR procedure is the key to procedural success. Currently transesophageal echocardiography (TOE), including real-time three-dimensional (RT-3D) imaging TOE, has been used for peri-interventional monitoring and guidance for TAVR. We describe our initial experience with real-time three-dimensional intracardiac echocardiography (RT-3DICE), imaging technology for the use in the TAVR procedure. We used RT-3DICE using an ACUSON SC2000 2.0v (Siemens Medical Solution), and a 10F AcuNav V catheter (Siemens-Acuson, Inc, Mountain View, California, USA) in addition to preoperative multislice CT (MSCT) in total of five patients undergoing TAVR procedure. Aortic annulus and sinus of valsalva diameters were measured using RT-3DICE. Aortic valve measurements obtained usi...