Femoral vessel complications after transfemoral TAVR-A contemporary sonography-based assessment of 480 patients with third-generation transcatheter valves

BACKGROUND

Postinterventional sonographic assessment of the femoral artery after transfemoral transcatheter aortic valve replacement (TF-TAVR) has the potential to identify several pathologies. We investigated the incidence and risk factors of femoral vessel complications in a modern TAVR collective using postinterventional sonography.

METHODS

Between September 2017 and March 2022, 480 patients underwent TF-TAVR with postinterventional femoral sonography at a single center. Clinical outcomes and adverse events were analyzed after the Valve Academic Research Consortium 3 (VARC-3) criteria.

RESULTS

In this cohort (51.2% male; age 80 ± 7.5 years, median EuroSCORE II 3.7) 74.8% (n = 359) were implanted with a self-expandable and 25.2% (n = 121) with a balloon-expandable valve. The main access (valve-delivery) was located right in 91.4% (n = 438), and the primary closure system was Proglide in 95% (n = 456). Vascular complications (VC) were observed in 29.16% (n = 140) of patients; 23.3% (n = 112) presented with minor- and 5.8% (n = 28) with major VC. Postinterventional femoral artery stenosis on the main access was observed in 9.8% (n = 47). Multivariable logistic regression analysis revealed female sex (p = .03, odds ratio [OR] 2.32, 95% confidence interval [CI] 1.09-4.89) and the number of used endovascular closure devices (p = .014, OR 0.11, 95%CI 0.02-0.64) as predictive factors for femoral artery stenosis.

CONCLUSIONS

The incidence of postinterventional femoral artery stenosis following TF-TAVR was higher than expected with a number of used closure devices and female sex being independent risk factors. Considering the continuous advance of TAVR in low-risk patients with preserved physical activity, emphasis should be directed at the correct diagnosis and follow-up of these complications.

Aortic Valve Replacement in Adult Patients with Decellularized Homografts: A Single-Center Experience

BACKGROUND

decellularized aortic homografts (DAH) represent a promising alternative for aortic valve replacement in young adults due to their low immunogenicity and thrombogenicity. Herein, we report our midterm, single-center experience in adult patients with non-frozen DAH from corlife.

METHODS

safety, durability, and hemodynamic performance were evaluated according to current guidelines in all consecutive patients who had received a DAH at our center since 03/2016.

RESULTS

seventy-three (mean age 47 ± 11 years, 68.4% (n = 50) male) patients were enrolled. The mean diameter of the implanted DAH was 24 ± 2 mm. Mean follow-up was 36 ± 27 months, with a maximum follow-up of 85 months and cumulative follow-up of 215 years. No cases of stenosis were observed, in four (5.5%) cases moderate aortic regurgitation occurred, but no reintervention was required. No cases of early mortality, non-structural dysfunction, reoperation, valve endocarditis, or thrombosis were observed. Freedom from bleeding and thromboembolic events was 100%; freedom from re-intervention was 100%; survival was 98.6% (n = 72).

CONCLUSIONS

early and mid-term results showed low mortality and 100% freedom from reoperation, thromboembolic events, and bleeding at our center. However, in order for this novel approach to be established as a valid alternative to aortic valve replacement in young patients, long-term data are required.

Structural valve deterioration after aortic valve replacement with the Trifecta valve

OBJECTIVES

Despite promising short- and mid-term results for durability of the Trifecta valve, contradictory reports of early structural valve deterioration (SVD) do exist. We investigated the incidence of SVD after surgical aortic valve replacement (SAVR) with the Trifecta in our single-centre experience.

METHODS

Data of 347 consecutive patients (mean age 71.6 ± 9.5 years, 63.4% male) undergoing SAVR with the Trifecta between 2011 and 2017 were analysed. Clinical and echocardiographic reports were obtained with a median follow-up of 41 months (1114 patient years).

RESULTS

Isolated SAVR was performed in 122 patients (35.2%), whereas 225 patients (64.8%) underwent concomitant procedures. The median EuroSCORE II was 4.0 (0.9; 7.1) and 30-day mortality was 3.7% (n = 13). Kaplan-Meier estimates for the freedom of overall mortality at 1, 5 and 7 years were 88.7 ± 1.7%, 73.7 ± 2.6% and 64.7 ± 4.2%, respectively. SVD was observed in 25 patients (7.2%) with a median time to first diagnosis of 73 months. Freedom of SVD was 92.5 ± 0.9% at 5 years and 65.5 ± 7.1% at 7 years. Thirteen patients underwent reintervention for SVD (6 re-SAVR, 7 valve-in-valve), resulting in a freedom of reintervention for the SVD of 98.5 ± 1.1% at 5 years and 76.9 ± 6.9% at 7 years.

CONCLUSIONS

We herein report one of the highest rates of SVD after SAVR with the Trifecta. These data indicate that the durability of the prosthesis decreases at intermediate to long-term follow-up, leading to considerable rates of reintervention due to SVD.

Outcome of rapid deployment aortic valves: long-term experience after 700 implants

Background

The Edwards Intuity Valve System is a bioprosthesis with a balloon-expandable stent frame which enables rapid-deployment (RD). We aimed to analyze our single-center long-term experience with a follow-up until 9 years after aortic valve replacement (AVR) with this bioprosthesis.

Methods

Between May 2010 and May 2019, 700 consecutive patients with severe aortic stenosis or combined aortic valve disease, implanted with a RD valve at our institution, were included in a prospective database. Median follow-up was 19 months and the total accumulated follow-up was 2,140 patient-years. Pre-operative characteristics, operative parameters, survival rates, valve-related adverse events and valve hemodynamics were assessed.

Results

Mean age was 74±8 years, 45% female. Concomitant procedures were performed in 339 (48.4%) patients. In case of isolated AVR (361/700), a minimally invasive surgical (MIS) approach was conducted in 283 patients (78.4%). Cardio-pulmonary bypass (CPB) and cross-clamp times for isolated AVR were 107.7±28.2 and 73.8±21.3 minutes for MIS approaches and 92.8±28.8 and 57.5±20.6 minutes for full sternotomy (P<0.001), respectively. Mean gradients at discharge, 1, 3 and 5 years were 13±5, 11±4, 12±5 and 13±8 mmHg. New early pacemaker implantation was required in 8.9% of patients. Re-intervention or re-operation with valve explantation for structural degeneration, non-structural dysfunction or endocarditis, occurred in 21 cases (3%). Thirty-day mortality was 0.7% (5/700) and overall survival at 1, 3 and 5 years was 98%, 91% and 76%.

Conclusions

We report excellent long-term results in this updated single center experience for RD aortic valves regarding durability, safety and hemodynamic performance.

Rapid-Deployment Aortic Valves for Patients With a Small Aortic Root: A Single-Center Experience

BACKGROUND

Aortic valve replacement in patients with a small aortic root is a matter of concern in terms of prosthesis-patient mismatch. We evaluated the survival and hemodynamic performance after implantation of a small rapid-deployment aortic valve (EDWARDS INTUITY valve system sizes 19 and 21 mm).

METHODS

Between May 2010 and November 2018, 659 consecutive patients with severe aortic stenosis who received a rapid-deployment valve were included in a prospective and ongoing database. A small aortic bioprosthesis (sizes 19 mm and 21 mm) was implanted in 217 (32.9%) patients (mean age 74.9 ± 7.9 years, 85.3% women). Preoperative characteristics, operative parameters, and postoperative outcomes were assessed.

RESULTS

Mean gradients at discharge and 1 year were 14.8 ± 5.6 mm Hg and 13.6 ± 4.9 mm Hg, respectively. Mean effective orifice area and the indexed effective orifice area at discharge were 1.55 ± 0.36 cm² and 0.87 ± 0.22 cm²/m², respectively, and prosthesis-patient mismatch occurred in 77 (35.5%) patients (25.8% moderate and 9.7% severe). Perioperative mortality was 1.8% (n = 4 of 217) and overall survival at 1 year and 5 years was 91% and 79%, respectively. The presence of any prosthesis-patient mismatch degree did not have a significant influence on overall survival (hazard ratio, 0.95; 95% confidence interval, 0.75-1.19; P = .638). At the last follow-up, mean New York Heart Association functional class was 1.5 ± 0.7 vs 2.8 ± 0.6 at baseline (P < .001).

CONCLUSIONS

Surgical aortic valve replacement with rapid-deployment valves has shown improved results concerning hemodynamic performance, with decreased rates of prosthesis-patient mismatch. We observed excellent early-term and midterm survival and a significant improvement in functional class in this subgroup of patients with a small annulus.

Transcatheter edge-to-edge tricuspid repair for recurrence of valvular regurgitation after left ventricular assist device and tricuspid ring implantation

Tricuspid regurgitation in patients with left ventricular assist device (LVAD) has a significant impact on prognosis and quality of life, and its effects on liver and renal function could negatively impact planned heart transplantation. The aim of the present case is to report the feasibility and the clinical impact of tricuspid transcatheter edge‐to‐edge repair in LVAD patients as adjunctive bridge to transplantation strategy. A 59‐year‐old female patient previously treated with LVAD implantation (HeartMate III) and tricuspid valve repair with 32 mm rigid ring (Medtronic Contour 3D) as bridge to transplantation developed recurrence of significant tricuspid regurgitation with right ventricular decompensation needing inotropic support. Preoperative echo showed torrential tricuspid valve regurgitation Effective regurgitant orifice area(EROA 1.4 cm²) with suspicious of partial detachment of the prosthetic ring. The patient was successfully treated with transcatheter edge‐to‐edge repair with the MitraClip XTR device. Tricuspid regurgitation was reduced by 50% (postoperative EROA 0.7 cm²). She remained stable under continuous inotropic support with no other episodes of right ventricular decompensation and was successfully transplanted 30 days after the clipping procedure. Transcatheter treatment of tricuspid regurgitation in a patient with LVAD was an effective strategy to gain time and bridge the patient to heart transplantation.

Transcatheter Caval Valve Implantation of the Tricento Valve for Tricuspid Regurgitation Using Advanced Intraprocedural Imaging

A 75-year-old patient with previous mitral and tricuspid reconstruction experienced severe tricuspid regurgitation. On the basis of a prohibitive surgical risk, an interventional heterotopic tricuspid valve implantation was planned. Implantation was performed using fusion-imaging, which facilitated intraprocedural navigation. At 6-month follow-up, the patient presented in improved condition with reduced symptoms. (Level of Difficulty: Advanced.).

P4720Mitraclip XTR device used for the treatment of functional tricuspid regurgitation provides significant reduction of annular size

Background

Tricuspid valve regurgitation (TR) is a progressive disease strongly associated with increased cardiac and all-cause mortality. The transcatheter approach to this pathology has been recently described with promising results in the treatment of symptomatic patients despite optimal medical therapy. Development of annular dilation and leaflet tethering represent a continuous pattern in the pathophysiology of functional TR; for this reason, to reduce and stabilize the annulus is the goal of an efficacious therapy.

Purpose

In order to simplify leaflet grasping, the novel MitraClip XTRdevice has significantly longer clip arms compared to its predecessor. The increased grasping length could be able to apply a radial tension on the tricuspid annulus, reducing it in dimensions. Despite, the increased tension on the leaflets may theoretically impose a higher risk for leaflet tearing We analyzed our single-center experience in order to clarify the capability of the device in the feature of annular reshapement.

Methods

Five high-risk patients (4 females, 72 (quartiles 69–79) y.o., EuroSCORE II 10 (7.25–11.2)% affected by severe symptomatic functional TR were treated with MitraClip XTR implantation in tricuspid position. Right ventricular function was apparently preserved in all cases and the mean sPAP was 41 (quartiles 38–45) mmHg. Perioperative echo-results were collected prospectively and analyzed.

Results

Procedural success (defined as a reduction of more than 1 degree of TR) was achieved in 4 cases (80%). 3±1 devices were implanted per patient in the antero-septal commissure. The tricuspid annular diameter (measured in four chamber view) was reduced from 39 (quartiles 39–41) mm to 31 (quartiles 30–31) mm (p=0.043). Accordingly, the effective regurgitant orifice area (EROA) decreased from 110 (quartiles 70 to 160) mm2 to 45 (quartiles 9–55) mm2 (p=0.02) and the systolic VTI in the hepatic veins decreased by 42%. No significant increase of trans-valvular mean gradients was observed (2.5 (quartiles 2.25 to 2.75)) mmHg vs 3.75 (quartiles 3,75 to 4) mmHg; p=0.2) as well no cases of acute leaflet tearing.

Conclusion

The reduction in tricuspid annulus size with the novel XTRdevice represents an unexpected and interesting achievement of the procedure. A significant reduction of annular dimensions might provide a more durable reduction of functional TR. Long-term follow-up data will be required to clarify these initial results and as well as patient selection criteria.

Venus flytrap trigger hairs are micronewton mechano-sensors that can detect small insect prey

Venus flytraps detect moving insects via highly sensitive, action potential (AP)-producing trigger hairs, which act as high-sensitivity levers, crucial for prey capture and digestion. Controlled stimulation revealed that they can trigger APs for deflections >2.9°, angular velocities >3.4° s^-1 and forces >29 µN. Hairs became desensitized and subsequently responded to fast consecutive stimulations; desensitization increased at lower temperatures. Recording of ant trigger hair contact events revealed that even small insects exceed the hairs' sensitivity threshold.

Venus Flytrap HKT1-Type Channel Provides for Prey Sodium Uptake into Carnivorous Plant Without Conflicting with Electrical Excitability

The animal diet of the carnivorous Venus flytrap, Dionaea muscipula, contains a sodium load that enters the capture organ via an HKT1-type sodium channel, expressed in special epithelia cells on the inner trap lobe surface. DmHKT1 expression and sodium uptake activity is induced upon prey contact. Here, we analyzed the HKT1 properties required for prey sodium osmolyte management of carnivorous Dionaea. Analyses were based on homology modeling, generation of model-derived point mutants, and their functional testing in Xenopus oocytes. We showed that the wild-type HKT1 and its Na(+)- and K(+)-permeable mutants function as ion channels rather than K(+) transporters driven by proton or sodium gradients. These structural and biophysical features of a high-capacity, Na(+)-selective ion channel enable Dionaea glands to manage prey-derived sodium loads without confounding the action potential-based information management of the flytrap.

Comparison of magnetic wire navigation with the conventional wire technique for percutaneous coronary intervention of chronic total occlusions: a randomised, controlled study

Wire crossing of a chronic total coronary occlusion (CTO) is time consuming and limited by the amount of contrast agent and time of radiation exposure. Magnetic wire navigation (MWN) might accelerate wire crossing by maintaining a coaxial vessel orientation. This study compares MWN with the conventional approach for recanalization of CTOs. Forty symptomatic patients with CTO were randomised to MWN (n = 20) or conventional approach (n = 20) for antegrade crossing of the occlusion. In the intention-to-treat analysis, MWN showed a shorter crossing time (412 versus 1131 s; p = 0.001), and, consequently, lower usage of contrast agent (primary endpoint 42 versus 116 ml; p = 0.01), and lower radiation exposure (dose-area product: 29 versus 80 Gy*cm(2); p = 0.002) during wire crossing compared to the conventional approach. Accordingly, in the per-protocol analysis, the wire-crossing rate was, in trend, higher using the conventional approach (17 of 31) compared to MWN (9 of 28; p = 0.08). The use of MWN for revascularisation of CTOs is feasible and reduces crossing time, use of contrast agent, and radiation exposure. However, due to a broader selection of wires, the conventional approach enables wire crossing in cases failed by MWN and seems to be the more successful choice.

Evaluation of a Canine Cranial Cruciate Ligament Repair SystemR for Use in Equine Laryngoplasty

OBJECTIVE

To report the use of a nylon suture system (Canine Cranial Cruciate Ligament Repair System; Securos Inc Veterinary Orthopedics) as a prosthesis for equine laryngoplasty.

STUDY DESIGN

Experimental and prospective clinical study.

ANIMALS

Cadaver specimens (n = 5) and 7 horses with left laryngeal hemiplegia.

METHODS

A commercially available monofilament nylon suture system was implanted as a laryngeal prosthesis. Arytenoid cartilage abduction was achieved with a tensioning device applied to the suture prosthesis during transnasal endoscopic observation. Suture fixation was achieved with crimping clamps and a crimping device.

RESULTS

The nylon suture system was suitable as a laryngeal prosthesis for arytenoid cartilage abduction. The ratchet mechanism of the tensioning device facilitated abduction of the arytenoid cartilage and suture fixation was achieved by the crimped clamp without any loss of tension. Postoperatively, there was a slight loss of tension in 4 horses and complete loss of tension in 1 horse because of cartilage failure. After convalescence, none of the horses had abnormal respiratory noise, exercise intolerance or cough.

CONCLUSIONS

A nylon suture system designed for canine cranial cruciate ligament repair was used successfully as a laryngeal prosthesis and facilitated control of the degree of arytenoid cartilage abduction during laryngoplasty.

CLINICAL RELEVANCE

For improved control of the degree of arytenoid cartilage abduction during laryngoplasty, use of a nylon suture system with metal crimps should be considered.

Equine melanoma in a population of 296 grey Lipizzaner horses

REASONS FOR PERFORMING STUDY

Equine melanomas occur most commonly in grey horses at age 5 years or more. Generally, benign and malignant melanomas are distinguished by microscopy, but a more distinct classification would be helpful.

OBJECTIVES

The objectives of this study were to gain further evidence concerning the occurrence of melanotic tumours, and to evaluate the impact of heredity on melanoma development.

METHODS

A clinical study was conducted on a defined population of 296 grey horses of Lipizzaner breed. Individuals were classified according to their stage of disease using a 0-5 scale. Heritability was estimated on a sample of 296 grey horses with pedigrees traced back as far as 32 generations.

RESULTS

Of the 296 horses, dermal melanomas were present in 148 horses (50%), 68 of which were more than age 15 years; 51 of these were melanoma-bearing. In 75.6% of cases, melanotic tumours were detected underneath the tail. Although melanoma-bearing grey horses were encountered up to stage 4, none of the affected individuals suffered any severe clinical effect or was handicapped in performance. Statistical analysis revealed highly significant effects of stud and age (P < 0.0001), explaining 28% of the total variability.

CONCLUSIONS

In contrast to melanomas in solid-coloured horses characterised by early metastases, melanomas in grey horses showed less malignancy. Affected individuals often had encapsulated nodules or structures similar to human blue nevi. Grey horse-specific genetic factors inhibiting metastatic processes may be responsible for this phenomenon.

POTENTIAL CLINICAL RELEVANCE

Although the obtained heritability estimate of 0.36 with a standard error of 0.11 indicates a strong genetic impact on the development of melanoma in ageing grey horses, a possible influence of the genes with large effects was also suggested. Therefore, further analysis is required of melanoma development in the ageing grey horse.

Analgesics and NSAIDs in the treatment of the acute migraine attack

In the treatment of migraine attacks, an antiemetic in combination with an analgesic or ergot alkaloid is widely recommended. Medication should be introduced as early as possible, but only when there is no doubt that the headache is due to migraine. The antiemetic provides relief from the nausea and vomiting and also enhances the resorption of analgesics or ergot preparations. Domperidone 20 mg orally and 20 mg metoclopramide as suppository or 10-20 mg orally are mostly used as antiemetics. Analgesics such as 1000 mg acetylsalicylic acid as effervescent tablets, or 1000 mg paracetamol as effervescent tablets or suppositories should be given 15-20 min later. If this treatment fails, NSAIDs can be tried. In some studies naproxen in doses between 500 and 1000 mg and ibuprofen in doses between 400 and 800 mg have been shown to be effective, as well as NSAIDs like diclofenac, mefenamic acid, ketoprofen, tolfenamic acid and pirprofen. NSAIDs have been found to be superior to placebo and to standard reference drugs in the majority of the reviewed double-blind trials. Nevertheless, these effects are marginal in some studies or even without clinical relevance. Accordingly, there is still a need for further comparative studies.

Surgical treatment of ruptures of the Achilles tendon: a review of long-term results

The rupture of the Achilles tendon is frequently sports-related. In the time from 1 January, 1978 until 31 December, 1988, we treated 358 men and 54 women with such an injury at the Staatliche Orthopaedische Klinik in Munich. The average age of these patients was 43 years. The site of the rupture was generally located between 3-5 cm proximal of the distal insertion of the tendon. In the follow-up examination of 122 patients with surgical treatment of tendo calcaneus ruptures 85% showed 'good' to 'very good' subjective results. Of the operated patients 97% would choose the same treatment under similar circumstances. The isokinetic studies demonstrated a loss of static and dynamic strength in plantar flexion of the ankle joint of 9.1%, and 16.7% respectively, when compared to the healthy contralateral side. The ultrasound examination revealed a thickening of the tendon and of the dorsal paratenon with changes in the internal structure of the injured Achilles tendon. In spite of these favourable results, the high complication rate of 15.1% shows the need for new and extensive studies regarding the various alternative treatment forms, such as functional, non-operative options, to finally resolve the debate about the optimal treatment of Achilles tendon ruptures.

[Effect of the injury process on prognosis of surgically treated Achilles tendon rupture. A score for evaluating late results]

372 Achilles tendon ruptures are reported that were surgically treated at the Staatliche Orthopädische Klinik Munich from 1978 to 1988. 122 Patients were examined on average 5.9 years postoperative. Further 50 patients participated at a questionnaire interview. In this follow-up, special importance was attached to the connection between the mechanism of the trauma that lead to the rupture, the clinical result and the result subjectively assessed by the patient. The following results were obtained: 1. Specific trauma mechanisms like external force on the tendon, supination and pronation trauma and in general all traumas that are able to rupture even a healthy tendon, have a worse prognosis regarding the late results. 2. In case of these mechanisms leading to the trauma, the Achilles tendon rupture is on average diagnosed noticeably later. 3. An early diagnosis and hence quick treatment is of decisive importance for the further prognosis.

[Long-term results of surgically treated Achilles tendon ruptures]

The rupture of the Achilles tendon is a frequent sports injury. Between 1978 and 1988 we treated 358 men and 54 women, with an average age of 43 years, for this. In most cases the site of rupture was 3-5 cm proximal to the distal insertion of the tendon. The long-term subjective results of operative treatment of Achilles tendon ruptures (122 patients) were "good" or "very good" on follow-up examination in 85% of cases, and 97% of the patients treated surgically would choose the same therapy in the event of a new rupture. The isokinetic results demonstrated a (9.1%) loss of static and a 16.7% loss of dynamic strength in plantar flexion of the upper ankle joint compared with the healthy side. Ultrasound examination revealed thickening of the tendon itself and of the dorsal paratendon, with alterations in the tendon structure. In spite of the good results, the high rate of complications, 15.1%, shows that new and extensive studies on functional conservative therapy of Achilles tendon rupture are necessary to find whether conservative or operative therapy is better.