A novel approach for the green synthesis of iron nanoparticles using marigold extract, black liquor, and nanocellulose: Effect on marigold growth parameters

This study aimed to investigate a novel method for the green synthesis of iron nanoparticles (FeNPs) using marigold extract (Calendula officinalis L), kraft pulping black liquor, and nanocellulose. Then, the efficacy of FeNPs as a direct nanofertilizer on the growth parameters of marigold was investigated. Characterization techniques including FESEM, EDX, VSM, and FTIR were used to confirm the successful synthesis of FeNPs. The characterization results confirmed the formation and presence of FeNPs in the 20-100 nm range. FeNPs synthesized with nanocellulose notably enhanced marigold growth parameters compared to other materials. However, all nanoparticle variants, including those from marigold extract and black liquor, improved germination, plant height, root length, and plant dry weight compared to the control. Moreover, treatments exhibited higher available iron and total plant iron levels than the control. Thus, employing 10 mg FeNPs (prepared with 5.0 % nanocellulose) appears optimal for enhancing marigold growth and yield.

Incidence, predictors, and prognostic significance of impaired functional status early after transcatheter aortic valve replacement

INTRODUCTION AND OBJECTIVES

There are scarce data on the factors associated with impaired functional status after transcatheter aortic valve replacement (TAVR) and its clinical impact. This study aimed to determine the incidence, predictors, and prognostic implications of impaired functional class (NYHA class III-IV) following TAVR.

METHODS

This multicenter study included 3462 transarterial TAVR patients receiving newer generation devices. The patients were compared according to their NYHA class at 1 month of follow-up (NYHA I-II vs NYHA III-IV). A multivariate logistic regression was performed to identify the predictors of 30-day NYHA class III-IV. Patient survival was compared with the Kaplan-Meier method and factors associated with decreased survival were identified with Cox regression analysis.

RESULTS

The mean age of the study population was 80.3±7.3 years, with 47% of women, and a median Society of Thoracic Surgeons score of 3.8% [IQR, 2.5-5.8]. A total of 208 patients (6%) were in NYHA class III-IV 1 month after TAVR. Predictors of 30-day NYHA class III-IV were baseline NYHA class III-IV (OR, 1.76; 95%CI, 1.08-2.89; P=.02), chronic pulmonary obstructive disease (OR, 1.80; 95%CI, 1.13-2.83; P=.01), and post-TAVR severe mitral regurgitation (OR, 2.00; 95%CI, 1.21-3.31; P<.01). Patients in NYHA class III-IV 1 month after TAVR were at higher risk of death (HR, 3.68; 95%CI, 2.39-5.70; P<.01) and heart failure-related hospitalization (HR, 6.00; 95%CI, 3.76-9.60; P<.01) at 1-year follow-up.

CONCLUSIONS

Up to 6% of contemporary TAVR patients exhibited an impaired functional status following TAVR. Worse baseline NYHA class, chronic pulmonary obstructive disease, and severe mitral regurgitation predicted 30-day NYHA class III/IV, and this determined a higher risk of mortality and heart failure hospitalization at 1-year follow-up. Further studies on the prevention and treatment optimization of patients with impaired functional status after TAVR are needed.

Optimal oversizing in transcatheter aortic valve replacement with the self-expanding Evolut valve system

OBJECTIVES

Valve oversizing has been associated with reduced paravalvular leaks (PVL) and valve migration risk. However, no optimal cut-off oversizing value has been defined for the Evolut system (Medtronic). The aim of this study was to assess the relationship between the degree of oversizing and moderate-to-severe PVL and determine the optimal oversizing cut-off value.

METHODS

We conducted a multicenter study that included 740 consecutive patients with multidetector computed tomography (CT) data. Valve size was selected according to manufacturer recommendations, with oversizing ranging from 10% to 30%. The primary endpoint was moderate-to-severe PVL.

RESULTS

The median age was 84 years (79-87 years), with 58.4% women, and a median EuroSCORE II of 4.1% (2.4-7.3%). Moderate-to-severe PVL was observed in 7.0% of the patients. An inverse relationship was found between oversizing and both PVL (11.3%, 8.6%, 5.4%, and 2.7% for quartiles Q1 to Q4; P = .007) and the need for post-dilation (P = .016). The multivariable analysis showed an association between oversizing and PVL (OR: 0.915 for each 1%-increase, P = .002). The optimal oversizing cut-off value to predict PVL was 20%, and PVL was significantly higher in patients with oversizing less than 20% (10.5% vs.4.2%, P less than .001). There were no differences in major clinical events according to the degree of oversizing, and a higher oversizing did not translate into an increased risk of permanent pacemaker (18.4% vs18.3%, P = .976).

CONCLUSIONS

In TAVR with the Evolut valve, a higher oversizing was associated with lower rates of moderate-to-severe PVL and a lower need for post-dilation, with no negative impact on procedural and early clinical outcomes. A 20% oversizing threshold could be suggested to reduce PVLs. Further prospective studies are warranted to validate optimal oversizing for this valve system.

Transcatheter or Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis and Small Aortic Annulus: A Randomized Clinical Trial

BACKGROUND

The optimal treatment in patients with severe aortic stenosis and small aortic annulus (SAA) remains to be determined. This study aimed to compare the hemodynamic and clinical outcomes between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with a SAA.

METHODS

This prospective multicenter international randomized trial was performed in 15 university hospitals. Participants were 151 patients with severe aortic stenosis and SAA (mean diameter <23 mm) randomized (1:1) to TAVR (n=77) versus SAVR (n=74). The primary outcome was impaired valve hemodynamics (ie, severe prosthesis patient mismatch or moderate-severe aortic regurgitation) at 60 days as evaluated by Doppler echocardiography and analyzed in a central echocardiography core laboratory. Clinical events were secondary outcomes.

RESULTS

The mean age of the participants was 75.5±5.1 years, with 140 (93%) women, a median Society of Thoracic Surgeons predicted risk of mortality of 2.50% (interquartile range, 1.67%-3.28%), and a median annulus diameter of 21.1 mm (interquartile range, 20.4-22.0 mm). There were no differences between groups in the rate of severe prosthesis patient mismatch (TAVR, 4 [5.6%]; SAVR, 7 [10.3%]; P=0.30) and moderate-severe aortic regurgitation (none in both groups). No differences were found between groups in mortality rate (TAVR, 1 [1.3%]; SAVR, 1 [1.4%]; P=1.00) and stroke (TAVR, 0; SAVR, 2 [2.7%]; P=0.24) at 30 days. After a median follow-up of 2 (interquartile range, 1-4) years, there were no differences between groups in mortality rate (TAVR, 7 [9.1%]; SAVR, 6 [8.1%]; P=0.89), stroke (TAVR, 3 [3.9%]; SAVR, 3 [4.1%]; P=0.95), and cardiac hospitalization (TAVR, 15 [19.5%]; SAVR, 15 [20.3%]; P=0.80).

CONCLUSIONS

In patients with severe aortic stenosis and SAA (women in the majority), there was no evidence of superiority of contemporary TAVR versus SAVR in valve hemodynamic results. After a median follow-up of 2 years, there were no differences in clinical outcomes between groups. These findings suggest that the 2 therapies represent a valid alternative for treating patients with severe aortic stenosis and SAA, and treatment selection should likely be individualized according to baseline characteristics, additional anatomical risk factors, and patient preference. However, the results of this study should be interpreted with caution because of the limited sample size leading to an underpowered study, and need to be confirmed in future larger studies.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03383445.

Aortic Stenosis With Coronary Artery Disease: SAVR or TAVR-When and How?

The growing number of candidates for transcatheter aortic valve replacement (TAVR) has increased the interest in the concomitant presence of coronary artery disease (CAD) and severe aortic stenosis (AS), prompting the need to define the appropriate revascularization strategy for each case. The reported prevalence of concurrent AS and CAD has varied over the years on the basis of the CAD definition and the population evaluated. Revascularization for treating CAD in patients with severe AS involves additional interventions that could impact outcomes. The addition of coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) has demonstrated favourable effects on long-term prognosis, while the impact of adding percutaneous coronary intervention (PCI) to TAVR may depend on the CAD complexity and the feasibility of achieving complete or reasonably incomplete revascularization. Furthermore, the comparison between SAVR+CABG and TAVR+PCI in low-intermediate surgical risk and low-intermediate complex CAD patients did not reveal differences in all-cause mortality or stroke between the groups. However, there is some evidence showing a lower incidence of major cardiovascular events with the SAVR+CABG strategy for patients with complex CAD. Thus, SAVR+CABG seems to be the best option for patients with low-intermediate surgical risk and complex CAD, and TAVR+PCI for high surgical risk patients seeking complete and/or reasonable incomplete revascularization. After deciding between TAVR+PCI or SAVR+CABG, factors such as timing for PCI, low ejection fraction, coronary reaccess, and valve durability must be considered. Finally, alternative methods for assessing CAD severity are currently under evaluation to ascertain their real value for guiding revascularization in patients with severe AS with CAD.

Impact of transcatheter heart valve type on outcomes of surgical explantation after failed transcatheter aortic valve replacement: the EXPLANT-TAVR international registry

BACKGROUND

There are limited data on the impact of transcatheter heart valve (THV) type on the outcomes of surgical explantation after THV failure.

AIMS

We sought to determine the outcomes of transcatheter aortic valve replacement (TAVR) explantation for failed balloon-expandable valves (BEV) versus self-expanding valves (SEV).

METHODS

From November 2009 to February 2022, 401 patients across 42 centres in the EXPLANT-TAVR registry underwent TAVR explantation during a separate admission from the initial TAVR. Mechanically expandable valves (N=10, 2.5%) were excluded. The outcomes of TAVR explantation were compared for 202 (51.7%) failed BEV and 189 (48.3%) failed SEV.

RESULTS

Among 391 patients analysed (mean age: 73.0±9.8 years; 33.8% female), the median time from index TAVR to TAVR explantation was 13.3 months (interquartile range 5.1-34.8), with no differences between groups. Indications for TAVR explantation included endocarditis (36.0% failed SEV vs 55.4% failed BEV; p<0.001), paravalvular leak (21.2% vs 11.9%; p=0.014), structural valve deterioration (30.2% vs 21.8%; p=0.065) and prosthesis-patient mismatch (8.5% vs 10.4%; p=0.61). The SEV group trended fewer urgent/emergency surgeries (52.0% vs 62.3%; p=0.057) and more root replacement (15.3% vs 7.4%; p=0.016). Concomitant cardiac procedures were performed in 57.8% of patients, including coronary artery bypass graft (24.8%), and mitral (38.9%) and tricuspid (14.6%) valve surgery, with no differences between groups. In-hospital, 30-day, and 1-year mortality and stroke rates were similar between groups (allp>0.05), with no differences in cumulative mortality at 3 years (log-rank p=0.95). On multivariable analysis, concomitant mitral surgery was an independent predictor of 1-year mortality after BEV explant (hazard ratio [HR] 2.00, 95% confidence interval [CI]: 1.07-3.72) and SEV explant (HR 2.00, 95% CI: 1.08-3.69).

CONCLUSIONS

In the EXPLANT-TAVR global registry, BEV and SEV groups had different indications for surgical explantation, with more root replacements in SEV failure, but no differences in midterm mortality and morbidities. Further refinement of TAVR explantation techniques are important to improving outcomes.

Balloon- vs Self-Expanding Transcatheter Valves for Failed Small Surgical Aortic Bioprostheses: 1-Year Results of the LYTEN Trial

BACKGROUND

Data comparing valve systems in the valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) field have been obtained from retrospective studies.

OBJECTIVES

The authors sought to compare the 1-year hemodynamic performance and clinical outcomes between balloon-expandable valves (BEV) SAPIEN 3/ULTRA (Edwards Lifesciences) and self-expanding valves (SEV) Evolut R/PRO/PRO+ (Medtronic) in ViV-TAVR.

METHODS

Patients with a failed small (≤23 mm) surgical valve undergoing ViV-TAVR were randomized to receive a SEV or a BEV. Patients had a clinical and valve hemodynamic (Doppler echocardiography) evaluation at 1-year follow-up. Study outcomes were defined according to VARC-2/VARC-3 criteria. Intended performance of the valve was defined as mean gradient <20 mm Hg, peak velocity <3 m/s, Doppler velocity index ≥0.25 and less than moderate AR.

RESULTS

A total of 98 patients underwent ViV-TAVR (46 BEV, 52 SEV). At 1-year follow-up, patients receiving a SEV had a lower mean transaortic gradient (22 ± 8 mm Hg BEV vs 14 ± 7 mm Hg SEV; P < 0.001), and a higher rate of intended valve performance (BEV: 30%, SEV:76%; P < 0.001). There were no cases of greater than mild aortic regurgitation. There were no differences in functional status (NYHA functional class >II, BEV: 7.3%, SEV: 4.1%; P = 0.505) or quality of life (Kansas City Cardiomyopathy Questionnaire, BEV: 77.9 ± 21.2, SEV: 81.8 ± 14.8; P = 0.334). No differences in all-cause mortality (BEV: 6.5%, SEV: 3.8; P = 0.495), heart failure hospitalization (BEV: 6.5%, SEV: 1.9%; P = 0.214), stroke (BEV: 0%, SEV: 1.9%; P = 0.369), myocardial infarction (BEV: 0%, SEV: 1.9%; P = 0.347), or pacemaker implantation (BEV: 2.2%, SEV: 1.9%; P = 0.898) were found.

CONCLUSIONS

In patients who underwent ViV-TAVR for failed small aortic bioprostheses, those receiving a SEV exhibited a better valve hemodynamic profile at 1-year follow-up. There were no differences between SEV and BEV regarding functional status, quality of life, or clinical outcomes.

Investigating the safety and efficacy of nerve stimulation for management of groin pain after surgical herniorrhaphy: a systematic review and meta-analysis

PURPOSE

Chronic post-operative inguinal pain (CPIP) following inguinal hernia repair has been a major sequela affecting 4000-48000 patients annually. Optimal management of CPIP has been a challenge, and pharmacological management particularly with opioids has shown unsatisfactory results. The main objective of this systematic review is to investigate the safety and efficacy of neuromodulation as an alternative intervention for the management of post-operative inguinal pain.

METHODS

A literature search was conducted by three reviewers to identify all relevant studies on the use of neuromodulatory interventions for treating post-operative inguinal pain. Data on study characteristics, neuromodulatory modalities, and patient's clinical data such as pre/post-interventional pain scores and analgesic requirements were extracted and reported.

RESULTS

A total of 389 patients with 357 (95.9%) males and 15 (4.1%) females were evaluated. The mean age of study participants was 47.9 ± 10.4 years. There were 187 (48.1%) and 202 (51.9%) patients allocated to the control and trial groups, respectively. The most common neuromodulation modality was TENS (4, 36.4%), followed by SCS (3, 27.3%), PNS (3, 27.3%), and acupuncture-assisted (2, 18.2%). The overall mean follow-up duration of the entire cohort was 3.8 months. The mean difference between pre-operative and post-operative VAS scores in the trial groups was 4.65 (95% Confidence Interval [CI], 2.97, 6.33), which was statistically significant (P value < 0.05). Patient-reported outcome measures showed significant responsiveness toward their treatments.

CONCLUSION

Nerve stimulation, in its many forms, is a safe and feasible option for the management of post-operative inguinal pain.

Angina in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

INTRODUCTION AND OBJECTIVES

To evaluate the prevalence, clinical characteristics, and outcomes of patients with angina undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis.

METHODS

A total of 1687 consecutive patients with severe aortic stenosis undergoing TAVR at our center were included and classified according to patient-reported angina symptoms prior to the TAVR procedure. Baseline, procedural and follow-up data were collected in a dedicated database.

RESULTS

A total of 497 patients (29%) had angina prior to the TAVR procedure. Patients with angina at baseline showed a worse New York Heart Association (NYHA) functional class (NYHA class> II: 69% vs 63%; P=.017), a higher rate of coronary artery disease (74% vs 56%; P <.001), and a lower rate of complete revascularization (70% vs 79%; P <.001). Angina at baseline had no impact on all-cause mortality (HR, 1.02; 95%CI, 0.71-1.48; P=.898) and cardiovascular mortality (HR, 1.2; 95%CI, 0.69-2.11; P=.517) at 1 year. However, persistent angina at 30 days post-TAVR was associated with increased all-cause mortality (HR, 4.86; 95%CI, 1.71-13.8; P=.003) and cardiovascular mortality (HR, 20.7; 95%CI, 3.50-122.6; P=.001) at 1-year follow-up.

CONCLUSIONS

More than one-fourth of patients with severe aortic stenosis undergoing TAVR had angina prior to the procedure. Angina at baseline did not appear to be a sign of a more advanced valvular disease and had no prognostic impact; however, persistent angina at 30 days post-TAVR was associated with worse clinical outcomes.

Long-term echocardiographic data, mechanisms of failure, and reintervention outcomes of the Epic valve in mitral position-a large observational cohort

OBJECTIVES

Long-term echocardiographic reports on mitral valve (MV) porcine xenograft bioprosthesis (Epic) are lacking, and postreintervention outcomes of failed Epic are unknown. We aimed to assess the mechanisms and independent predictors of Epic failures and to compare short- and mid-term outcomes according to reintervention type.

METHODS

We included consecutive patients (n = 1397; mean age: 72 ± 8 years; 46% female; mean follow-up: 4.8 years) who received the Epic during mitral valve replacement (MVR) at our institution. Clinical, echocardiographic, reintervention, and outcomes data were retrieved from our prospective institution's database or government statistics.

RESULTS

Gradients and effective orifice area of the Epic were stable over 5-years follow-up. A total of 70 (5%) patients had a MV reintervention at median follow-up of 3.0 (0.7-5.4) years due to prosthesis failure, by redo-MVR (n = 38; 54%), valve-in-valve (n = 19; 27%), paravalvular leak (PVL) closure (n = 12; 17%), or thrombectomy (n = 1). Mechanisms of failure were 27 (1.9%) structural valve deterioration (SVD; all leaflet tear); 16 (1.1%) non-SVD (15 PVL, 1 pannus); 24 (1.7%) endocarditis; and 4 (0.3%) thrombosis. Freedom from all-cause and SVD-related MV reintervention at 10 years are 88% and 92%, respectively. Independent predictors of reintervention were age, baseline atrial fibrillation, initial MV etiology, and moderate or greater PVL at discharge (all P ≤ .05). Comparison of redo-MVR and valve-in-valve revealed no significant difference in early outcomes or mid-term mortality (all P ≥ .16).

CONCLUSIONS

The Epic Mitral valve has stable hemodynamics through 5 years and is associated with low incidence of SVD and reintervention, mostly due to endocarditis and leaflet tear without calcification. Reintervention type had no influence on early outcomes and mid-term mortality.

Is Transcatheter Aortic Valve Replacement Futile in Patients Over Ninety Years of Age?

Background

Clinical outcomes and quality of life (QoL) indices are not well described after transcatheter aortic valve replacement (TAVR) in patients aged ≥ 90 years.

Methods

We conducted a retrospective cohort study of TAVR among nonagenarian patients between 2008 and 2020. The survival of TAVR patients among nonagenarians was compared to the provincial estimated survival for an age- and sex-matched general population. QoL was assessed up to 1 year postintervention, using standardized questionnaires.

Results

During the study period, n = 268 patients aged ≥ 90 years were evaluated for severe aortic stenosis. TAVR was performed in n = 171 (48% female; median [IQR] Rockwood Clinical Frailty Scale score: 4 [3-4]); n = 84 underwent medical therapy; and n = 13 underwent surgical aortic valve replacement. Survival was significantly better following TAVR, compared to that after MT (adjusted hazard ratio [95% CI]: 1.99 [1.37-2.88], P < 0.001). TAVR patients demonstrated a survival advantage compared with the general population, with an estimated relative mortality of 0.86 (0.75-0.87). TAVR patients showed sustained improvements in functional status and QoL up to 1 year compared to baseline (all P < 0.05): the 6-minute walk test results improved from 192 to 252 m; the Kansas City Cardiomyopathy Questionnaire score improved from 64 to 81; the Duke Activity Status Index score improved from 13 to 16; and the health state scale result of the Euro Quality of life - 5 Dimensions improved from 63% to 74%.

Conclusions

Nonagenarians undergoing TAVR experience a slightly better survival rate, compared to that of an age- and sex-matched general population, and they have significant improvements in functional status and several QoL indices following the procedure.

Cardiac Death After Transcatheter Aortic Valve Replacement With Contemporary Devices

BACKGROUND

The burden of cardiac death after transcatheter aortic valve replacement (TAVR), particularly from advanced heart failure (HF) and sudden cardiac death (SCD), remains largely unknown.

OBJECTIVES

This study sought to evaluate the incidence and predictors of SCD and HF-related death in TAVR recipients treated with newer-generation devices.

METHODS

This study included a total of 5,421 consecutive patients who underwent TAVR with newer-generation devices using balloon (75.7%) or self-expandable (24.3%) valves.

RESULTS

After a median follow-up of 2 (IQR: 1-3) years, 976 (18.0%) patients had died, 50.8% from cardiovascular causes. Advanced HF and SCD accounted for 11.6% and 7.5% of deaths, respectively. Independent predictors of HF-related death were atrial fibrillation (HR: 2.17; 95% CI: 1.47-3.22; P < 0.001), prior pacemaker (HR: 1.79; 95% CI: 1.10-2.92; P = 0.01), reduced left ventricular ejection fraction (HR: 1.08 per 5% decrease; 95% CI: 1.01-1.14; P = 0.02), transthoracic approach (HR: 2.50; 95% CI: 1.37-4.55; P = 0.003), and new-onset persistent left bundle branch block (HR: 1.85; 95% CI: 1.14-3.02; P = 0.01). Two baseline characteristics (diabetes, HR: 1.81; 95% CI: 1.13-2.89; P = 0.01; and chronic kidney disease, HR: 1.72; 95% CI: 1.02-2.90; P = 0.04) and 3 procedural findings (valve in valve, HR: 2.17; 95% CI: 1.01-4.64; P = 0.04; transarterial nontransfemoral approach, HR: 2.23; 95% CI: 1.23-4.48; P = 0.01; and periprocedural ventricular arrhythmia, HR: 7.19; 95% CI: 2.61-19.76; P < 0.001) were associated with an increased risk of SCD after TAVR.

CONCLUSIONS

Advanced HF and SCD accounted for a fifth of deaths after TAVR in contemporary practice. Potentially treatable factors leading to increased risk of HF deaths and SCD were identified, such as arrhythmia/dyssynchrony factors for HF and valve-in-valve TAVR or periprocedural ventricular arrhythmias for SCD.

Incidence, Predictors, and Prognostic Impact of Bleeding Events After TAVR According to VARC-3 Criteria

BACKGROUND

The updated Valve Academic Research Consortium (VARC) definition for bleeding events after transcatheter aortic valve replacement (TAVR) lacks of clinical validation.

OBJECTIVES

The aim of this study was to determine the incidence, predictors, and clinical impact of bleeding events following TAVR as defined by recent VARC-3 criteria.

METHODS

A total of 2,384 consecutive patients with severe symptomatic aortic stenosis undergoing TAVR were included. Early (at index hospitalization) and late (after hospital discharge) bleeding complications were defined according to VARC-3 criteria as type 1, 2, 3, or 4. Baseline, procedural, and follow-up (24 [IQR: 12-43] months) data were prospectively collected.

RESULTS

Bleeding events occurred in 761 patients (31.9%): types 1, 2, 3, and 4 in 169 (22.2%), 399 (52.4%), 149 (19.6%), and 44 (5.8%) patients, respectively. The primary vascular access site and gastrointestinal locations were the most common bleeding sources among early and late bleeding events, respectively. Female sex, thoracotomy access, larger (14-F) sheath use, and dual antiplatelet therapy determined an increased risk of early bleeding events (P < 0.02 for all). The use of the radial artery for secondary access was associated with a significant risk reduction of early bleeding (P < 0.001). Type 2 and type 3 events were associated with an increased mortality risk at 30-day (HR: 2.94 [95% CI: 1.43-6.03; P = 0.003] and HR: 4.91 [95% CI: 2.19-11.03; P < 0.001], respectively) and 1-year (HR: 1.86 [95% CI: 1.28-2.69; P = 0.001] and HR: 2.28 [95% CI: 1.41-3.66; P = 0.001], respectively) follow-up. A similar prognostic pattern was observed when applying VARC-2 criteria but with a much lower global incidence of early bleeding events (19% vs 27%; P < 0.001).

CONCLUSIONS

Bleeding events after TAVR were associated with poorer short- and long-term survival. The magnitude of this correlation was proportional to bleeding severity defined according to VARC-3 criteria. Further studies on bleeding prevention following TAVR are warranted to improve procedural safety and patient prognosis.

Mid-term clinical and echocardiographic results of the INSPIRIS RESILIA aortic valve: a retrospective comparison to the Magna Ease

OBJECTIVES

The INSPIRIS aortic valve combines the RESILIA proprietary tissue preservation process and an expandable stent frame to benefit future transcatheter valve-in-valve procedures. As the INSPIRIS valve became commercially available in 2017, mid-term outcome reports are scarce. We aimed to evaluate mid-term safety and echocardiographic performance of the INSPIRIS valve in comparison to its predecessor, the Carpentier Edwards Perimount Magna Ease (ME).

METHODS

This study was a retrospective single-centre study. Clinical results included early postoperative outcomes, mid-term mortality and readmission for cardiovascular cause or stroke. Echocardiographic follow-up (FU) was performed at discharge and 1-3, 6, 12 and 24 months. Clinical end point analyses were accomplished with a propensity score matching analysis and FU echocardiographic data comparisons using pairwise analyses and linear mixed-effect models.

RESULTS

We included 953 patients who received an INSPIRIS (n = 488) or ME (n = 463) bioprosthesis between January 2018 and July 2021. In the matched population (n = 217 per group), no significant difference in short-term outcomes was observed, survival was similar at 30 months (INSPIRIS: 94% vs ME: 91%, P = 0.89), but freedom from readmission was higher in the INSPIRIS group (94% vs 86%, P = 0.014). INSPIRIS valves had a lower gradient at discharge (∼10 vs 14 mmHg, P < 0.001), 1-3 months (∼10 vs 12 mmHg, P < 0.001) and 24 months (∼11 vs 17 mmHg, P < 0.001) in paired analyses and significantly lower evolution of mean transvalvular gradients compared to ME.

CONCLUSIONS

This study represents the largest comparative evaluation of the INSPIRIS to the ME valves, which demonstrated safe clinical outcomes and favourable haemodynamic performance at 2 years. Long-term FU is underway.

Fractional Flow Reserve to Assess Coronary Artery Disease in Patients with Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation: Long-Term Outcomes

Background

The long-term outcomes of patients undergoing functional assessment of coronary lesions with fractional flow reserve (FFR) while awaiting transcatheter aortic valve implantation (TAVI) are unknown. Data on the safety of intracoronary adenosine use in this setting are scarce. The objectives of this study were to describe (1) the long-term outcomes based on the coronary artery disease (CAD) assessment strategy used and (2) the safety of intracoronary adenosine in patients with severe aortic stenosis (AS).

Methods

1023 patients with severe AS awaiting TAVI were included. Patients were classified according to their CAD assessment strategy: angiography guided or FFR guided. Patients were further subdivided according to the decision to proceed with percutaneous coronary intervention (PCI): angiography-guided PCI (375/1023), angiography-guided no-PCI (549/1023), FFR-guided PCI (50/1023), and FFR-guided no-PCI (49/1023). Patients were followed up for the occurrence of major adverse cardiac and cerebrovascular events (MACCEs).

Results

At a mean follow-up of 33.7 months, we observed no significant differences in terms of major adverse cardiovascular and cerebrovascular events (MACCE) in the angiography-guided group (42.4%) compared with the FFR-guided group (37.4%) (p = 0.333). When comparing outcomes of the FFR-guided no-PCI group (32.7%) with the angiography-guided PCI group (46.4%), no significant difference was noted (p = 0.999). Following intracoronary adenosine, a single adverse event occurred.

Conclusions

In this population, intracoronary adenosine is safe and well tolerated. We found no significant benefit to an FFR-guided strategy compared with an angiography-guided strategy with respect to MACCEs. Although clinically compelling, avoiding the procedural risks of PCI by deferring the intervention in functionally insignificant lesions failed to show a statistically significant benefit.

Syncope in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

No data exist on the clinical and prognostic significance of syncope in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis.

METHODS

A total of 1705 consecutive patients with severe aortic stenosis undergoing TAVR in a tertiary university centre between 2007 and 2021 were included and classified according to the presence of syncope before the TAVR procedure. Baseline, procedural, and follow-up data were collected prospectively in a dedicated database.

RESULTS

A total of 115 patients (7%) presented with syncope before the TAVR procedure. Of these, 15 patients (13%) showed arrhythmic episodes as the probable cause of the syncope, and all of them had pacemakers implanted at a median of 13 (6 to 53) days before the TAVR procedure. Patients with syncope were older (82 ± 8 years vs 80 ± 8 years, P = 0.001) and had a higher rate of pacemaker implantation before the TAVR procedure (27% vs 14%, P < 0.001), with no differences between groups regarding the severity of aortic stenosis (transvalvular gradient, valve area). There were no differences between groups in 30-day (adjusted hazard ratio [HR], 1.28; 95% confidence interval [CI], 0.46-3.60) and 1-year (adjusted HR, 0.71; 95% CI, 0.0.35-1.45) mortality following TAVR.

CONCLUSIONS

Syncope was not associated with a more advanced valvular disease and had no significant prognostic impact on patients undergoing TAVR. However, arrhythmias and conduction-system disturbances were more common in patients with previous syncope and might play a relevant role in the pathogenesis of syncope in patients with aortic stenosis.

Managing the challenge of a small aortic annulus in patients with severe aortic stenosis

INTRODUCTION

Small aortic annulus (SAA) poses a challenge in the management of patients with severe aortic stenosis requiring aortic valve replacement - both surgical and transcatheter - since it has been associated with worse clinical outcomes.

AREAS COVERED

This review aims to comprehensively summarize the available evidence regarding the management of aortic stenosis in patients with SAA and discuss the current controversies as well as future perspectives in this field.

EXPERT OPINION

It is paramount to agree in a common definition for diagnosing and properly treating SAA patients, and for that purpose, multidetector computer tomography is essential. The results of recent trials led to the expansion of transcatheter aortic valve replacement among patients of all the surgical-risk spectrum, and the choice of treatment (transcatheter, surgical) should be based on patient comorbidities, anatomical characteristics, and patient preferences.

Myocardial Injury After Transcatheter Aortic Valve Replacement According to VARC-3 Criteria

BACKGROUND

The Valve Academic Research Consortium (VARC)-3 definition for myocardial injury after transcatheter aortic valve replacement (TAVR) lacks of clinical validation.

OBJECTIVES

This study sought to determine the incidence, predictors, and clinical impact of periprocedural myocardial injury (PPMI) following TAVR as defined by recent VARC-3 criteria.

METHODS

We included 1,394 consecutive patients who underwent TAVR with a new-generation transcatheter heart valve. High-sensitivity troponin levels were assessed at baseline and within 24 hours after the procedure. PPMI was defined according to VARC-3 criteria as an increase ≥70 times in troponin levels (vs ≥15 times according to the VARC-2 definition). Baseline, procedural, and follow-up data were prospectively collected.

RESULTS

PPMI was diagnosed in 193 (14.0%) patients. Female sex and peripheral artery disease were independent predictors of PPMI (P < 0.01 for both). PPMI was associated with a higher risk of mortality at 30-day (HR: 2.69, 95% CI: 1.50-4.82; P = 0.001) and 1-year (for all-cause mortality, HR: 1.54; 95% CI: 1.04-2.27; P = 0.032; for cardiovascular mortality, HR: 3.04; 95% CI: 1.68-5.50; P < 0.001) follow-up. PPMI according to VARC-2 criteria had no impact on mortality.

CONCLUSIONS

About 1 out of 10 patients undergoing TAVR in the contemporary era had PPMI as defined by recent VARC-3 criteria, and baseline factors like female sex and peripheral artery disease determined an increased risk. PPMI had a negative impact on early and late survival. Further studies on the prevention of PPMI post-TAVR and implementing measures to improve outcomes in PPMI patients are warranted.

Preoperative physical frailty assessment among octogenarians undergoing cardiac surgery: Upgrading the "eyeball" test

OBJECTIVES

There are many well-described, but as yet unproven, physical ability tools to assess frailty. The objective of this study was to evaluate the effectiveness of 4 preoperative physical tests in predicting mortality, morbidity, and functional outcomes among octogenarians undergoing cardiac surgery.

METHODS

Between 2016 and 2019, 200 patients aged 80 years or more undergoing elective cardiac surgery were prospectively recruited. Four physical tests were performed preoperatively: 5-m walk time, timed up-and-go, 5 time sit-to-stand, and handgrip strength tests. The primary end point was a composite of in-hospital mortality, neurologic, and pulmonary complications. Multivariate analysis was performed.

RESULTS

In-hospital mortality was 1.5%. Slow performance on the 5-m walk test (time ≥6.4 seconds) was the only independent predictor of the composite end point among the tests evaluated (odds ratio, 2.70; 95% confidence interval, 1.34-5.45; P = .006). At follow-up, patients with a slow 5-m walk test had a significantly lower midterm survival compared with patients with a normal test result (1-year survival 91.5% vs 98.7%, log-rank P = .03). Mean Physical and Mental Component Scores of the 12-item short form survey were 47.2 ± 8.3 and 53.6 ± 5.9, respectively, which are comparable to those of a general population aged more than 75 years.

CONCLUSIONS

The 5-m walk time test is an independent predictor of a composite of in-hospital mortality and major morbidity, as well as midterm survival. This test could be used as a simple adjunctive preoperative tool for octogenarians undergoing cardiac surgery.

Effect of High-Dose Selenium on Postoperative Organ Dysfunction and Mortality in Cardiac Surgery Patients: The SUSTAIN CSX Randomized Clinical Trial

Importance

Selenium contributes to antioxidative, anti-inflammatory, and immunomodulatory pathways, which may improve outcomes in patients at high risk of organ dysfunctions after cardiac surgery.

Objective

To assess the ability of high-dose intravenous sodium selenite treatment to reduce postoperative organ dysfunction and mortality in cardiac surgery patients.

Design, Setting, and Participants

This multicenter, randomized, double-blind, placebo-controlled trial took place at 23 sites in Germany and Canada from January 2015 to January 2021. Adult cardiac surgery patients with a European System for Cardiac Operative Risk Evaluation II score-predicted mortality of 5% or more or planned combined surgical procedures were randomized.

Interventions

Patients were randomly assigned (1:1) by a web-based system to receive either perioperative intravenous high-dose selenium supplementation of 2000 μg/L of sodium selenite prior to cardiopulmonary bypass, 2000 μg/L immediately postoperatively, and 1000 μg/L each day in intensive care for a maximum of 10 days or placebo.

Main Outcomes and Measures

The primary end point was a composite of the numbers of days alive and free from organ dysfunction during the first 30 days following cardiac surgery.

Results

A total of 1416 adult cardiac surgery patients were analyzed (mean [SD] age, 68.2 [10.4] years; 1043 [74.8%] male). The median (IQR) predicted 30-day mortality by European System for Cardiac Operative Risk Evaluation II score was 8.7% (5.6%-14.9%), and most patients had combined coronary revascularization and valvular procedures. Selenium did not increase the number of persistent organ dysfunction-free and alive days over the first 30 postoperative days (median [IQR], 29 [28-30] vs 29 [28-30]; P = .45). The 30-day mortality rates were 4.2% in the selenium and 5.0% in the placebo group (odds ratio, 0.82; 95% CI, 0.50-1.36; P = .44). Safety outcomes did not differ between the groups.

Conclusions and Relevance

In high-risk cardiac surgery patients, perioperative administration of high-dose intravenous sodium selenite did not reduce morbidity or mortality. The present data do not support the routine perioperative use of selenium for patients undergoing cardiac surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT02002247.

Clinical impact of the heart team on the outcomes of surgical aortic valve replacement among octogenarians

OBJECTIVES

The effectiveness of a multidisciplinary heart team in the management of patients with severe symptomatic aortic stenosis is unknown. This study evaluated the impact of a heart team on the outcomes of surgical aortic valve replacement in octogenarians.

METHODS

Between May 2007 and January 2016, 528 patients aged 80 years or more were referred to our institutional heart team for a transcatheter aortic valve replacement. Among these, 101 were redirected to surgical aortic valve replacement (heart team group). These patients were compared with a surgical aortic valve replacement cohort (n = 506) without prior heart team screening (non-heart team group), taken from the same time period. Propensity score matching with bootstrap analysis was performed; 76 heart team patients were matched to 76 non-heart team patients. Early and late outcomes including survival and readmission for cardiovascular causes were compared.

RESULTS

Matched subgroups were largely comparable; congestive heart failure and echocardiographic pulmonary hypertension were more prevalent in the heart team group. In-hospital mortality was significantly lower in the matched heart team group (0% vs 6.0%, bootstrap mean difference 6.0%, 95% confidence interval, 2.2-9.8). The risk of stroke, low cardiac output state, reexploration for bleeding, pneumonia, and prolonged ventilation was also significantly lower in the heart team group. There was no significant between-group difference regarding late survival (hazard ratio, 0.86, 95% confidence interval, 0.55-1.33, P = .49) or readmission for cardiovascular reasons (hazard ratio, 0.70, 95% confidence interval, 0.41-1.20, P = .19).

CONCLUSIONS

Preoperative multidisciplinary assessment of octogenarians by a heart team was associated with lower in-hospital mortality and adverse events after surgical aortic valve replacement.

Prosthetic choice in mitral valve replacement for severe chronic ischemic mitral regurgitation: Long-term follow-up

BACKGROUND

Prosthetic choice for mitral valve replacement is generally driven by patient age and patient and surgeon preference, and current guidelines do not discriminate between different etiologies of mitral valve disease. Our objective was to assess and compare short- and long-term outcomes after mitral valve replacement among patients with biological or mechanical prostheses in the setting of severe ischemic mitral regurgitation.

METHODS

Between 2000 and 2016, 424 patients underwent mitral valve replacement for severe ischemic mitral regurgitation at our institution, using biological prosthesis in 188 (44%) and mechanical prosthesis in 236 (56%). A 1:1 propensity score match (n = 126 per group) and inverse probability of treatment weighting were used to compare groups. Short-term outcomes included in-hospital mortality and other cardiovascular adverse events. Long-term outcomes included survival and hospital readmission for cardiovascular causes, stroke, and major bleeding.

RESULTS

In-hospital mortality and early postoperative adverse events were similar between groups in the propensity score match and inverse probability of treatment weighting cohorts. Overall long-term survival was similar at 5 and 9 years, but mechanical prosthesis recipients were more frequently readmitted to hospital for cardiovascular causes, including stroke and non-neurological bleeding in propensity score matching and inverse probability of treatment weighting analyses (all P values < .004). Type of prosthesis did not independently influence all-cause mortality (hazard ratio, 1.01; 95% confidence interval, 0.71-1.43; P = .959), but placement of a mechanical prosthesis was associated with increased risk of readmission for cardiovascular events (hazard ratio, 1.65; 95% confidence interval, 1.17-2.32; P = .004) among matched patients.

CONCLUSIONS

The type of prosthesis has no influence on long-term survival among patients with severe ischemic mitral regurgitation undergoing mitral valve replacement. There may be an increased risk of neurologic events and serious bleeding associated with mechanical prostheses.

New-onset persistent left bundle branch block following sutureless aortic valve replacement

OBJECTIVE

To evaluate the incidence, predictive factors and prognostic value of new-onset persistent left bundle branch block (NOP-LBBB) in patients undergoing sutureless surgical aortic valve replacement (SU-SAVR).

METHODS

A total of 329 consecutive patients without baseline conduction disturbances or previous permanent pacemaker implantation (PPI) who underwent SU-SAVR with the Perceval valve (LivaNova Group, Saluggia, Italy) in two centres from 2013 to 2019 were included. Patients were on continuous ECG monitoring during hospitalisation and 12-lead ECG was performed after the procedure and at hospital discharge. NOP-LBBB was defined as a new postprocedural LBBB that persisted at hospital discharge. Baseline, procedural and follow-up clinical and echocardiography data were collected in a dedicated database.

RESULTS

New-onset LBBB was observed in 115 (34.9%) patients, and in 76 (23.1%) persisted at hospital discharge. There were no differences in baseline and procedural characteristics between patients with (n=76) and without (n=253) NOP-LBBB. After a median follow-up of 3.3 years (2.3-4.4 years), patients with NOP-LBBB had a higher incidence of PPI (14.5% vs 6.3%, p=0.016), but exhibited similar rates of all-cause mortality (19.4% vs 19.2%, p=0.428), cardiac mortality (8.1% vs 9.4%, p=0.805) and heart failure readmission (21.0% vs 23.2%, p=0.648), compared with the no/transient LBBB group. NOP-LBBB was associated with a decrease in left ventricular ejection fraction (LVEF) at 1-year follow-up (delta: -5.7 vs +0.2, p<0.001).

CONCLUSIONS

NOP-LBBB occurred in approximately a quarter of patients without prior conduction disturbances who underwent SU-SAVR and was associated with a threefold increased risk of PPI along with a negative impact on LVEF at follow-up.

Incidence and clinical impact of tachyarrhythmic events following transcatheter aortic valve replacement: A review

Transcatheter aortic valve replacement (TAVR) is well established for treating severe symptomatic aortic stenosis. Whereas broad information on the epidemiology, clinical implications, and management of bradyarrhythmias after TAVR is available, data about tachyarrhythmic events remain scarce. Despite the progressively lower risk profile of TAVR patients and the improvement in device characteristics and operator skills, approximately 10% of patients develop new-onset atrial fibrillation (NOAF) after TAVR. The proportion of patients in whom NOAF actually corresponds to previously undiagnosed silent atrial fibrillation (AF) has not been properly determined. The transapical approach, the need for pre- or post- balloon dilation, and the presence of periprocedural complications have been associated with a higher risk of NOAF. Older age, left atrial volume, or worse functional class are patient-derived risk factors shared with preprocedural AF. NOAF after TAVR has been associated with poorer survival and a higher incidence of cerebrovascular events. However, patient management differs markedly among different centers, especially with regard to anticoagulation in patients with short-duration AF episodes detected in the periprocedural setting and in cases of silent NOAF detected during continuous electrocardiographic (ECG) monitoring. Evidence about ventricular arrhythmias is even more scarce than for AF. Some case reports of sudden cardiac death after TAVR in patients with a pacemaker have identified ventricular tachycardia or ventricular fibrillation in device interrogation. TAVR has been shown to reduce the arrhythmic burden, but a significant proportion of patients (16%) present with complex premature ventricular complex arrhythmias within the year after TAVR. Whether these events are related to poorer outcomes is unknown. Continuous ECG monitoring after TAVR may help describe the frequency, risk factors, and prognostic implications of tachyarrhythmias in this population.

Macroscopic and microscopic features of surgically explanted transcatheter aortic valve prostheses

OBJECTIVES

With the extended indications of transcatheter aortic valve (TAV) replacement (TAVR) to lower-risk patients, there is an increasing number of patients requiring surgical explantation of failed TAV. We sought to describe macroscopic and microscopic features of surgically explanted percutaneous aortic valve prostheses.

METHODS

Preoperative and surgical characteristic of patients undergoing surgical explantation of TAV were retrospectively analyzed from 2007 to 2020. Surgical and pathologic features of these valves, and outcomes of the surgical valve replacement were described.

RESULTS

Out of 1764 patients who underwent a TAVR procedure, 21 were operated for TAV failure. Isolated or combined indications for surgery included: significant paravalvular leak (n = 15), delayed prosthesis migration (n = 5), significant increase of trans-TAV gradients (n = 6), and endocarditis (n = 3). Mean time elapsed between TAVR and explantations was 674.9 ± 803.9 days. Macroscopic lesions found on explanted percutaneous valves were severe adhesions to the aorta (n = 10), calcifications (n = 7), leaflet thrombosis (n = 4), and vegetations (n = 3). Except for patients with endocarditis, one or more pathological lesions were found in 15 patients. Pathology analyses on these valves showed fibro-calcific degenerations (n = 12), pannus formation (n = 9), and chronic inflammation (n = 3). One patient (4.8%) died after surgical explantation, and 13 (61.9%) had concomitant procedures. The survival rate at 1 year was 94.4%.

CONCLUSIONS

Microscopic findings of fibro-calcific leaflet degeneration, and pannus formation in addition to macroscopic calcification and thrombosis present early, (within a mean of 2 years) after TAVR. Further investigation with a higher number of patients and echocardiographic follow-up is warranted.

From the Evolut Pro to the Evolut FX self-expanding transcatheter aortic valve replacement systems: current status and future perspectives

INTRODUCTION

Since the initial experience with the CoreValve (Medtronic, Minneapolis, Minnesota), there have been continuous iterations of this valve system in order to improve procedural success and reduce periprocedural complications. The Evolut Pro, Pro+, and FX are the latest generations of this transcatheter heart valve (THV).

AREAS COVERED

This review paper aims to analyze the main characteristics and clinical evidence about the Evolut Pro THV and summarize the main iterations of the newer generation Evolut FX valve system.

EXPERT OPINION

The Evolut Pro system has been associated with good clinical outcomes and excellent valve hemodynamic performance including reduced rates of paravalvular leaks. Technical enhancements to improve valve positioning, orientation, and vascular access have been implemented in the newer generation Evolut FX system.

Transcatheter versus surgical aortic valve replacement in patients with morbid obesity: a multicentre propensity score-matched analysis

BACKGROUND

Morbidly obese (MO) patients are increasingly undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS). However, the best therapeutic strategy for these patients remains a matter for debate.

AIMS

Our aim was to compare the periprocedural and mid-term outcomes in MO patients undergoing TAVR versus SAVR.

METHODS

A multicentre retrospective study including consecutive MO patients (body mass index ≥40 kg/m², or ≥35 kg/m² with obesity-related comorbidities) from 18 centres undergoing either TAVR (n=860) or biological SAVR (n=696) for severe AS was performed. Propensity score matching resulted in 362 pairs.

RESULTS

After matching, periprocedural complications, including blood transfusion (14.1% versus 48.1%; p<0.001), stage 2-3 acute kidney injury (3.99% versus 10.1%; p=0.002), hospital-acquired pneumonia (1.7% versus 5.8%; p=0.005) and access site infection (1.5% versus 5.5%; p=0.013), were more common in the SAVR group, as was moderate to severe patient-prosthesis mismatch (PPM; 9.9% versus 39.4%; p<0.001). TAVR patients more frequently required permanent pacemaker implantation (14.4% versus 5.6%; p<0.001) and had higher rates of ≥moderate residual aortic regurgitation (3.3% versus 0%; p=0.001). SAVR was an independent predictor of moderate to severe PPM (hazard ratio [HR] 1.80, 95% confidence interval [CI]: 1.25-2.59; p=0.002), while TAVR was not. In-hospital mortality was not different between groups (3.9% for TAVR versus 6.1% for SAVR; p=0.171). Two-year outcomes (including all-cause and cardiovascular mortality, and readmissions) were similar in both groups (log-rank p>0.05 for all comparisons). Predictors of all-cause 2-year mortality differed between the groups; moderate to severe PPM was a predictor following SAVR (HR 1.78, 95% CI: 1.10-2.88; p=0.018) but not following TAVR (p=0.737).

CONCLUSIONS

SAVR and TAVR offer similar mid-term outcomes in MO patients with severe AS, however, TAVR offers some advantages in terms of periprocedural morbidity.

Should Bilateral Internal Thoracic Arteries be Used in Patients with Chronic Kidney Disease?

Preoperative renal dysfunction is a major determinant of operative and long-term mortality following cardiac surgery. The objective of this study was to assess early and long-term results of CABG in patients with preoperative chronic kidney disease (CKD) using a bilateral internal thoracic artery (BITA) strategy, compared to those without CKD. We retrospectively analyzed data for 2,111 consecutive patients who underwent CABG with BITA between 2000 and 2019. One-to-many propensity score matching was performed to produce a cohort of 132 patients with CKD (defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2), matched to 358 patients with normal renal function (non-CKD). The primary end-point of interest was late freedom from all-cause mortality. Late hospital readmissions were also assessed. Mean eGFR and serum creatinine were: 49.8 versus 84.3 mL/min/m2 and 146.1 versus 83.6 µmol/L (CKD vs non-CKD, P< 0.001). In-hospital outcomes were similar among matched patients, including mortality (CKD 0.8% vs non-CKD 0%, P= 0.31). At a median follow-up of 6.9 years, there was no significant difference in survival between both groups (hazard ratio (HR) 1.37, 95% confidence interval (CI) 0.87-2.16, P= 0.17). Hospital readmission for cardiovascular causes (including repeat coronary revascularization) was comparable between the 2 groups. However, the risk of hospital readmission for renal causes was higher in patients with CKD (6.7%) compared to non-CKD (1.2%). In a propensity score-matched cohort of patients undergoing BITA-CABG, CKD was not associated with increased early or late mortality, nor was there a greater risk of hospital readmission for cardiovascular events.

Incidence, Predictors and Prognostic Value of Permanent Pacemaker Implantation Following Sutureless Valve Implantation in Low-Risk Aortic Stenosis Patients

OBJECTIVES

SU-SAVR has been associated with higher rates of permanent pacemaker (PPM) compared with conventionally implanted aortic bioprostheses. The purpose of this study was to determine the incidence, predictors and mid-term prognostic impact of PPM after Perceval (Livanova, London, UK) SU-SAVR in low-risk patients.

METHODS

A total of 400 consecutive low-risk (EuroSCORE II < 4%) patients without prior pacemaker who underwent SAVR with the Perceval prosthesis from 2013 to 2019 in two centres were included. Baseline, clinical and electrocardiographic parameters, procedural characteristics, and follow-up data were collected.

RESULTS

PPM was required in 36 (9%) patients after SU-SAVR, with a median time between the procedure and PPM implantation of 7.5 (4.5-10.5) days. Older age and prior right bundle branch block (RBBB) were associated with an increased risk of PPM (p < 0.05 for all), but only baseline RBBB was found to be an independent predictor of new PPM requirement (Odds ratio: 2.60, 95% confidence interval: 1.15-5.81; p = 0.022). At a median follow-up of 3.4 (2.3-4.5) years, there were no differences between groups in mortality (PPM: 36%, no PPM: 22%, p = 0.105) or heart failure rehospitalization (PPM: 25%, no PPM: 21%, p = 0.839).

CONCLUSIONS

About 1 out of 10 low-risk patients with aortic stenosis undergoing SU-SAVR with the Perceval prosthesis required PPM implantation. Prior RBBB determined an increased risk (close to 3 times) of PPM following the procedure. PPM was not associated with a higher risk of clinical events at 3-year follow-up.

Balloon- Versus Self-Expanding Valve Systems for Treating Small Failed Surgical Aortic Bioprostheses: The LYTEN Trial

BACKGROUND

Data comparing valve systems in the valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) field has been obtained from retrospective studies.

OBJECTIVES

To compare the hemodynamic results between the balloon-expandable SAPIEN (3/ULTRA) (BEV) and self-expanding Evolut (R/PRO/PRO+) (SEV) valves in ViV-TAVR.

METHODS

Patients with a failed small (≤23 mm) surgical valve. were randomized to receive a BEV or a SEV. The primary endpoint was valve hemodynamics (maximal/mean residual gradients; severe prosthesis patient mismatch [PPM] or moderate-severe aortic regurgitation [AR]) at 30 days as evaluated by Doppler-echocardiography.

RESULTS

A total of 102 patients were randomized, and of these, 98 patients finally underwent a ViV-TAVR procedure (BEV: 46, SEV: 52). The procedure was successful in all cases, with no differences in clinical outcomes at 30 days between groups (no death or stroke events). Patients in the SEV group exhibited lower mean and maximal transvalvular gradient values (15±8 vs 23±8 mmHg, p˂0.001; 28±16 vs 40±13 mmHg, p ˂0.001), and a tendency towards a lower rate of severe PPM (44% vs. 64%, p=0.07). There were no cases of moderate-severe AR. 55 consecutive patients (SEV: 27, BEV: 28) underwent invasive valve hemodynamic evaluation during the procedure, with no differences in mean and peak transvalvular gradients between both groups (p=0.41 and p=0.70, respectively).

CONCLUSIONS

In patients with small failed aortic bioprostheses, ViV-TAVR with a SEV was associated with improved valve hemodynamics as evaluated by echocardiography. There were no differences between groups in intra-procedural invasive valve hemodynamics and 30-day clinical outcomes (NCT03520101).

Aortic Pseudoaneurysm After Type A Aortic Dissection: Results of Conservative Management

Aortic pseudoaneurysms after acute Type A aortic dissection (ATAAD) repair have been reported as high as 10-24% and surgical treatment is usually recommended. The objective of this article is to examine the safety and efficacy of a conservative approach to aortic pseudoaneurysm and to compare this approach to standard surgical treatment. We retrospectively examined 39 patients who had an aortic pseudoaneurysm after ATAAD surgery in order to examine outcomes (baseline characteristics, presentation and freedom from aortic events and mortality). We initially identified 31 patients treated conservatively (CT). After close follow up, 5 of them were operated so 13 patients were treated surgically (ST) and analyzed at a long-term follow-up while 26 were in the conservative group. Mean follow- - up of the whole cohort was 7.9 ± 5.9 years. The freedom from aortic-related mortality at 1, 5, and 10 years was 100%, 83.3% and 72.9% for the ST group and 95.8%, 77.3%, and 77.3% for the CT group (P = 0.35). A conservative approach to aortic pseudoaneurysms could be justified in asymptomatic patients. A close follow-up by a dedicated aortic clinic is mandatory so that patients are referred for surgery when necessary.

Late Access Site Complications Following Transfemoral Aortic Valve Implantation

Few data exist on late vascular complications (VCs) after transfemoral (TF) transcatheter aortic valve implantation (TAVI). The objective of this study was to evaluate the incidence and predictors of late access site VC after TF TAVI. A total of 128 patients (mean age: 80 ± 8 years, women: 52%) who underwent TF TAVI without major VC were included. A femoral US-Doppler evaluation was performed in all patients at a median of 5 (3 to 15) months after the procedure, and 76 patients (59.4%) also had a preprocedural ultrasound (US)-Doppler examination. The impact of baseline and procedural factors (including the use of simple 2 Proglides or complex additional Proglide or Angioseal device on top of the 2 Proglide technique, hemostasis techniques, and the use of balloon dilation for optimizing femoral hemostasis) were evaluated. The follow-up US-Doppler evaluation detected 2 asymptomatic VCs (1.6%), and 5 (3.9%) patients exhibited significant femoral stenosis (peak systolic velocity [PSV] ≥300 cm/s). Female gender (p <0.001) and smaller femoral diameter (p = 0.045) were associated with higher femoral PSV values. In those patients who underwent a pre-TAVI femoral US-Doppler, the median PSV values after TAVI were higher compared with those obtained pre-TAVI (p <0.001), but similar results were found for the contralateral femoral arteries. A complex hemostasis technique or the use of balloon optimization at the puncture site was not associated with any increase in PSV values. In conclusion, percutaneous femoral hemostasis after TAVI was associated with a low rate of late VC. The results were similar irrespective of the hemostasis technique and the use of balloon dilation at the puncture site, but women and a smaller femoral size were associated with increased PSV values. Further studies are needed to determine the optimal femoral hemostasis technique in TAVI procedures.

Tomographic phase and attenuation extraction for a sample composed of unknown materials using x-ray propagation-based phase-contrast imaging

Propagation-based phase-contrast x-ray imaging (PB-PCXI) generates image contrast by utilizing sample-imposed phase-shifts. This has proven useful when imaging weakly attenuating samples, as conventional attenuation-based imaging does not always provide adequate contrast. We present a PB-PCXI algorithm capable of extracting the x-ray attenuation  β and refraction  δ, components of the complex refractive index of distinct materials within an unknown sample. The method involves curve fitting an error-function-based model to a phase-retrieved interface in a PB-PCXI tomographic reconstruction, which is obtained when Paganin-type phase retrieval is applied with incorrect values of δ and β. The fit parameters can then be used to calculate true δ and β values for composite materials. This approach requires no a priori sample information, making it broadly applicable. Our PB-PCXI reconstruction is single-distance, requiring only one exposure per tomographic angle, which is important for radiosensitive samples. We apply this approach to a breast-tissue sample, recovering the refraction component  δ, with 0.6-2.4% accuracy compared with theoretical values.

Unplanned Hospital Readmissions After Transcatheter Aortic Valve Replacement in the Era of New-Generation Devices

OBJECTIVES

Unplanned hospital readmissions after transcatheter aortic valve replacement (TAVR) are frequent and have been associated with a poor prognosis. We sought to determine the trends in the incidence and causes of unplanned hospital readmission after TAVR in patients receiving new-generation devices (NGDs) vs early-generation devices (EGDs).

METHODS

The study population consisted of 1802 consecutive TAVR recipients (863 EGDs and 939 NGDs). Early and late readmissions were defined as those occurring ≤30 days and >30 days to 1-year post TAVR, respectively.

RESULTS

A total of 986 unplanned hospital readmissions (cardiac cause, 38.4%; non-cardiac cause, 61.6%) were recorded at a median time of 110 days (interquartile range [IQR], 37-217) post TAVR. The rates of early (12.3% vs 9.4%; P=.046) and late (39.1% vs 31.6%; P<.01) readmission were lower in the NGD population. In the NGD group, major/life-threatening periprocedural bleeding (hazard ratio [HR], 2.40, 95% confidence interval [CI], 1.06-5.42; P=.04) and estimated glomerular filtration rate (eGFR) <60 mL/min at hospital discharge (HR, 1.80; 95% CI, 1.15-2.83; P=.01) were associated with an increased risk of early readmission post TAVR. Chronic obstructive pulmonary disease (HR, 1.42; 95% CI, 1.07-1.88; P=.02), eGFR <60 mL/min (HR, 1.43; 95% CI, 1.11-1.84; P<.01), and combining antiplatelet and anticoagulation therapy (HR, 1.37; 95% CI, 1.01-1.85; P=.04) determined an increased risk of late readmission.

CONCLUSIONS

TAVR recipients receiving NGDs exhibited a significant but modest reduction in unplanned hospital readmissions, with about one-third of patients still requiring rehospitalization at 1-year follow-up in the contemporary TAVR era. Non-cardiac comorbidities, periprocedural bleeding events, and intensive antithrombotic therapy determined an increased risk.

Cranial nerve injury during transcarotid transcatheter aortic valve replacement

BACKGROUND

No data exist about cranial nerve injury (CNI) as a potential complication of transcarotid (TC) transcatheter valve replacement (TAVR).

METHODS

This monocentric study included 318 consecutive patients undergoing TC-TAVR from May 2015 to August 2021.

RESULTS

CNI occurred in 7 (2.2%) TAVR-TC patients. Five out of the 7 patients (71.4%) had an injury of the laryngeal branch of the vagus nerve, and 2 patients (28.6%) had an injury of the facial nerve. The majority of patients were male (85.7%), with high body mass index (35.6 (IQR: 30.1-37.3) kg/m2). The induced disabilities were clinically important especially for patients with dysphonia.

CONCLUSIONS

CNI is a potential complication of TC-TAVR likely avoidable by a meticulous surgical technique. Structural heart teams must be aware of this serious setback.

Design and validation of a tool to assess the safety principles of working with nanomaterials in nanotechnology laboratories

Introduction: The unique properties of nanomaterials, in addition to their applications in science and technology, can be a threat to human health and the environment. Exposure to these materials may occur in workplaces or research laboratories. It can be said that about half of people with occupational exposure to nanomaterials work in academic environments and laboratories. So, the present study was conducted to design and validate a tool to investigate the principles of working safely with nanomaterials in research laboratories. Materials & Methods: The tool was designed using reports, instructions and articles related to " Methods of working safely with nanomaterials". The validity of the tool was assessed using Lawshe method by calculating CVI and CVR. The reliability of the instrument was evaluated using Cronbach's alpha coefficient and kappa coefficient. Results: The tool was designed in 5 sections: "General Information", "Transportation and Storage of Nanomaterials", "Engineering Controls", "Administrative Controls" and "Personal Protection Equipment". After validation, 5 items did not get the necessary points to stay in the tool and were removed. The Cronbach's alpha value for each section of the tool was more than 0.80, indicating that the was "appropriate". Conclusion: According to the results, it seems that the tool studied in this study is compatible for the designed purpose and is ready to be used as a questionnaire or checklist.