Valve-in-valve transcatheter aortic valve implantation: The issues behind crossing a bioprosthesis

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing.

[Management of patent foramen ovale in non-cardiac surgery]

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Rheumatic diseases in migrant patients resident in Tuscany: epidemiological data analysis and single-center experience

OBJECTIVE

In the last decades, the number of foreigners in Tuscany has considerably increased with a multiethnic distribution. We reviewed the main rheumatic diseases in the foreign population resident in Tuscany and also reported the experience at the Rheumatology Division of the University Hospital of Careggi, Florence, in order to identify the areas of origin of these patients and the main rheumatic diseases observed in them.

METHODS

The collaboration with the Tuscan Region provided data about foreign patients residing in Tuscany on January 1, 2021 (country of origin, chronic diseases). Moreover, we conducted a retrospective review of the clinical charts of our Rheumatologic Division from January 1, 2019, to December 31, 2020.

RESULTS

In Tuscany, on January 1, 2021, there were 61,373 patients with chronic inflammatory rheumatic diseases, and 3994 of them (6.51%) were foreigners. Most patients were born in Europe (39.03%), followed by the Balkans (15%), South America (11.27%), and North Africa (10.31%). Inflammatory joint diseases, Sjögren syndrome, and systemic lupus erythematosus were the most frequent diseases. In the period 2019-2020, 511 foreign patients visited our Rheumatology Division and mainly originated from the Balkans (34.64%), South America (18%), and European countries (16.44%). In these patients, chronic inflammatory joint diseases and connective tissue diseases (systemic sclerosis, Sjögren syndrome, and systemic lupus erythematosus) were the most prevalent diseases.

CONCLUSIONS

This study provides a picture of the rheumatic diseases affecting foreign patients residing in Tuscany that are in agreement with the epidemiological data previously provided.

Characterisation of coronary microvascular dysfunction in patients with severe aortic stenosis undergoing TAVI

BACKGROUND

Microvascular resistance reserve (MRR) is a validated measure of coronary microvascular function independent of epicardial resistances.

AIMS

We sought to assess whether MRR is associated with adverse cardiac remodelling, a low-flow phenotype and extravalvular cardiac damage (EVCD) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

METHODS

Invasive thermodilution-based assessment of the coronary microvascular function of the left anterior descending artery was performed in a prospective, multicentre cohort of patients undergoing TAVI. Coronary microvascular dysfunction (CMD) was defined as the lowest MRR tertile of the study cohort. Haemodynamic measurements were performed at baseline and then repeated immediately after TAVI. EVCD and markers of a low-flow phenotype were assessed with echocardiography.

RESULTS

A total of 134 patients were included in this study. Patients with low MRR were more frequently females, had a lower estimated glomerular filtration rate and a higher rate of atrial fibrillation. MRR was significantly lower in patients with advanced EVCD (median 1.80 [1.26-3.30] vs 2.50 [1.87-3.41]; p=0.038) and in low-flow, low-gradient AS (LF LG-AS) (median 1.85 [1.20-3.04] vs 2.50 [1.87-3.40]; p=0.008). Overall, coronary microvascular function tended to improve after TAVI and, in particular, MRR increased significantly after TAVI in the subgroup with low MRR at baseline. However, MRR was significantly impaired in 38 (28.4%) patients immediately after TAVI. Advanced EVCD (adjusted odds ratio 3.08 [1.22-7.76]; p=0.017) and a low-flow phenotype (adjusted odds ratio 3.36 [1.08-10.47]; p=0.036) were significant predictors of CMD.

CONCLUSIONS

In this observational, hypothesis-generating study, CMD was associated with extravalvular cardiac damage and a low-flow phenotype in patients with severe AS undergoing TAVI.

Impact of balloon post-dilation on valve durability and long-term clinical outcomes after self-expanding transcatheter aortic valve implantation

BACKGROUND

Balloon post-dilation (BPD) is a widely adopted strategy to optimize acute results of TAVI, with a positive impact on both paravalvular leak and mean gradients. On the other hand, the inflation of the balloon inside prosthetic leaflets may damage them increasing the risk of structural valve deterioration (SVD). Furthermore, the impact of BPD on long-term clinical outcomes and valve hemodynamics is yet unknown.

AIMS

To evaluate the impact of BPD on valve durability and long-term clinical outcomes in patients undergoing self-expanding transcatheter valve implantation (TAVI).

METHODS

Echocardiographic and clinical data from the ClinicalService (a nation-based data repository and medical care project) were analyzed. Patients were divided into two groups, those who underwent BPD after TAVI and those who did not. Coprimary endpoints were all-cause death and SVD. Cumulative incidence functions for SVD were estimated.

RESULTS

Among 1835 patients included in the study, 417 (22.7%) underwent BPD and 1418 (77.3%) did not undergo BPD. No statistically significant differences at 6-year follow-up were found between groups in terms of all-cause mortality (HR: 1.05, 95% CI: 0.9-1.22; p = 0.557) and SVD (2.1% vs. 1.4%, p = 0.381). In addition, BPD did not predispose to higher risk of cardiovascular death, myocardial infarction, valve thrombosis, and endocarditis at 6-year follow-up.

CONCLUSIONS

BPD following TAVI with a self-expanding prosthesis does not seem to be associated with an increased risk of adverse clinical outcomes or SVD at 6-year follow-up.

Direct oral anticoagulants versus percutaneous left atrial appendage occlusion in atrial fibrillation: 5-year outcomes

BACKGROUND

LAAO is an emerging option for thromboembolic event prevention in patients with NVAF. We previously reported data on comparison between LAAO and DOAC at two-year follow-up in NVAF patients at HBR (HAS-BLED ≥3).

AIMS

Limited data are available on long term follow-up. We aimed to evaluate the efficacy and safety of DOACs versus LAAO indication after 5 years.

METHODS

We enrolled 193 HBR treated with LAAO and 189 HBR patients with DOACs. At baseline, LAAO group had higher HAS-BLED (4.2 vs 3.3, p < 0.001) and lower CHADS-VASc (4.3 vs. 4.7, p = 0.005). After 1:1 PSM, 192 patients were included (LAAO n = 96; DOACs n = 96).

RESULTS

At 5-year follow-up the rate of the combined safety and effectiveness endpoint (ISTH major bleeding and thromboembolic events) was significantly higher in LAAO group (p = 0.042), driven by a higher number of thromboembolic events (p = 0.047). The rate of ISTH-major bleeding events was similar (p = 0.221). After PSM no significant difference in the primary effectiveness (LAAO 13.3% vs DOACs 9.5%, p = 0.357) and safety endpoint (LAAO 7.5% vs DOACs 7.5%; p = 0.918) were evident. Overall bleeding rate was significantly higher in DOACs group (25.0% vs 13.7%, p = 0.048), while a non-significant higher number of TIA was reported in LAAO group (5.4% vs 1.1%, p = 0.098). All-cause and cardiovascular mortality were higher in LAAO group at both unmatched and matched analysis.

CONCLUSION

We confirmed safety and effectiveness of both DOAC and LAAO in NVAF patients at HBR, with no significant differences in thromboembolic events or major bleeding were at 5-year follow-up. The observed increased mortality after LAAO warrants further investigations in RCTs.

Ischemia With No Obstructive Coronary Artery Disease: Are Misdiagnosis and Undertreatment Always Behind the Corner?

Ischemia with no obstructive coronary artery disease (INOCA) is not an uncommon diagnosis in patients presenting with chest pain who undergo clinically indicated coronary angiography. However, the symptoms reported by patients with INOCA may be heterogeneous, leading to misdiagnosis and undertreatment. Herein we report 3 clinical cases of INOCA misdiagnosis and describe how the cases were reinvestigated following the appropriate diagnostic pathway. (Level of Difficulty: Advanced.).

Collateral presence and extent do not predict myocardial viability and ischemia in chronic total occlusions: A stress-CMR study

BACKGROUND

Well-developed collaterals are assumed as a marker of viability and ischemia in chronic total occlusions (CTO). We aim to correlate viability and ischemia with collateral presence and extent in CTO patients by cardiac magnetic resonance (CMR).

METHODS

Multicentre study of 150 CTO patients undergoing stress-CMR, including adenosine if normal systolic function, high-dose-dobutamine for patients with akinetic/>2 hypokinetic segments and EF ≥35%, otherwise low-dose-dobutamine (LDD); all patients underwent late gadolinium enhancement (LGE) imaging. Viability was defined as mean LGE transmurality ≤50% for adenosine, as functional improvement for dobutamine-stress-test, ischemia as ≥1.5 segments with perfusion defects outside the scar zone.

RESULTS

Rentrop 3/CC 2 defined well-developed (WD, n = 74) vs poorly-developed collaterals (PD, n = 76). Viability was equally prevalent in WD vs PD: normo-functional myocardium with ≤50% LGE in 52% vs 58% segments, p = 0.76, functional improvement by LDD in 48% vs 52%, p = 0.12. Segments with none, 1-25%,26-50%,51-75% LGE showed viability by LDD in 90%,84%,81%,61% of cases, whilst in 12% if 76-100% LGE (p < 0.01). There was no difference in WD vs PD for ischemia presence (74% vs 75%, p = 0.99) and extent (2.7 vs 2.8 segments, p = 0.77).

CONCLUSIONS

In a large cohort of CTO patients, presence and extent of collaterals did not predict viability and ischemia by stress-CMR. Scar extent up to 75% LGE was still associated with viability, whereas ischemia was undetectable in 25% of patients, suggesting that the assessment of CTO patients with CMR would lead to a more comprehensive evaluation of viability and ischemia to guide revascularization.

Sex-Specific Considerations in Degenerative Aortic Stenosis for Female-Tailored Transfemoral Aortic Valve Implantation Management

The impact of sex on pathophysiological processes, clinical presentation, treatment options, as well as outcomes of degenerative aortic stenosis remain poorly understood. Female patients are well represented in transfemoral aortic valve implantation (TAVI) trials and appear to derive favorable outcomes with TAVI. However, higher incidences of major bleeding, vascular complications, and stroke have been reported in women following TAVI. The anatomical characteristics and pathophysiological features of aortic stenosis in women might guide a tailored planning of the percutaneous approach. We highlight whether a sex-based TAVI management strategy might impact on clinical outcomes. This review aimed to evaluate the impact of sex from diagnosis to treatment of degenerative aortic stenosis, discussing the latest evidence on epidemiology, pathophysiology, clinical presentation, therapeutic options, and outcomes. Furthermore, we focused on technical sex-oriented considerations in TAVI including the preprocedural screening, device selection, implantation strategy, and postprocedural management.

Grade 3 coronary artery perforations in chronic total occlusion-percutaneous coronary intervention: Mechanisms, locations, and outcomes from the G3CAP Registry

AIM

The impact of Grade III coronary perforations (G3-CP) in the setting of CTO-PCI is not well assessed.

METHODS AND RESULTS

We reviewed 7773 CTO-PCI and 98,819 non CTO-PCI performed in 10 European centers: G3 perforation occurred in 87 patients (1.1%) during CTO PCI and 224 patients (0.22%) during non CTO-PCI (p < 0.001). G3-CP involved the CTO segment in 68% of patients and the retrograde channels in 14% of cases. In the CTO PCI group, wire induced G3-CP (50.5% vs. 32.5%, p = 0.02) occurred predominantly when dedicated CTO tapered and highly penetrative wires were used. Intra-procedural and in-hospital death rates were 4.6% vs. 5.8% and 3.6% vs. 7.5% respectively for CTO PCI and non-CTO PCI groups (p = NS). At a median follow up of 24 months, the overall mortality and MAE were respectively 7.8% and MAE 19% without difference among groups.

CONCLUSIONS

We showed similar in-hospital and long-term outcomes when G3 perforations occurred during CTO PCI and non CTO-PCI.

C31 UPDATE ON SUPRA–ANNULAR SIZING OF TRANSCATHETER AORTIC VALVE PROSTHESES IN RAPHE–TYPE BICUSPID AORTIC VALVE DISEASE ACCORDING TO THE LIRA METHOD

Aims

Recent evidences have shown that transcatheter heart valve (THV) anchoring in BAV patients might occur at the raphe–level, known as the LIRA (Level of Implantation at the RAphe) plane. A novel supra–annular sizing method based on the measurement of the perimeter at the raphe–level (LIRA–method) was shown to be safe and effective in 20 consecutive BAV patients with severe aortic stenosis. The purpose of this study was to confirm the safety and the efficacy of the LIRA method in a larger study population.

Methods

the LIRA plane method was applied to all consecutive patients with raphe–type BAV disease between November 2018 to October 2021 in our centre. We prospectively sized TAVI prosthesis according to the manufacture recommendations on the basis of baseline CT scan perimeters at the LIRA plane. Post–procedural device success, defined according to Valve Academic Research Consortium–2 (VARC–2) criteria, was evaluated in the overall cohort.

Results

50 patients were identified as having a raphe–type BAV disease at pre–TAVI CT scans. Mean patient age was 80 ± 6.2 years. Three different BAV anatomies (47 patients with BAV type 1 and 3 patients with BAV type 2) were implanted with different types of TAVI prostheses (28 Acurate Neo/Neo 2, 21 Core Valve Evolut R/Pro,1 Lotus) sized prospectively according to the LIRA plane method. In all patients, there was a significant discrepancy between LIRA and virtual basal ring (VBR) (mean perimeter LIRA 73.1 ± 8.3 mm vs mean perimeter VBR 81.5 ± 6.6 mm; p &lt; 0.001). The median prosthesis size was 26 mm (23–27). Pre–dilatation was frequently performed (88%) with a median balloon size of 20 mm (20–23), whereas post–dilatation was applied in 26% of the cases with a median balloon size of 23 mm (22–24). The LIRA plane method appeared to be highly successful (100% VARC–2 device success) with no procedural mortality, no valve migration, residual trivial/mild paravalvular leak with no cases of moderate–severe regurgitation and no cases of mean gradient &gt;20 mmHg pre–discharge. The rate of new pacemaker implantation was 10%.

Conclusions

Supra–annular sizing according to the LIRA plane method confirmed to be safe with a high device success in a larger study population. The application of the LIRA plane method might optimize TAVI prosthesis sizing in patients with raphe–type BAV disease.

Update on supra-annular sizing of transcatheter aortic valve prostheses in raphe-type bicuspid aortic valve disease according to the LIRA method

Recent evidence has shown that transcatheter heart valve (THV) anchoring in bicuspid aortic valve (BAV) patients occurs at the level of the raphe, known as the LIRA (Level of Implantation at the RAphe) plane. Our previous work in a cohort of 20 patients has shown that the delineation of the perimeter and device sizing at this level is associated with optimal procedural outcome. The goals of this study were to confirm the feasibility of this method, evaluate 30-day outcomes of LIRA sizing in a larger cohort of patients, assess interobserver variation and reproducibility of this sizing methodology, and analyse the interaction of LIRA-sized prostheses with the surrounding anatomy. The LIRA sizing method was applied to consecutive patients presenting to our centre with raphe-type BAV disease between November 2018 and October 2021. Supra-annular self-expanding THVs were sized based on baseline CT scan perimeters at the LIRA plane and the virtual basal ring. In cases where there was discrepancy between the two measurements, the plane with the smallest perimeter was considered the reference for prosthesis sizing. Post-procedural device success, defined according to Valve Academic Research Consortium-2 (VARC-2) criteria, was evaluated in the overall cohort. A total of 50 patients (mean age 80 ± 6 years, 70% male) with raphe-type BAV disease underwent transcatheter aortic valve replacement (TAVR) using different THV prostheses. The LIRA plane method appeared to be highly successful (100% VARC-2 device success) with no procedural mortality, no valve migration, no moderate-severe paravalvular leak, and low transprosthetic gradients (residual mean gradient 8.2 ± 3.4 mmHg). There were no strokes, no in-hospital or 30-day mortality, and an incidence of in-hospital pacemaker implantation of 10%. Furthermore, measurement of the LIRA plane perimeter was highly reproducible between observers (r = 0.980; P < 0.001) and predictive of the post-procedural prosthetic valve perimeter on CT scanning (r = 0.981; P < 0.001). We confirm the feasibility of supra-annular sizing using the LIRA method in a large cohort of patients with high procedural success and good clinical outcomes at 30 days. Application of the LIRA method optimizes THV prosthesis sizing in patients with raphe-type BAV disease.

467 Update on supra-annular sizing of transcatheter aortic valve prostheses in raphe-type bicuspid aortic valve disease according to the LIRA method

Aims

Transcatheter Aortic Valve Replacement (TAVR) in patients with bicuspid aortic valve (BAV) still represents a challenge due to the peculiar anatomy and the lack of consensus for the optimal CT scan sizing method for prosthesis selection. Recent evidences have shown that transcatheter heart valve (THV) anchoring in BAV patients might occur at the raphe-level, known as the LIRA (Level of Implantation at the RAphe) plane. Furthermore, a novel supra-annular sizing method based on the measurement of the perimeter at the raphe-level (LIRA-method) was shown to be safe and effective in 20 consecutive BAV patients with severe aortic stenosis. The purpose of this study was to confirm the safety and the efficacy of the LIRA method in a larger study population.

Methods and results

the LIRA plane method was applied to all consecutive patients with raphe-type BAV disease between November 2018 to September 2021 in our centre. We prospectively sized TAVI prosthesis according to the manufacture recommendations on the basis of baseline CT scan perimeters at the LIRA plane. Post-procedural device success, defined according to Valve Academic Research Consortium-2 (VARC-2) criteria, was evaluated in the overall cohort. Forty-four patients were identified as having a raphe-type BAV disease at pre-TAVI CT scans. Mean patient age was 80 ± 6.2 years and 74% were males; median Society of Thoracic Surgeons (STS) predicted risk of mortality score was 4.3 (3.0–6.5). Three different BAV anatomies (36 patients with BAV type 1 with calcific raphe, 5 patients with BAV type 1 with fibrotic raphe, and 3 patients with BAV type 2) were implanted with different types of TAVI prostheses (6 Acurate Neo 2,16 Acurate Neo, 21 Core Valve Evolut R/Pro , 1 Lotus) sized prospectively according to the LIRA plane method. In all patients, there was a significant discrepancy between LIRA and virtual basal ring (VBR) measurements with LIRA plane perimeter smaller than VBR perimeter (mean perimeter LIRA 73.1 ± 8.3 mm vs. mean perimeter VBR 81.5 ± 6.6 mm; P &lt; 0.001). The prostheses were sized according to the manufacture recommendations on the basis of the LIRA plane perimeter (diameter prosthesis implanted/diameter prosthesis according to LIRA plane = 1) (DPI/DP LIRA = 1) and significantly downsized according to the VBR perimeter (DPI/DP VBR 0.89; P &lt; 0.001). The median prosthesis size was 25 mm (23–27). Pre-dilatation was frequently performed (86%) with a median balloon size of 20 mm (18–22), whereas post-dilatation was applied in 27% of the cases with a median balloon size of 23 mm (20–26). The LIRA plane method appeared to be highly successful (100% VARC-2 device success) with no procedural mortality, no valve migration, residual trivial/mild paravalvular leak with no cases of moderate-severe regurgitation and low transprosthetic gradient (residual mean gradient of 8.3 ± 3.5 mmHg) with no cases of mean gradient &gt;20 mmHg pre-discharge. The rate of new pacemaker implantation was 9%.

Conclusions

Supra-annular sizing according to the LIRA plane method confirmed to be safe with a high device success in a larger study population. The application of the LIRA plane method might optimize TAVI prosthesis sizing in patients with raphe-type BAV disease.

Patients younger than 70 undergoing transcatheter aortic valve implantation: Procedural outcomes and mid-term survival

INTRODUCTION

Based on recent data, the indication for transcatheter aortic valve implantation (TAVI) is expanding to individuals at lower surgical risk, who are generally younger than subjects historically treated for severe aortic stenosis. Indeed, younger patients have traditionally been under-represented in current TAVI literature. The aim of the present study is to report about clinical features, procedural outcomes and mid-term outcomes of patients younger than 70 who underwent TAVI in a single high-volume center.

MATERIALS AND METHODS

Consecutive patients younger than 70 years of age who underwent TAVI for severe, symptomatic aortic stenosis between 2007 and 2019 at a single, tertiary referral center have been included in this retrospective study. Procedural and mid-term outcomes were analyzed, comparing 1st generation with 2nd generation devices.

RESULTS

Between 2007 and 2019, 1740 TAVI procedures were performed in our center. Among these, one hundred twenty-nine (7.4%) patients were younger than 70 years at the time of the intervention and were included in the present analysis. Fifty-eight patients (45%) were implanted with a 1st generation prosthesis while seventy-one patients (55%) were implanted with a 2nd generation device. Reasons which lead to a transcatheter approach in this population were: previous CABG (27.9%); porcelain aorta (24%); severe left ventricular systolic dysfunction (21.7%); prior chest radiation (19.4%); severe lung disease (8.5%); hemodynamic instability (7.0%); advanced liver disease (4.6%) and active cancer (3.9%). Overall device success rate was 89%, with no differences among 1st and 2nd generation devices. Threeyears all-cause mortality was 34%, with no difference among the two groups. Low incidence of aortic-valve re-intervention was observed at mid-term follow-up (late valve re-intervention = 2.3%).

CONCLUSIONS

TAVI in young patient with appropriate indication for intervention is a safe procedure, associated with low rate of in hospital mortality and low rate of severe complications both with 1st and with 2nd generation devices. When considering long term durability, more data are needed; in our case series long-term follow up shows a good survival and also an extremely low rate of valve re-intervention.

Incidence, Management, Immediate and Long-Term Outcome of Guidewire and Device Related Grade III Coronary Perforations (from G3CAP - Cardiogroup VI Registry)

Ellis grade III coronary artery perforations (G3-CAP) remain a life-threatening complication of percutaneous coronary intervention (PCI), with high morbidity and mortality and lack of consensus regarding optimal treatment strategies. We reviewed all PCIs performed in 10 European centers from 1993 to 2019 recording all G3-CAP along with management strategies, in-hospital and long-term outcome according to Device-related perforations (DP) and Guidewire-related perforations (WP). Among 106,592 PCI (including 7,773 chronic total occlusions), G3-CAP occurred in 311 patients (0.29%). DP occurred in 194 cases (62.4%), more commonly in proximal segments (73.2%) and frequently secondary to balloon dilatation (66.0%). WP arose in 117 patients (37.6%) with chronic total occlusions guidewires involved in 61.3% of cases. Overall sealing success rate was 90.7% and usually required multiple maneuvers (80.4%). The most commonly adopted strategies to obtain hemostasis were prolonged balloon inflation (73.2%) with covered stent implantation (64.4%) in the DP group, and prolonged balloon inflation (53.8%) with coil embolization (41%) in the WP group.  Procedural or in-hospital events arose in 38.2% of cases: mortality was higher after DP (7.2% vs 2.6%, p = 0.05) and acute stent thrombosis 3-fold higher (3.1% vs 0.9%, p = 0.19). At clinical follow-up, median 2 years, a major cardiovascular event occurred in one-third of cases (all-cause mortality 8.2% and 7.1% respectively, without differences between groups). In conclusion, although rare and despite improved rates of adequate perforation sealing G3-CAP cause significant adverse events. DP and WP result in different patterns of G3-CAP and management strategies should be based on this classification.

Intravascular Ultrasound-Guided Coronary Lithotripsy Treatment of In-Stent Restenosis in Saphenous Venous Graft

To the best of our knowledge, this is the first description of intravascular-ultrasound guided coronary lithotripsy on saphenous vein graft because of severely calcific in-stent restenosis, showing good result without procedural complications.

Self-expanding transcatheter aortic valve infolding: Current evidence, diagnosis, and management

BACKGROUND

Prosthetic valve infolding is a rare but severe complication of transcatheter aortic valve implantation (TAVI) with self-expanding valves. However, currently available clinical data are limited and fragmented.

OBJECTIVES

This report aims to provide a comprehensive overview of this complication focusing on predisposing factors, clinical presentation, diagnostic findings, treatment and clinical outcomes.

METHODS

A systematic review of the literature was performed to identify cases of infolding occurring during TAVI with self-expanding valves published until August 2020. These data were pooled with all the retrospectively identified infolding cases occurred at San Raffaele Scientific Institute between December 2014 and August 2020.

RESULTS

A total of 34 cases were included. Among patients with available data, 38% received a first-generation CoreValve, and 62% a second-generation Evolut R (82%) or Evolut PRO (18%). Infolding occurred mostly with ≥29-mm valves (94%). Predisposing factors included resheathing of a second-generation valve (82%), heavy calcification of the native valve (65%), lack of predilatation (16%), Sievers type-1 bicuspid aortic valve (11%), and improper valve loading (5%). Infolding resulted in severe PVL causing hemodynamic instability (29%) or cardiac arrest (12%). Postdilatation was the treatment strategy in 68%, while prosthesis replacement with a new device in 23% of cases. Device success rate was 82%. Death and stroke occurred in 3% and 12% of cases.

CONCLUSIONS

Prosthetic valve infolding is typically observed after resheathing of a large-size self-expanding TAVI. When infolding is timely diagnosed, prosthesis removal and replacement should be pursued. Further studies are required to precisely define predisposing factors to prevent this complication.

TAVI durability

Background

TAVI (Transcatheter aortic valve implantation) is now established as the preferred treatment option for patients with symptomatic severe aortic stenosis at prohibitive or high surgical risk and its application is increasingly supported by an accumulating evidence base in patients at intermediate and low risk, but the issue of valve durability are still unsettled.

Purpose

To evaluate long-term clinical outcomes and bioprosthesis valve dysfunction after TAVI.

Methods

All patients treated with transfemoral TAVI, from November 2007 to December 2014 were analyzed. Baseline clinical, procedural and in-hospital outcomes were collected and revised. Clinical and echocardiographic follow-up was conducted either by clinic visits or telephone consultations. All definitions of the clinical endpoints and bioprosthesis valve failure used were in concordance with the Valve Academic Research Consortium 2 and the European Society of Cardiology consensus, respectively.

Results

Four hundred and eight patients were included in the analysis. Median follow-up was 2.733 days (7.5 years), with the longest follow-up at 4.096 days (11.2 years). At 7.5 years (IQR 5.4–9.3 years), all-cause mortality was 64.5% (n=263), of these cardiovascular death was adjudicated in 33.6% (n=137), non-cardiovascular death in 30.9% (n=126) and valve-related death was 1.9% (n=8). Structural valve deterioration occurred in 2.9% (n=12), non-structural valve deterioration in 0.2% (n=1), thrombosis in 2.2% (n=9) and endocarditis in 3.2% of patients (n=13). Fourteen patients (3.4%) required surgical (1.2%) or percutaneous (2.2%) aortic valve re-intervention.

Conclusions

Percutaneous aortic bioprosthesis demonstrated a low bioprosthesis valve failure at a median of 7.5 years of clinical follow-up after implantation, with low rate of degeneration or need of re-intervention. Overall mortality was high with acceptable rates of cardiovascular mortality and low rates of valve-related deaths.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): EAPCI Education and Training Grants

Complex Plug-Prosthesis Interaction During Percutaneous Closure of Mitral Paravalvular Leak: The Butterfly Effect

This case shows how interaction between imaging experts and interventionists allowed us to overcome the challenge of plug-prosthesis interaction in a complex procedure.

Impact of Left Ventricular Outflow Tract Calcification on Pacemaker Implantation After Transcatheter Aortic Valve Implantation With Second-Generation Devices

OBJECTIVE

To evaluate the impact of left ventricular outflow tract calcification (LVOT-CA) localization and extension on permanent pacemaker implantation (PPI) rates after transcatheter aortic valve implantation (TAVI) with second-generation devices.

METHODS

This single-center retrospective study included all consecutive patients who underwent transfemoral TAVI with second-generation devices at San Raffaele Hospital in Milan, Italy from January 2014 to June 2017. The localization and extension of LVOT-CA were evaluated using computed tomography imaging; LVOT regions were categorized according to the overlying coronary cusps.

RESULTS

The study population consisted of 377 patients, of which LVOT-CA was present in 133 patients (35.3%). Patients with LVOT-CA had significantly a higher rate of post-TAVI PPI (32.0% vs 19.2% in patients with no LVOT-CA; P<.01). Multivariable analysis demonstrated LVOT-CA in the non-coronary cusp, as well as preprocedural right bundle-branch block, age, body mass index, and mechanically expanded prosthesis implantation, to be strong independent predictors of PPI.

CONCLUSIONS

LVOT-CA in the non-coronary cusp is a strong independent predictor of PPI after TAVI with second-generation devices. Further studies are needed to confirm these data in a larger, multicenter population.

Multicenter experience with the antegrade fenestration and reentry technique for chronic total occlusion recanalization

OBJECTIVES

We aimed to evaluate the efficacy and safety of antegrade fenestration and reentry (AFR) for chronic total occlusion (CTO) recanalization in a multicenter registry.

BACKGROUND

Adoption of antegrade dissection/reentry (ADR) for CTO recanalization has been limited, and novel ADR techniques are needed.

METHODS

AFR involves the balloon-induced creation of multiple fenestrations between the false and true lumen. A targeted true lumen reentry is subsequently achieved with a low tip-load polymer-jacketed guidewire. Following the initial description and dissemination of AFR, patients undergoing AFR-based CTO recanalization at nine centers were included in the present registry. Study endpoints were AFR success, procedural success, and target-lesion failure (TLF) on follow-up.

RESULTS

We included 41 patients. Mean J-CTO score was 2.5 ± 1.4. In 80.5% of cases, AFR was performed after failed antegrade wire escalation. Another ADR technique was used before AFR in one-third of cases. AFR achieved distal true lumen reentry in n = 27/41 (65.9%) cases. In n = 14/41 (34.1%) cases with AFR failure, use of alternative techniques led to successful CTO recanalization in eight additional patients. The overall technical and procedural success rates were 85.4% and 82.9%, respectively. No AFR-related complications were observed. One-year TLF rate was 8.3% overall, with no differences between successful and failed AFR.

CONCLUSIONS

We report on AFR feasibility in a multicenter registry of patients undergoing CTO recanalization. We observed a moderate success rate, coupled with the absence of complications. Moreover, even a failed AFR attempt did not preclude the use of alternative techniques to achieve recanalization. Further studies should confirm and extend our findings.

Percutaneous mitral valve prostheses: 2019 update

During the last few years, there has been significant advances in the treatment of patients with severe mitral incompetence either too high risk for surgery or inoperable, this because of the improvements in percutaneous mitral valve prostheses, as alternative to the transcatheter mitral repair techniques. Percutaneous mitral valve replacement offers several advantages over the repair techniques, such as the opportunity to treat mitral valve with different anatomic characteristics, even the more complex ones, and the occasion to correct completely mitral regurgitation. The development of such prostheses has been a long process, still on the making. During the initial stages of the procedure, the transapical approach was preferred. On the other hand, the transseptal approach, which has already been used in some patients, is the proper development path for this transcatheter technique. Many valvular prostheses have been produced, each using a different mechanism for secure anchoring and elimination of regurgitation. Early mortality for this procedure, although decreasing since the preliminary studies, is still high, not only because the technology is still in its initial phase but also for the very high risk of the patients treated. It is foreseeable, though, that in the near future, as the technology and patients selection improves, better results will follow.

Percutaneous coronary intervention in aorto-ostial coronary chronic total occlusion: outcomes and technical considerations in a multicenter registry

INTRODUCTION AND OBJECTIVES

Percutaneous coronary intervention (PCI) for aorto-ostial chronic total coronary occlusion (CTO) can be a particularly challenging lesion subset. The aim of this study was to analyze the technical aspects and outcomes of aorto-ostial CTO PCI in a multicenter registry.

METHODS

Patients undergoing aorto-ostial CTO PCI at 4 centers between February 2013 and December 2018 were included. Success rates, as well as procedural aspects and outcomes, were analyzed.

RESULTS

A total of 103 patients were included. Mean age was 64±10 years and the mean J-CTO score was 3.1±1.1. Thirty-one lesions (30.4%) were flush ostial CTOs. Technical and procedural success were achieved in 79 (76.7%) and 78 (75.7%) of the patients, respectively. The retrograde approach was the most frequent successful crossing technique (n=49; 62.0%), especially in flush vs nonflush aorto-ostial CTOs (82.6% vs 53.5%; P=.02). The only variable independently associated with technical failure was the absence of interventional collaterals (OR, 12.38; 95%CI, 4.02-38.15; P <.001). Coronary perforation occurred in 4 patients (3.9%) requiring covered stent implantation (without subsequent cardiac tamponade) and 2 patients (1.9%) had a stroke (one of which was a transient ischemic attack). During a median follow-up of 31 months, 3 (2.9%) patients died from cardiovascular causes and 13 (12.6%) required repeat target vessel revascularization.

CONCLUSIONS

Aorto-ostial occlusions represent a challenging subset for PCI. However, an acceptable success rate with favorable outcomes during follow-up can be achieved by experienced operators. The presence of interventional collaterals allowing the use of the retrograde approach is key for achieving procedural success.

Rotational atherectomy-based percutaneous coronary intervention and the risk of contrast-induced nephropathy

BACKGROUND

Rotational atherectomy (RA)-related complications (e.g., no-reflow and perforation) may be associated with increased risk of contrast-induced nephropathy (CIN), causing hypotension, acute heart failure, and periprocedural myocardial infarction. Our aim was to evaluate the incidence of CIN in patients undergoing RA-based vs. non-RA-based percutaneous coronary intervention (PCI).

METHODS

This single-center retrospective registry included all patients who underwent PCI between 2012 and 2016 for whom post-procedural creatinine was determined. Study endpoint was CIN, defined as an increase of serum creatinine ≥0.3 mg/dL or ≥50% from baseline within 72 h post-PCI. Propensity score matching (PSM) was performed to account for selection bias between RA and non-RA patients.

RESULTS

Study population included 2580 patients: 70 (3%) had RA PCI and 2510 (97%) had non-RA PCI. Following PSM, there were 70 patients in RA and 280 patients in non-RA group with good overall adjustment between groups, although RA patients received larger contrast volume (263±126 vs. 224±118 mL, P=0.01) and showed higher Mehran risk score at baseline (11.1±6.6 vs. 8.9±4.8, P=0.01). The incidence of CIN was similar between RA and non-RA patients (15.7% vs. 13.2%, P=0.59). New need for dialysis was required in 0% vs. 0.7% patients, respectively (P=0.48). On multivariate analysis, RA PCI was not independently associated with development of CIN.

CONCLUSIONS

Despite being performed in patients with a higher burden of comorbidities and with larger volumes of contrast, RA PCI is not associated with higher risk of CIN, compared with PCI in non-RA patients.

Long-Term Outcomes of Chronic Total Occlusion Recanalization Versus Percutaneous Coronary Intervention for Complex Non-Occlusive Coronary Artery Disease

The durability of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is uncertain. We aimed to compare the long-term outcomes of CTO PCI with those of complex non-CTO PCI. We built a single-center registry including all patients who underwent CTO and complex non-CTO PCI between 2012 and 2017. Complex non-CTO PCI was defined as: 3 vessels treated, ≥3 stents implanted, total stent length >60 mm, saphenous vein graft intervention, 2-stent bifurcation intervention, left main PCI, protected PCI, or rotational/laser atherectomy. The primary endpoint was target-lesion failure, a composite of cardiac death, myocardial infarction, and target-lesion revascularization. A total of 2,396 patients were included (n=609 CTO PCI, n=1,787 complex non-CTO PCI). Patients who underwent CTO PCI were younger and had higher prevalence of cardiovascular comorbidities. CTO PCI patients exhibited worse procedural metrics and success rate (74% vs 98%, p <0.001). They also suffered a higher incidence of coronary perforation (3.5% vs 2.0%, p = 0.04) and cardiac tamponade (0.8% vs 0.1%, p = 0.001). However, there was no difference in the overall incidence of in-hospital major adverse cardiac and cerebrovascular events (4.1% vs 5.0%, p = 0.40). At 36 months, there were no differences in the incidence of target-lesion failure (10.1% vs 9.9%, p = 0.91) or its individual components, between the CTO and complex non-CTO group. This finding was confirmed on multivariable analysis. In conclusion, CTO PCI is associated with lower success rates and higher risk for coronary perforation and tamponade compared with complex non-CTO PCI. The incidence of other in-hospital and long-term adverse events is similar and reasonably low.

Sex and Transcatheter Aortic Valve Implantation: Impact of Female Sex on Clinical Outcomes

Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for severe symptomatic aortic stenosis in patients who are not suitable for surgery or are at high surgical risk. Approximately 50% of patients undergoing TAVI are female and this is reflected by a higher inclusion rate of women in TAVI trials. However, women undergoing TAVI have different baseline clinical characteristics in comparison to men, with fewer comorbidities and a more preserved left ventricular ejection fraction. This translates into favourable outcomes after TAVI, despite a higher rate of peri-procedural complications. This article discusses gender differences in terms of presentation, procedural characteristics and post-procedural results in patients with aortic stenosis undergoing TAVI, with particular focus on possible sex-specific factors affecting outcome.

Conventional vascular access site approach versus fully trans-wrist approach for chronic total occlusion percutaneous coronary intervention: a multicenter registry

OBJECTIVES

To evaluate the incidence of vascular complication and major bleeding in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with a fully trans-wrist access (TWA) approach versus a conventional approach based on trans-femoral access (TFA).

BACKGROUND

TFA is the preferred vascular access in CTO PCI, but it has been associated with a non-negligible risk of complications.

METHODS

This retrospective registry included all patients undergoing CTO PCI at five institutions between July 2011 and October 2018. Patients were divided into two groups: Conventional (patients treated with at least one TFA) and Fully TWA (subjects exclusively treated with one or two TWA). The primary safety endpoint was a composite of vascular complications and major bleeding. The primary efficacy endpoint was procedural success.

RESULTS

We included 1,900 patients (Conventional n = 1,496 and Fully TWA n = 404). Conventional patients showed higher occlusion complexity (J-CTO score 2.1 ± 1.2 vs. 1.5 ± 1.1, p < .001). Procedural success showed no significant difference between both groups (85.7 vs. 83.0%, p = .17). The primary safety endpoint occurred more frequently in the Conventional group (10.3 vs. 4.5%, p < .001), driven by vascular complications (9.4 vs. 3.7%, p < .001). On multivariate analysis, not using a Fully TWA approach was an independent predictor of the study endpoint, after adjusting for age, sex, diabetes, body mass index, chronic kidney disease, prior coronary artery bypass graft, and J-CTO score.

CONCLUSIONS

Embracing a Fully TWA approach for CTO PCI might be associated with lower incidence of a composite endpoint of vascular complications and major bleeding, compared with a Conventional approach.