Impact of moderate or severe left ventricular outflow tract calcification on clinical outcomes of patients with severe aortic stenosis undergoing transcatheter aortic valve implantation with self- and balloon-expandable valves: a post hoc analysis from the SOLVE-TAVI trial

BACKGROUND

Left ventricular outflow tract (LVOT) calcification has been associated with worse outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) and may influence the selection of prosthetic valve type.

AIMS

We aimed to evaluate the impact of LVOT calcification on outcomes after TAVI with a self-expanding valve (SEV) versus a balloon-expandable valve (BEV).

METHODS

Patients of the SOLVE-TAVI trial, randomised to Edwards SAPIEN 3 or Medtronic Evolut R, were divided according to LVOT calcification into no/mild (≤1 calcium nodule extending <5 mm and covering <10% of the LVOT perimeter) and moderate/severe LVOT calcification groups. The primary endpoint was a composite of death, stroke, moderate/severe paravalvular regurgitation, permanent pacemaker implantation and annulus rupture at 30 days. Additional endpoints included all-cause and cardiovascular mortality at 1 year.

RESULTS

Out of 416 eligible patients, moderate/severe LVOT calcification was present in 143 (34.4%). Moderate/severe LVOT calcification was associated with significantly longer fluoroscopy time and higher rates of pre- and post-dilation. Regardless of the LVOT calcification group, there was no significant difference in the primary endpoint associated with the valve type (no/mild LVOT calcification group: SEV 25.0% vs BEV 27.0%; hazard ratio [HR] 1.10, 95% confidence interval [95% CI]: 0.68-1.73; p=0.73 and moderate/severe LVOT calcification group: SEV 25.0% vs BEV 19.4%; HR 0.76, 95% CI: 0.38-1.61; p=0.49), no significant interaction between LVOT calcification and valve type (pint=0.29) and no differences between SEV vs BEV within LVOT calcification groups regarding 1-year all-cause and cardiovascular mortality.

CONCLUSIONS

Moderate/severe LVOT calcification was associated with longer fluoroscopy time and an increased need for pre- and post-dilation, but not with a higher incidence of early and mid-term adverse clinical outcomes, regardless of valve type. (ClinicalTrials.gov: NCT02737150).

Stand-alone Focal Impulse and Rotor Modulation (FIRM) ablation versus second-generation cryoballoon pulmonary vein isolation for paroxysmal atrial fibrillation

INTRODUCTION

Focal Impulse and Rotor Modulation (FIRM) guided catheter ablation aiming at stable rotors has been investigated as a treatment option in patients with atrial fibrillation (AF). The objective of this study was to compare the safety and efficacy of FIRM-guided ablation with second-generation cryoballoon pulmonary vein isolation (CB2-PVI) in paroxysmal AF.

METHODS

Consecutive patients (n=22, mean age 60 ± 11 years, 59.1% of males) who were treated with a stand-alone FIRM-guided ablation were included in this retrospective single-center study. Procedural data and arrhythmia-free survival at 12 months were compared with n=86 consecutive patients (mean age 62 ± 13 years, 62.4% of males) who received de-novo CB2-PVI.

RESULTS

Median procedure duration was significantly longer in the FIRM group than in the CB2-PVI group (152 [IQR 120;176] minutes versus 122 [110;145] minutes; p=0.031). One patient (1.2%) in the CB2-PVI group and 5 patients (22.7%) in the FIRM group had vascular access complications. Atrial tachyarrhythmias recurred in 15 patients in the FIRM group and 11 in the CB2-PVI group. Kaplan-Meier estimation of single-procedure arrhythmia-free survival at 12 months was 25% (95% CI 6-44%) in the FIRM group and 87% (95% CI 78-96%) in the CB2-PVI group (p<0.001). Repeat ablations were performed in 14/20 (70.0%) patients in the FIRM group and in 12/85 (14.1%) in the CB2-PVI group (p<0.001).

CONCLUSION

De novo ablation of AF using FIRM-guided AF ablation results in shorter arrhythmia-free survival after 12 months compared to CB2-PVI and a need for repeat ablation in the majority of patients to achieve stable sinus rhythm. This article is protected by copyright. All rights reserved.

Metabolic and Lipidomic Markers Differentiate COVID-19 From Non-Hospitalized and Other Intensive Care Patients

Coronavirus disease 2019 (COVID-19) is a viral infection affecting multiple organ systems of great significance for metabolic processes. Thus, there is increasing interest in metabolic and lipoprotein signatures of the disease, and early analyses have demonstrated a metabolic pattern typical for atherosclerotic and hepatic damage in COVID-19 patients. However, it remains unclear whether this is specific for COVID-19 and whether the observed signature is caused by the disease or rather represents an underlying risk factor. To answer this question, we have analyzed 482 serum samples using nuclear magnetic resonance metabolomics, including longitudinally collected samples from 12 COVID-19 and 20 cardiogenic shock intensive care patients, samples from 18 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody-positive individuals, and single time point samples from 58 healthy controls. COVID-19 patients showed a distinct metabolic serum profile, including changes typical for severe dyslipidemia and a deeply altered metabolic status compared with healthy controls. Specifically, very-low-density lipoprotein and intermediate-density lipoprotein particles and associated apolipoprotein B and intermediate-density lipoprotein cholesterol were significantly increased, whereas cholesterol and apolipoprotein A2 were decreased. Moreover, a similarly perturbed profile was apparent when compared with other patients with cardiogenic shock who are in the intensive care unit when looking at a 1-week time course, highlighting close links between COVID-19 and lipid metabolism. The metabolic profile of COVID-19 patients distinguishes those from healthy controls and also from patients with cardiogenic shock. In contrast, anti-SARS-CoV-2 antibody-positive individuals without acute COVID-19 did not show a significantly perturbed metabolic profile compared with age- and sex-matched healthy controls, but SARS-CoV-2 antibody-titers correlated significantly with metabolic parameters, including levels of glycine, ApoA2, and small-sized low- and high-density lipoprotein subfractions. Our data suggest that COVID-19 is associated with dyslipidemia, which is not observed in anti-SARS-CoV-2 antibody-positive individuals who have not developed severe courses of the disease. This suggests that lipoprotein profiles may represent a confounding risk factor for COVID-19 with potential for patient stratification.

Comparison between Amulet and Watchman left atrial appendage closure devices: A real-world, single center experience

Background

Data reporting a head-to-head comparison between Amulet and Watchman devices are scarce. The aim of this study was to compare the Watchman™ versus Amulet™ left atrial appendage closure (LAAC) devices in a consecutive, industry-independent registry.

Methods

Patients who underwent LAAC using Watchman or Amulet devices from January 2014 to December 2019 at the University Heart Center Lübeck, Lübeck, Germany were included in the present analysis. Primary endpoints included periprocedural complications (in-hospital death, pericardial tamponade, device embolization, stroke, major bleeding and vascular access complications), and complications during long-term follow-up (ischemic stroke, hemorrhagic stroke, thromboembolism, device thrombus, bleeding and death).

Results

After matching the patients for age (±5 years), gender, CHA2DS2Vasc score (±1) and HASBLED score (±1), each of the Watchman and the Amulet groups included 113 patients. Patients in the Amulet group had significantly more periprocedural complications (2.7% vs 10.6%, p = 0.029; respectively) and more major bleeding complications (0% vs 5.3%, p = 0.029; respectively). During long-term follow-up, the rate of events was comparable between the Watchman and Amulet groups (18.3% versus 20.8%, p = 0.729; respectively).

Conclusion

Amulet LAAC device was associated with increased periprocedural complications as compared to Watchman LAAC device. On long-term follow-up, both devices showed comparable efficacy and safety.

Comparison of risk prediction models in infarct-related cardiogenic shock

AIMS

Several prediction models have been developed to allow accurate risk assessment and provide better treatment guidance in patients with infarct-related cardiogenic shock (CS). However, comparative data between these models are still scarce. The objective of the study is to externally validate different risk prediction models in infarct-related CS and compare their predictive value in the early clinical course.

METHODS AND RESULTS

The Simplified Acute Physiology Score (SAPS) II Score, the CardShock score, the IABP-SHOCK II score, and the Society for Cardiovascular Angiography and Intervention (SCAI) classification were each externally validated in a total of 1055 patients with infarct-related CS enrolled into the randomized CULPRIT-SHOCK trial or the corresponding registry. The primary outcome was 30-day all-cause mortality. Discriminative power was assessed by comparing the area under the curves (AUC) in case of continuous scores. In direct comparison of the continuous scores in a total of 161 patients, the IABP-SHOCK II score revealed best discrimination [area under the curve (AUC = 0.74)], followed by the CardShock score (AUC = 0.69) and the SAPS II score, giving only moderate discrimination (AUC = 0.63). All of the three scores revealed acceptable calibration by Hosmer-Lemeshow test. The SCAI classification as a categorical predictive model displayed good prognostic assessment for the highest risk group (Stage E) but showed poor discrimination between Stages C and D with respect to short-term-mortality.

CONCLUSION

Based on the present findings, the IABP-SHOCK II score appears to be the most suitable of the examined models for immediate risk prediction in infarct-related CS. Prospective evaluation of the models, further modification, or even development of new scores might be necessary to reach higher levels of discrimination.

Comparison of risk prediction models in infarct-related cardiogenic shock

Background

Several prediction models have been developed to allow accurate risk assessment and provide better treatment guidance in patients with infarct-related cardiogenic shock (CS). However, comparative data between these models are still scarce.

Objectives

To externally validate different risk prediction models in infarct-related CS and compare their predictive value in the early clinical course.

Methods

The Simplified Acute Physiology Score (SAPS)-II Score, the CardShock score, the IABP-SHOCK II score and the Society for Cardiovascular Angiography and Intervention (SCAI) classification were each externally validated in a total of 1055 patients with infarct-related CS enrolled into the randomized CULPRIT-SHOCK trial or the corresponding registry. Discriminative power was assessed by comparing area under the curves (AUC) in case of continuous scores.

Results

In direct comparison of the continuous scores in a total of 161 patients, the IABP-SHOCK II score revealed best discrimination (AUC=0.74), followed by the CardShock score (AUC=0.69) and the SAPS-II score, giving only moderate discrimination (AUC=0.63). All of the three scores revealed acceptable calibration by Hosmer-Lemeshow test. The SCAI classification as a categorical predictive model displayed good prognostic assessment for the highest risk group (stage E), but showed poor discrimination between stages C and D with respect to short-term-mortality.

Conclusion

Based on the present findings, the IABP-SHOCK II score appears to be the most suitable of the examined models for immediate risk prediction in infarct-related CS. Prospective evaluation of the models, further modification or even development of new scores might be necessary to reach higher levels of discrimination.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, German Centre for Cardiovascular Research Survival probabilities continuous scoresSurvival probabilities SCAI

The C5a/C5a receptor 1 axis controls tissue neovascularization through CXCL4 release from platelets

Platelets contribute to the regulation of tissue neovascularization, although the specific factors underlying this function are unknown. Here, we identified the complement anaphylatoxin C5a-mediated activation of C5a receptor 1 (C5aR1) on platelets as a negative regulatory mechanism of vessel formation. We showed that platelets expressing C5aR1 exert an inhibitory effect on endothelial cell functions such as migration and 2D and 3D tube formation. Growth factor- and hypoxia-driven vascularization was markedly increased in C5ar1^-/- mice. Platelet-specific deletion of C5aR1 resulted in a proangiogenic phenotype with increased collateralization, capillarization and improved pericyte coverage. Mechanistically, we found that C5a induced preferential release of CXC chemokine ligand 4 (CXCL4, PF4) from platelets as an important antiangiogenic paracrine effector molecule. Interfering with the C5aR1-CXCL4 axis reversed the antiangiogenic effect of platelets both in vitro and in vivo.In conclusion, we identified a mechanism for the control of tissue neovascularization through C5a/C5aR1 axis activation in platelets and subsequent induction of the antiangiogenic factor CXCL4.

Impact of Anesthesia Strategy and Valve Type on Clinical Outcomes After Transcatheter Aortic Valve Replacement

BACKGROUND

The randomized SOLVE-TAVI (compariSon of secOnd-generation seLf-expandable vs. balloon-expandable Valves and gEneral vs. local anesthesia in Transcatheter Aortic Valve Implantation) trial compared newer-generation self-expanding valves (SEV) and balloon-expandable valves (BEV) as well as local anesthesia with conscious sedation (CS) and general anesthesia (GA) in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR). Both strategies showed similar outcomes at 30 days.

OBJECTIVES

The purpose of this study was to compare clinical outcomes during 1-year follow-up in the randomized SOLVE-TAVI trial.

METHODS

Using a 2 × 2 factorial design 447 intermediate- to high-risk patients with severe, symptomatic aortic stenosis were randomly assigned to transfemoral TAVR using either the SEV (Evolut R, Medtronic Inc., Minneapolis, Minnesota) or the BEV (Sapien 3, Edwards Lifesciences, Irvine, California) as well as CS or GA at 7 sites.

RESULTS

In the valve-comparison strategy, rates of the combined endpoint of all-cause mortality, stroke, moderate or severe paravalvular leakage, and permanent pacemaker implantation were similar between the BEV and SEV group (n = 84, 38.3% vs. n = 87, 40.4%; hazard ratio: 0.94; 95% confidence interval: 0.70 to 1.26; p = 0.66) at 1 year. Regarding the anesthesia comparison, the combined endpoint of all-cause mortality, stroke, myocardial infarction, and acute kidney injury occurred with similar rates in the GA and CS groups (n = 61, 25.7% vs. n = 54, 23.8%; hazard ratio: 1.09; 95% confidence interval: 0.76 to 1.57; p = 0.63).

CONCLUSIONS

In intermediate- to high-risk patients undergoing transfemoral TAVR, newer-generation SEV and BEV as well as CS and GA showed similar clinical outcomes at 1 year using a combined clinical endpoint. (SecOnd-generation seLf-expandable Versus Balloon-expandable Valves and gEneral Versus Local Anesthesia in TAVI [SOLVE-TAVI]; NCT02737150).

Impact of Morphine Treatment With and Without Metoclopramide Coadministration on Myocardial and Microvascular Injury in Acute Myocardial Infarction: Insights From the Randomized MonAMI Trial

Background

Intravenous morphine administration can adversely affect platelet inhibition induced by P2Y₁₂ receptor inhibitors after acute myocardial infarction. In contrast, some evidence suggests that opioid agonists may have cardioprotective effects on the myocardium. The aim of this prospective, randomized MonAMI (Impact of Morphine Treatment With and Without Metoclopramide Coadministration on Platelet Inhibition in Acute Myocardial Infarction) trial was, therefore, to investigate the impact of morphine with or without metoclopramide coadministration on myocardial and microvascular injury.

Methods and Results

Patients with acute myocardial infarction (n=138) were assigned in a 1:1:1 ratio to ticagrelor 180 mg plus: (1) intravenous morphine 5 mg (morphine group); (2) intravenous morphine 5 mg and metoclopramide 10 mg (morphine+metoclopramide group); or (3) intravenous placebo (control group) administered before primary percutaneous coronary intervention. Cardiac magnetic resonance imaging was performed in 104 patients on day 1 to 4 after the index event. Infarct size was significantly smaller in the morphine only group as compared with controls (percentage of left ventricular mass, 15.5 versus 17.9; P=0.047). Furthermore, the number of patients with microvascular obstruction was significantly lower after morphine administration (28% versus 54%; P=0.022) and the extent of microvascular obstruction was smaller (percentage of left ventricular mass, 0 versus 0.74; P=0.037). In multivariable regression analysis, morphine administration was independently associated with a reduced risk for the occurrence of microvascular obstruction (odds ratio, 0.37; 95% CI, 0.14–0.93 [P=0.035]). There was no significant difference in infarct size (P=0.491) and extent (P=0.753) or presence (P=0.914) of microvascular obstruction when comparing the morphine+metoclopramide group with the control group.

Conclusions

In this randomized study, intravenous administration of morphine before primary percutaneous coronary intervention resulted in a significant reduction of myocardial and microvascular damage following acute myocardial infarction. This effect was not observed in the morphine plus metoclopramide group.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02627950.

Novel Cryoballoon Ablation System for Single Shot Pulmonary Vein Isolation - The Prospective ICE-AGE-X Study

BACKGROUND

The arctic front cryoballoon (AF-CB) provides effective and durable pulmonary vein isolation (PVI) associated with encouraging clinical outcome. The POLARx cryoballoon incorporates unique features and design changes that may translate into improved efficacy, safety and further simplified balloon-based procedures. Efficacy and safety of the novel POLARx cryoballoon was compared to the fourth generation AF-CB (AF-CB4).Methods and Results:Twenty-five consecutive patients with paroxysmal or persistent atrial fibrillation were prospectively enrolled, underwent POLARx-based PVI (POLARx group) and were compared to 25 consecutive patients treated with the AF-CB4 (AF-CB4 group). All PVs were successfully isolated utilizing the POLARx and AF-CB4. A significant difference regarding the mean minimal cryoballoon temperatures reached using the AF-CB4 and POLARx (-50±6℃ vs. -57±7℃, P=0.004) was observed. Real-time PVI was visualized in 81% of POLARx patients and 42% of AF-CB4 patients (P<0.001). Utilizing the POLARx, a trend towards shorter median procedure time (POLARx: 45 [39, 53] min vs. AF-CB4: 55 [50, 60] min; P=0.062) was found. No differences were observed between AF-CB4 and POLARx concerning catheter maneuverability, catheter stability and periprocedural complications.

CONCLUSIONS

The novel POLARx showed similar safety and efficacy compared to the AF-CB4. A higher rate of real-time PV recordings and significantly lower minimal balloon temperatures were observed using the POLARx.

Experience and procedural efficacy of pulmonary vein isolation using the fourth and second generation cryoballoon: The shorter, the better?

BACKGROUND

The second-generation cryoballoon (CB2) provides effective and durable pulmonary vein isolation (PVI) associated with encouraging clinical outcome. The novel fourth-generation cryoballoon (CB4) incorporates a 40% shorter distal tip. This design change may translate into an increased rate of PVI real-time signal recording, facilitating an individualized ablation strategy using the time to effect (TTE).

METHODS AND RESULTS

Three hundred consecutive patients with paroxysmal or persistent atrial fibrillation were prospectively enrolled. The first 150 consecutive patients underwent CB2 based PVI (CB2 group) and the last 150 consecutive patients were treated with the CB4 (CB4 group). A total of 594/594 (100%, CB4) and 589/594 (99.2%, CB2) pulmonary veins (PVs) were successfully isolated utilizing the CB4 and CB2, respectively (p = .283). The real-time PVI visualization rate was 47% (CB4) and 39% (CB2; p = .005) and the mean freeze cycle duration 200 ± 90 s (CB4) and 228 ± 110 s (CB2; p < .001), respectively. The total procedure time did not differ between the groups (CB4: 64 ± 32 min) and (CB2: 62 ± 29 min, p = .370). No differences in periprocedural complications were detected.

CONCLUSIONS

A higher rate of real-time electrical PV recordings are seen using the CB4 as compared to CB2, which may facilitate an individualized ablation strategy using the TTE.

Impact of transcatheter mitral valve repair on ventricular arrhythmias

AIMS

Patients with heart failure and severe mitral regurgitation (MR) have a poor prognosis and carry an increased risk for ventricular arrhythmias. The present study evaluates the impact of transcatheter mitral valve repair using the MitraClip on the potential reduction of ventricular arrhythmias.

METHODS AND RESULTS

Patients undergoing MitraClip implantation were prospectively enrolled into the present study and received 24 h Holter ECG assessment prior to and 6 months after the procedure. In addition, left ventricular dimensions and function were assessed at baseline and follow-up. A total of 50 patients with mainly functional MR (82%) were included. Non-sustained or sustained ventricular tachycardia (nsVT and/or sVT) occurred in 32% of patients and was reduced to 14% at follow-up (P = 0.01). Also, premature ventricular complex (PVC) burden ≥5% decreased from 16% to 4% (P = 0.04). Patients with persistent (n = 6) or new (n = 1) nsVT and/or sVT at follow-up showed a significant decrease in left ventricular ejection fraction from 38% (interquartile range 26-45%) to 33% (interquartile range 22-44%; P = 0.03).

CONCLUSIONS

In this prospective study, transcatheter mitral valve repair using MitraClip was associated with a reduced prevalence of ventricular arrhythmias. The subset of patients with persistent or new ventricular arrhythmias after MitraClip implantation showed progression of left ventricular dysfunction.

Impact of morphine treatment with and without metoclopramide co-administration on myocardial and microvascular injury in acute myocardial infarction: insights from a randomized trial

Background

Intravenous morphine administration in patients with acute myocardial infarction (AMI) can adversely affect platelet inhibition induced by P2Y12 receptor antagonists, potentially resulting in an increased risk of adverse clinical events. In contrast, some evidence suggests that opioid agonists may have cardioprotective effects on the myocardium. Currently available data in this regard are, however, sparse, inconsistent, and methodologically limited.

Purpose

The aim of this study was to investigate the impact of morphine with or without metoclopramide (MCP) co-administration on myocardial and microvascular injury after AMI assessed by cardiac magnetic resonance (CMR).

Methods

This prospective, randomized, single-center study assigned 138 patients with AMI in a 1:1:1 ratio to (a) ticagrelor 180 mg plus intravenous morphine 5 mg (morphine group); (b) ticagrelor 180 mg plus intravenous morphine 5 mg and MCP 10 mg (morphine + MCP group); or (c) ticagrelor 180 mg plus intravenous placebo (control group). Study drugs were administered before primary percutaneous coronary intervention. CMR was performed in 101 patients on day 1–4 after the index event to assess infarct size, microvascular obstruction, and left ventricular ejection fraction.

Results

Infarct size was significantly smaller in the morphine only group as compared to controls (15.5%LV [IQR 5.0 to 21.4%LV] vs. 17.9%LV [IQR 12.3 to 32.9%LV]; p=0.047). Furthermore, the number of patients with microvascular obstruction was significantly lower after morphine administration (10/36 [28%] versus 21/39 [54%]; p=0.022) and the extent of microvascular obstruction was smaller (0%LV [0 to 1.40%LV] versus 0.74%LV [0 to 3.10%LV]; p=0.037). In multivariable regression analysis, morphine administration was independently associated with a reduced risk for the occurrence of microvascular obstruction (odds ratio 0.37; 95% confidence interval 0.14 to 0.93; p=0.035). Left ventricular ejection fraction did not differ significantly between the morphine and the control group (p=0.970) and there was no significant difference in left ventricular ejection fraction (p=0.790), infarct size (p=0.491), and extent (p=0.753) or presence (p=0.914) of microvascular obstruction when comparing the morphine + MCP group to the control group.

Conclusions

In this randomized study, intravenous administration of morphine prior to primary percutaneous coronary intervention resulted in a significant reduction of myocardial and microvascular damage following AMI. This potential cardioprotective effect of morphine requires further evaluation in well-designed future trials with clinical endpoints.

Funding Acknowledgement

Type of funding source: None

General Versus Local Anesthesia With Conscious Sedation in Transcatheter Aortic Valve Implantation

Background:

In clinical practice, local anesthesia with conscious sedation (CS) is performed in roughly 50% of patients undergoing transcatheter aortic valve replacement. However, no randomized data assessing the safety and efficacy of CS versus general anesthesia (GA) are available.

Methods:

The SOLVE-TAVI (Comparison of Second-Generation Self-Expandable Versus Balloon-Expandable Valves and General Versus Local Anesthesia in Transcatheter Aortic Valve Implantation) trial is a multicenter, open-label, 2×2 factorial, randomized trial of 447 patients with aortic stenosis undergoing transfemoral transcatheter aortic valve replacement comparing CS versus GA. The primary efficacy end point was powered for equivalence (equivalence margin 10% with significance level 0.05) and consisted of the composite of all-cause mortality, stroke, myocardial infarction, infection requiring antibiotic treatment, and acute kidney injury at 30 days.

Results:

The primary composite end point occurred in 27.2% of CS and 26.4% of GA patients (rate difference, 0.8 [90% CI, −6.2 to 7.8]; P equivalence =0.015). Event rates for the individual components were as follows: all-cause mortality, 3.2% versus 2.3% (rate difference, 1.0 [90% CI, −2.9 to 4.8]; P equivalence <0.001); stroke, 2.4% versus 2.8% (rate difference, −0.4 [90% CI, −3.8 to 3.8]; P equivalence <0.001); myocardial infarction, 0.5% versus 0.0% (rate difference, 0.5 [90% CI, −3.0 to 3.9]; P equivalence <0.001), infection requiring antibiotics 21.1% versus 22.0% (rate difference, −0.9 [90% CI, −7.5 to 5.7]; P equivalence =0.011); acute kidney injury, 9.0% versus 9.2% (rate difference, −0.2 [90% CI, −5.2 to 4.8]; P equivalence =0.0005). There was a lower need for inotropes or vasopressors with CS (62.8%) versus GA (97.3%; rate difference, −34.4 [90% CI, −41.0 to −27.8]).

Conclusions:

Among patients with aortic stenosis undergoing transfemoral transcatheter aortic valve replacement, use of CS compared with GA resulted in similar outcomes for the primary efficacy end point. These findings suggest that CS can be safely applied for transcatheter aortic valve replacement.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02737150.

In vitro comparison of everting vs. non-everting suture techniques for the implantation of a supra-annular biological heart valve

Background

The aim of this study was to evaluate the hemodynamic effect of different suturing techniques for aortic valve replacement (AVR) in vitro. Whether or not the applied suturing technique impacts the outflow tract diameter by narrowing the annulus diameter was examined.

Methods

The commonly applied non-everting pledget forced suture technique (NE, n=13) was compared with an everting pledget forced suture (ET, n=13) for AVR using the 25 mm St. Jude Trifecta aortic valve. Hemodynamic parameters were obtained in a pulsatile flow simulator. A high speed camera captured the visual aspects of the suturing technique.

Results

Despite some kind of left ventricular outflow narrowing due to protruding pledgets using the NE suture technique, mean pressure gradients of both techniques were nearly similar (NE 5.88±2.7 mmHg, ET 5.23±1.31 mmHg, P=0.44). Closing volume (NE 3.16±0.48 mL; ET 3.51±0.68 mL; P=0.14) and the leakage volume (NE: 8.09±2.53 mL; ET: 8.35±3.65 mL; P=0.83) also showed no differences.

Conclusions

AVR using either suturing techniques leads to a similar hemodynamic performance in vitro. The impact of the suturing technique may be higher in a smaller annulus. Therefore, further studies using smaller prostheses are necessary.

Rapid pulmonary vein isolation utilizing the third-generation laserballoon - The PhoeniX registry

Background

Balloon-based ablation systems for pulmonary vein isolation (PVI) are providing procedural safety and efficacy as well as favourable clinical outcome. Although second-generation laser balloon (LB2) based PVI has been shown safety and efficacy relatively long procedural duration was a strong limitation. The third-generation laser balloon (LB3) offers and automized ablation for rapid PVI. We determined safety, efficacy and procedural characteristics of this new promising ablation system.

Methods and results

A total of 15 consecutive patients were prospectively enrolled. All patients underwent PVI using the LB3. A total 59/59 PVs (100%) were successfully isolated. Procedural data was compared to the last 15 consecutive patients treated by the LB2. The median procedure time significantly declined from LB2 (91 (86, 105) min) to LB3 (77 (68, 87) min), p < 0.001. Similarly, the median left atrial dwelling time significantly decreased from LB2 (72 (62, 84) min) to LB3 (45 (38, 52) min), p < 0.0001. The total laser time decreased from LB2 (1920 (1765, 2193) sec) to LB3 (1077 (896, 1165) sec), p < 0.00001. A pure single shot PVI was performed in 18/59 PVs (31%). For major adverse events no differences were detected between the groups (LB2 1/15 (6.7%) and LB3 1/15 (6.7%), p = 0.999).

Conclusion

The LB3 was safe and effective for PVI. Procedure time, LA dwelling time and total laser time significantly decreased compared to LB2.

Sex-Specific Management in Patients With Acute Myocardial Infarction and Cardiogenic Shock: A Substudy of the CULPRIT-SHOCK Trial

BACKGROUND

Women are more likely to suffer and die from cardiogenic shock (CS) as the most severe complication of acute myocardial infarction. Data concerning optimal management for women with CS are scarce. Aim of this study was to better define characteristics of women experiencing CS and to the influence of sex on different treatment strategies.

METHODS

In the CULPRIT-SHOCK trial (The Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock), patients with CS complicating acute myocardial infarction and multivessel coronary artery disease were randomly assigned to one of the following revascularization strategies: either percutaneous coronary intervention of the culprit-lesion-only or immediate multivessel percutaneous coronary intervention. Primary end point was composite of death from any cause or severe renal failure leading to renal replacement therapy within 30 days. We investigated sex-specific differences in general and according to the revascularization strategies.

RESULTS

Among all 686 randomized patients included in the analysis, 24% were women. Women were older and had more often diabetes mellitus and renal insufficiency, whereas they had less often history of previous acute myocardial infarction and smoking. After 30 days, the primary clinical end point was not significantly different between groups (56% women versus 49% men; odds ratio, 1.29 [95% CI, 0.91-1.84]; P=0.15). There was no interaction between sex and coronary revascularization strategy regarding mortality and renal failure (P_interaction=0.11). The primary end point occurred in 56% of women treated by the culprit-lesion-only strategy versus 42% men, whereas 55% of women and 55% of men in the multivessel percutaneous coronary intervention group.

CONCLUSIONS

Although women presented with a different risk profile, mortality and renal replacement were similar to men. Sex did not influence mortality and renal failure according to the different coronary revascularization strategies. Based on these data, women and men presenting with CS complicating acute myocardial infarction and multivessel coronary artery disease should not be treated differently. However, further randomized trials powered to address potential sex-specific differences in CS are still necessary. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01927549.

Comparison of newer generation self-expandable vs. balloon-expandable valves in transcatheter aortic valve implantation: the randomized SOLVE-TAVI trial

Aims

Transcatheter aortic valve implantation (TAVI) has emerged as established treatment option in patients with symptomatic aortic stenosis. Technical developments in valve design have addressed previous limitations such as suboptimal deployment, conduction disturbances, and paravalvular leakage. However, there are only limited data available for the comparison of newer generation self-expandable valve (SEV) and balloon-expandable valve (BEV).

Methods and results

SOLVE-TAVI is a multicentre, open-label, 2 × 2 factorial, randomized trial of 447 patients with aortic stenosis undergoing transfemoral TAVI comparing SEV (Evolut R, Medtronic Inc., Minneapolis, MN, USA) with BEV (Sapien 3, Edwards Lifesciences, Irvine, CA, USA). The primary efficacy composite endpoint of all-cause mortality, stroke, moderate/severe prosthetic valve regurgitation, and permanent pacemaker implantation at 30 days was powered for equivalence (equivalence margin 10% with significance level 0.05). The primary composite endpoint occurred in 28.4% of SEV patients and 26.1% of BEV patients meeting the prespecified criteria of equivalence [rate difference −2.39 (90% confidence interval, CI −9.45 to 4.66); Pequivalence = 0.04]. Event rates for the individual components were as follows: all-cause mortality 3.2% vs. 2.3% [rate difference −0.93 (90% CI −4.78 to 2.92); Pequivalence &lt; 0.001], stroke 0.5% vs. 4.7% [rate difference 4.20 (90% CI 0.12 to 8.27); Pequivalence = 0.003], moderate/severe paravalvular leak 3.4% vs. 1.5% [rate difference −1.89 (90% CI −5.86 to 2.08); Pequivalence = 0.0001], and permanent pacemaker implantation 23.0% vs. 19.2% [rate difference −3.85 (90% CI −10.41 to 2.72) in SEV vs. BEV patients; Pequivalence = 0.06].

Conclusion

In patients with aortic stenosis undergoing transfemoral TAVI, newer generation SEV and BEV are equivalent for the primary valve-related efficacy endpoint. These findings support the safe application of these newer generation percutaneous valves in the majority of patients with some specific preferences based on individual valve anatomy.

P2846Focal impulse and rotor modulation ablation versus pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation (FIRMAP AF study)

Background

Based on the assumption of trigger elimination, pulmonary vein isolation (PVI) currently presents the gold standard of atrial fibrillation (AF) ablation. Recently, rapidly spinning rotors or focal impulse formation has been raised as a crucial sustaining mechanism of AF. Ablation of these rotors may potentially obviate the need for trigger elimination with PVI.

Purpose

This study sought to compare the safety and effectiveness of Focal Impulse and Rotor Modulation (FIRM) guided catheter ablation only with the gold standard of pulmonary vein isolation (PVI) in patients with paroxysmal AF.

Methods

This was a post-market, prospective, single-blinded, randomized, multi-center trial. Patients were enrolled at three centers and equally (1:1) randomized between those undergoing conventional RF ablation with PVI (PVI group) vs. those treated with FIRM-guided RF ablation without PVI (FIRM group). Data was collected at enrollment, procedure, and at 7-day, 3-month, 6-month, and 12-month follow-up visits. The study was closed early by the sponsor. At the time of study closure, any pending follow-up visits were waived.

Results

From February 2016 until February 2018, a total of 51 (out of a planned 170) patients (mean age 63±10.6 years, 57% male) were enrolled and randomized. Four patients withdrew from the study prior to treatment, resulting in 23 patients allocated to the FIRM group and 24 in the PVI group. Only 13 patients in the FIRM group and 11 patients in the PVI group completed the 12-month follow-up. Statistical analysis was not completed given the small number of patients.

Single-procedure effectiveness (freedom from AF/atrial tachycardia recurrence after blanking period) was 52.9% (9/17) in the FIRM group and 85.7% (12/14) in the PVI group at 6 months; and 31.3% (5/16) in the FIRM group and 80% (8/10) in the PVI group at 12 months. Repeat procedures were performed in 45.8% (11/24) patients in the FIRM group and 7.4% (2/27) in the PVI group.

The acute safety endpoint [freedom from procedure-related serious adverse events (SAE)] was achieved in 87% (20/23) of FIRM group patients and 100% (24/24) of PVI group patients. Procedure related SAEs occurred in three patients in the FIRM group: 1 femoral artery aneurysm and 2 injection site hematomas. No additional procedure-related SAEs were reported >7 days post-procedure.

Conclusions

These partial study effectiveness results reinforce the importance of PVI in paroxysmal atrial fibrillation patients and suggest that FIRM-guided ablation alone (without PVI) is not an effective strategy for treatment of paroxysmal AF in most patients. Further study is needed to understand the effectiveness of adding FIRM-guided ablation as an adjunct to PVI in this patient group.

Acknowledgement/Funding

Abbot

P1719Sex-specific PCI strategies in patients with AMI and cardiogenic shock: a substudy of the culprit-shock trial

Background and purpose

Women are more likely to suffer from a cardiogenic shock (CS) as the most severe complication of an acute myocardial infarction (AMI) and tend to have a higher mortality. Data concerning optimal management among women with CS are lacking. Aim of this study was therefore to better define characteristics of women suffering a CS and to investigate the influence of sex on different coronary revascularisation strategies

Methods and results

In the CULPRIT-SHOCK trial, patients with CS complicating AMI and multivessel coronary artery disease were randomly assigned to one of the following coronary revascularisation strategies: either percutaneous coronary intervention (PCI) of the culprit lesion only or immediate multivessel PCI. Primary end-point was a composite of death from any cause or severe renal failure leading to renal-replacement within 30 days after randomisation. We investigated sex-specific differences in general and according to the revascularisation strategies.

Among all 706 randomised patients 26% were women. After 30 days, the primary end-point occurred in 55% women and 49% men (p=0.20), showing a relative risk of 1.14; 95% CI 0.94–1.38; p=0.17, women vs. men. Those women were older, more frequent diabetic and had more peripheral artery disease and less frequent smokers and less often family history of coronary artery disease.

Regarding revascularisation strategy the composite end-point occurred in 55.8% women treated with the culprit-only strategy (vs. 42.4% men, p=0.04) and in 54.7% women in the multivessel group (vs. 55.6% men, p=0.99). This resulted in a no-significant difference among both groups (interaction p-value of 0.11).

Conclusions

In this large randomised trial among patients with multivessel coronary disease and CS complicating AMI, women had similar outcome for mortality and severe renal failure. Sex did not show to influence mortality and renal failure according to the different coronary revascularisation strategies. These data suggest that women and men presenting with CS should be treated equally.

P1697Determinants and prognostic value of cardiac magnetic resonance imaging derived infarct characteristics in Non-ST-Elevation Myocardial Infarction

Background

The prognostic significance of cardiac magnetic resonance (CMR) derived infarct characteristics has been demonstrated in ST-elevation myocardial infarction (STEMI) cohorts but is undefined in non-ST-elevation myocardial infarction (NSTEMI) patients.

Purpose

To investigate determinants and the long-term prognostic impact of CMR imaging derived infarct characteristics in patients with NSTEMI.

Methods

Infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction (MVO) were assessed using CMR imaging in 311 consecutive NSTEMI patients undergoing percutaneous coronary intervention (PCI) in three centers. CMR imaging was performed 3 [interquartile range (IQR) 2–4] days after admission. The clinical endpoint was defined as major adverse cardiac events (MACE) during a median follow-up of 4.4 (IQR 3.6–4.9) years.

Results

Median IS was 7.0% (IQR 2.3–13.5) of LV myocardial mass (%LV) and MSI was 65.2 (IQR 36.7–82.9). Age (p=0.003), heart rate (p=0.002) and TIMI flow grade before PCI (p<0.001) were independent predictors of IS. Independent predictors of the MSI were age (p=0.001), heart rate (p=0.01), the number of diseased coronary arteries (p=0.001) and the TIMI flow grade before PCI (p<0.001). MACE occurred in 75 (24.1%) patients. CMR-derived infarct characteristics had no additional prognostic value over and above LV ejection fraction in multivariable analysis.

Conclusions

In this prospective, multicenter NSTEMI cohort reperfused by PCI, age, heart rate, the number of diseased coronary arteries and TIMI flow grade before PCI were independent predictors of IS and MSI assessed by CMR. However, in contrast to STEMI patients there was no additional long-term prognostic value of CMR-derived infarct characteristics above and beyond traditional risk markers.

Determinants and prognostic value of cardiac magnetic resonance imaging-derived infarct characteristics in non-ST-elevation myocardial infarction

Aims

The prognostic significance of cardiac magnetic resonance (CMR)-derived infarct characteristics has been demonstrated in ST-elevation myocardial infarction (STEMI) cohorts but is undefined in non-ST-elevation myocardial infarction (NSTEMI) patients. We aimed to investigate determinants and the long-term prognostic impact of CMR imaging-derived infarct characteristics in patients with NSTEMI.

Methods and results

Infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction were assessed using CMR imaging in 284 NSTEMI patients undergoing percutaneous coronary intervention (PCI) in three centres. CMR imaging was performed 3 [interquartile range (IQR) 2–4] days after admission. The primary clinical endpoint was defined as major adverse cardiac events during median follow-up of 4.4 (IQR 3.6–4.9) years. Median IS was 7.2% (IQR 2.2–13.7) of left ventricular (LV) myocardial mass (%LV) and MSI was 65.7 (IQR 39.3–84.9). Age (P ≤ 0.003), heart rate (P ≤ 0.02), the number of diseased coronary arteries (P ≤ 0.01), and Thrombolysis In Myocardial Infarction (TIMI) flow grade before PCI (P &lt; 0.001) were independent predictors of IS and MSI. The primary endpoint occurred in 64 (22.5%) patients. CMR-derived infarct characteristics had no additional prognostic value beyond LV ejection fraction in multivariable analysis.

Conclusion

In this prospective, multicentre NSTEMI cohort reperfused by PCI, age, heart rate, the number of diseased coronary arteries, and TIMI flow grade before PCI were independent predictors of IS and MSI assessed by CMR. However, in contrast to STEMI patients there was no additional long-term prognostic value of CMR-derived infarct characteristics over and above LV ejection fraction.

Clinicaltrials.gov

NCT03516578.

Intraaortic Balloon Pump in Cardiogenic Shock Complicating Acute Myocardial Infarction: Long-Term 6-Year Outcome of the Randomized IABP-SHOCK II Trial

BACKGROUND

The role of intraaortic balloon counterpulsation (IABP) in cardiogenic shock is still a subject of intense debate despite the neutral results of the IABP-SHOCK II trial (Intraaortic Balloon Pump in Cardiogenic Shock II) with subsequent downgrading in international guidelines. So far, randomized data on the impact of IABP on long-term clinical outcomes in patients with cardiogenic shock complicating acute myocardial infarction are lacking. Furthermore, only limited evidence is available on general long-term outcomes of patients with cardiogenic shock treated by contemporary practice.

METHODS

The IABP-SHOCK II trial is a multicenter, randomized, openlabel trial. Between 2009 and 2012, 600 patients with cardiogenic shock complicating acute myocardial infarction undergoing early revascularization were randomized to IABP versus control.

RESULTS

Long-term follow-up was performed 6.2 years (interquartile range 5.6-6.7) after initial randomization. Follow-up was completed for 591 of 600 patients (98.5%). Mortality was not different between the IABP and the control group (66.3% versus 67.0%; relative risk, 0.99; 95% CI, 0.88-1.11; P=0.98). There were also no differences in recurrent myocardial infarction, stroke, repeat revascularization, or rehospitalization for cardiac reasons (all P>0.05). Survivors' quality of life as assessed by the EuroQol 5D questionnaire and the New York Heart Association class did not differ between groups.

CONCLUSIONS

IABP has no effect on all-cause mortality at 6-year longterm follow-up. Mortality is still very high, with two thirds of patients with cardiogenic shock dying despite contemporary treatment with revascularization therapy.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov/. Unique identifier: NCT00491036.

One-Year Outcomes after PCI Strategies in Cardiogenic Shock

BACKGROUND

Among patients with acute myocardial infarction, cardiogenic shock, and multivessel coronary artery disease, the risk of a composite of death from any cause or severe renal failure leading to renal-replacement therapy at 30 days was found to be lower with percutaneous coronary intervention (PCI) of the culprit lesion only than with immediate multivessel PCI. We evaluated clinical outcomes at 1 year.

METHODS

We randomly assigned 706 patients to either culprit-lesion-only PCI or immediate multivessel PCI. The results for the primary end point of death or renal-replacement therapy at 30 days have been reported previously. Prespecified secondary end points at 1 year included death from any cause, recurrent myocardial infarction, repeat revascularization, rehospitalization for congestive heart failure, the composite of death or recurrent infarction, and the composite of death, recurrent infarction, or rehospitalization for heart failure.

RESULTS

As reported previously, at 30 days, the primary end point had occurred in 45.9% of the patients in the culprit-lesion-only PCI group and in 55.4% in the multivessel PCI group (P=0.01). At 1 year, death had occurred in 172 of 344 patients (50.0%) in the culprit-lesion-only PCI group and in 194 of 341 patients (56.9%) in the multivessel PCI group (relative risk, 0.88; 95% confidence interval [CI], 0.76 to 1.01). The rate of recurrent infarction was 1.7% with culprit-lesion-only PCI and 2.1% with multivessel PCI (relative risk, 0.85; 95% CI, 0.29 to 2.50), and the rate of a composite of death or recurrent infarction was 50.9% and 58.4%, respectively (relative risk, 0.87; 95% CI, 0.76 to 1.00). Repeat revascularization occurred more frequently with culprit-lesion-only PCI than with multivessel PCI (in 32.3% of the patients vs. 9.4%; relative risk, 3.44; 95% CI, 2.39 to 4.95), as did rehospitalization for heart failure (5.2% vs. 1.2%; relative risk, 4.46; 95% CI, 1.53 to 13.04).

CONCLUSIONS

Among patients with acute myocardial infarction and cardiogenic shock, the risk of death or renal-replacement therapy at 30 days was lower with culprit-lesion-only PCI than with immediate multivessel PCI, and mortality did not differ significantly between the two groups at 1 year of follow-up. (Funded by the European Union Seventh Framework Program and others; CULPRIT-SHOCK ClinicalTrials.gov number, NCT01927549 .).

Second-generation cryoballoon for pulmonary vein isolation in patients with pulmonary vein abnormality: Safety, efficacy and lessons from re-ablation procedures

Second generation cryoballoon (CB) has been shown to be effective for treatment of paroxysmal and persistent atrial fibrillation (AF). However, the fixed size of the non-compliant balloon may limit its use in patients with pulmonary vein (PV) abnormalities. In this study we investigated the acute success, procedural complications and long term outcome of CB based PV isolation (PVI) in patients with PV abnormality. A total of 238 patients [64.8 ± 11.1 years; 91 paroxysmal (38.2%), 147 persistent AF (61.8%)] underwent PVI using the second generation CB without preprocedural imaging. In 43/238 (18.1%) patients PV abnormality (left common PV in 26, right middle PV in 20) was observed. All targeted veins including abnormal PVs were isolated (100%). Transient phrenic nerve palsy (PNP) occurred in one (2.3%) patient in the PV anomalous group and 6 (3.0%) in the control group (p = NS). There was no other adverse event including PV stenosis, atrio-esophageal fistula or cerebrovascular events related to the procedure. During mean follow-up of 11.8 ± 5.4 month a total of 59 patients (24.7%) had atrial tachyarrhythmia (ATA) recurrence [27 (11.3%) had AT recurrence]. In the PV anomalous group, 20/43 (46.5%) patients had ATA recurrence compared to 39/195 (20%) in the control group (p < 0.001). AT recurrence was observed in 27 (11.3) patients [11 (25.5%) in the PV anomalous group and 16 (8.2%) in controls respectively, p = 0.003]. In patients with PV abnormality CB-based AF ablation results in a similar acute PVI rate but a higher ATA recurrence rate during follow up as compared to patients without PV abnormality.

PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock

BACKGROUND

In patients who have acute myocardial infarction with cardiogenic shock, early revascularization of the culprit artery by means of percutaneous coronary intervention (PCI) improves outcomes. However, the majority of patients with cardiogenic shock have multivessel disease, and whether PCI should be performed immediately for stenoses in nonculprit arteries is controversial.

METHODS

In this multicenter trial, we randomly assigned 706 patients who had multivessel disease, acute myocardial infarction, and cardiogenic shock to one of two initial revascularization strategies: either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. The primary end point was a composite of death or severe renal failure leading to renal-replacement therapy within 30 days after randomization. Safety end points included bleeding and stroke.

RESULTS

At 30 days, the composite primary end point of death or renal-replacement therapy had occurred in 158 of the 344 patients (45.9%) in the culprit-lesion-only PCI group and in 189 of the 341 patients (55.4%) in the multivessel PCI group (relative risk, 0.83; 95% confidence interval [CI], 0.71 to 0.96; P=0.01). The relative risk of death in the culprit-lesion-only PCI group as compared with the multivessel PCI group was 0.84 (95% CI, 0.72 to 0.98; P=0.03), and the relative risk of renal-replacement therapy was 0.71 (95% CI, 0.49 to 1.03; P=0.07). The time to hemodynamic stabilization, the risk of catecholamine therapy and the duration of such therapy, the levels of troponin T and creatine kinase, and the rates of bleeding and stroke did not differ significantly between the two groups.

CONCLUSIONS

Among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock, the 30-day risk of a composite of death or severe renal failure leading to renal-replacement therapy was lower among those who initially underwent PCI of the culprit lesion only than among those who underwent immediate multivessel PCI. (Funded by the European Union 7th Framework Program and others; CULPRIT-SHOCK ClinicalTrials.gov number, NCT01927549 .).

Multivessel versus culprit lesion only percutaneous coronary intervention in cardiogenic shock complicating acute myocardial infarction: A systematic review and meta-analysis

Background:

Early revascularisation of the culprit lesion is the therapeutic cornerstone in cardiogenic shock complicating acute myocardial infarction. The optimal management of additional non-culprit lesions is unclear. This systematic review and meta-analysis aims to summarise current evidence on the comparison of immediate multivessel percutaneous coronary intervention (MV-PCI) or culprit lesion only PCI with possible staged revascularisation (C-PCI) in patients with cardiogenic shock complicating acute myocardial infarction.

Methods:

Medical literature databases were screened to identify analyses comparing MV-PCI with C-PCI in patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease. In absence of randomised trials, 10 cohort studies were included in the current meta-analysis. The primary outcome of short-term mortality was assessed at hospital discharge or 30 days after hospital admission. Secondary outcomes were long-term mortality as well as myocardial re-infarction, stroke, acute renal failure, and bleeding at short-term follow-up.

Results:

Of 6051 patients, 1194 (19.7%) received MV-PCI and 4857 (80.3%) C-PCI. Short-term mortality was 37.5% in patients undergoing MV-PCI compared with 28.8% in C-PCI patients (risk ratio 1.26, 95% confidence interval 1.12–1.41, p=0.001). Long-term mortality ( p=0.77), myocardial re-infarction ( p=0.77), stroke ( p=0.12), acute renal failure ( p=0.17) and bleeding ( p=0.53) did not differ significantly between the two revascularisation groups.

Conclusions:

Results of this first meta-analysis on the interventional management of patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease do not support MV-PCI over C-PCI. However, possible treatment selection bias in the individual studies must be taken into account.

Does Undersizing of Transcatheter Aortic Valve Bioprostheses during Valve-in-Valve Implantation Avoid Coronary Obstruction? An In Vitro Study

Background The transcatheter aortic valve-in-valve implantation (TAViVI) is an evolving treatment strategy for degenerated surgical aortic valve bioprostheses (SAVBs) in patients with high operative risk. Although hemodynamics is excellent, there is some concern regarding coronary obstruction, especially in SAVB with externally mounted leaflet tissue, such as the Trifecta (St. Jude Medical Inc., St. Paul, Minnesota, United States). We investigated coronary flow and hydrodynamics before and after TAViVI in a SAVB with externally mounted leaflet tissue (St. Jude Medical, Trifecta) with an undersized transcatheter aortic valve bioprosthesis (Edwards Sapien XT; Edwards Lifesciences LLC, Irvine, California, United States) in an in vitro study. Materials and Methods An aortic root model was constructed incorporating geometric dimensions known as risk factors for coronary obstruction. Investigating the validity of this model, we primarily performed recommended TAViVI with the Sapien XT (size 26 mm) in a Trifecta (size 25 mm) in a mock circulation. Thereafter, hydrodynamic performance and coronary flow (left/right coronary diastolic flow [lCF/rCF]) after TAViVI with an undersized Sapien XT (size 23 mm) in a Trifecta (size 25 mm) were investigated at two different coronary ostia heights (COHs, 8 and 10 mm). Results Validation of the model led to significant coronary obstruction (p < 0.001). Undersized TAViVI showed no significant reduction with respect to coronary flow (lCF: COH 8 mm, 0.90-0.87 mL/stroke; COH 10 mm, 0.89-0.82 mL/stroke and rCF: COH 8 mm, 0.64-0.60 mL/stroke; COH 10 mm, 0.62-0.58 mL/stroke). Mean transvalvular gradients (4-5 mm Hg, p < 0.001) increased significantly after TAViVI. Conclusions In our in vitro model, undersized TAViVI with the balloon-expandable Sapien XT into a modern generation SAVB (Trifecta) successfully avoided coronary flow obstruction.

Hemodynamics of the Edwards Sapien XT transcatheter heart valve in noncircular aortic annuli

OBJECTIVES

During implantation of transcatheter aortic valves into severe calcified aortic annuli, misdeployments due to asymmetric shapes of the target region were reported. Whether the resultant stent deformations influence valve performance has not been quantified. The objective of this study was to investigate in vitro hemodynamics of the Edwards Sapien XT (Edwards Lifesciences, Irvine, Calif) after valve deployment in noncircular aortic annuli.

METHODS

Six Edwards Sapien XT valves were implanted into a model of the aortic annulus with different shapes (elliptical, triangular, and bulged compared with ideal circular) and investigated in a pulsatile flow simulator. Leakage was determined by ultrasonic flow measurements, and leaflet coaptation was visualized by high-speed video. In addition, the origin of leakage was investigated under static pressure.

RESULTS

The lowest amount of leakage occurred in the ideal circular shape, whereas in most of the noncircular configurations increased transvalvular leakage due to paravalvular leaks and folds at the free edges of the leaflets was found, more often by implantation of the valve within a triangular annulus shape. Implantation of the valves into the elliptical configuration with the prosthesis commissure directed to the longitudinal axis of the annular plane showed similar values compared with the circular annulus. Pressure gradients were not influenced by the valve distortion.

CONCLUSIONS

Implantation of the Edwards Sapien XT transcatheter valve into non-circular-shaped aortic annuli leads to increased leakage. Annulus shape and relative position of the prosthesis are main determinants of leakage. Implantation into elliptical annuli, as found in bicuspid aortic valves, seems feasible.