Results of new-generation self-expanding transcatheter Porticoтм valve implantation in patients with degenerative aortic stenosis

Aim    To evaluate 30-day results of the transcatheter correction of degenerative aortic stenosis using a novel self-expandable valve, PorticoTM.Material and methods    Transcatheter aortic valve implantation (TAVI) was performed in 42 patients with an intermediate surgical risk (mean age, 74.3±6.5 years, 8 men, 34 women, EuroSCORE II risk, 2.5 (1.5;4.1)) with severe degenerative aortic stenosis (AS). 20 (48 %) patients had ischemic heart disease; 8 (19%) of patients had atrial fibrillation, and 16 (38%) of patients had type 2 diabetes mellitus. Most of the patients (88 %) had preserved systolic function, and 5 patients had a pronounced decrease in left ventricular ejection fraction. Early efficacy and safety of the intervention were evaluated with VARC-2 criteria.Results    In-hospital and 30-day mortality following TAVI was absent. Also, there were no adverse events, including cerebrovascular disorders, perioperative myocardial infarction, and conversion to open surgery. One patient had prosthesis migration to the aorta, which required implantation of the second self-expandable valve. Mean duration of the procedure was 90 min (80;110), fluoroscopy time was 21 min (19;24), and contrast volume 154 ml (200;240). Following TAVI, the mean aortic valve (AV) pressure gradient significantly decreased from 56.1±21.2 to 11.2±4.0 mm Hg, the maximal gradient decreased from 88.9±27.8 to 20.0±7.0 mm Hg, and the AV effective orifice area increased from 0.67±0.2 to 1.9±0.3 cm2 (p<0.001). By the time of discharge from the hospital, all patients showed regression of AS clinical manifestations. The percentage of patients with NYHA functional class III chronic heart failure reduced from 62 % to 7 % (p<0.001) after TAVI. In one case after the implantation, grade 3 aortic regurgitation was observed, which required endovascular occlusion to close the paraprosthetic fistula. Moderate paraprosthetic regurgitation (grade <2) was observed in 3 (7 %) patients. Only 2 (4.8%) patients required permanent pacemaker implantation.Conclusion    Results of the single-center prospective TAVI study using a novel self-expandable valve Porticoтм showed satisfactory hemodynamic parameters, efficacy and safety of the procedure for the 30-day follow-up period. A relatively low radial force of the carcass can be beneficial for reducing the incidence of permanent pacemaker implantation after TAVI.

[Experience of complex application of cardiac contractility modulation by Optimizer Smart System and endovascular mitral valve repair by the MitraClip System in the treatment of heart failure]

A 58-year-old female patient with severe chronic heart failure and mitral regurgitation receiving an optimal drug therapy was implanted with an Optimizer Smart device for modulation of cardiac contractility and underwent transcatheter mitral plasty using a MitraClip system. The complex therapy resulted in a significant clinical improvement and beneficial dynamics of echocardiographic parameters.

[Transcheter aortic valve implantation as a method of treatment of chronic heart failure in elderly and old patients: Literature review (part 2).]

The most common heart valve defect among the elderly and senile is aortic valve stenosis. The traditional method of treating severe aortic valve stenosis is open surgery to replace aortic valve. At the same time, a more modern, minimally invasive method of correcting aortic stenosis is transcatheter aortic valve implantation (TAVI). This intervention is primarily indicated for patients of old age suffering from severe chronic heart failure associated with aortic stenosis, who have a high surgical risk. Currently, TAVI has evolved from a complex and dangerous procedure into an effective and safe method of treatment thanks to the development of a new generation of devices. Currently, there are still topical issues of using TAVI in individual clinical cases (use of TAVI in the elderly (60-75 years), TAVI in centenarians (90 years or more), TAVI in frailty, the feasibility of performing TAVI with low surgical risk, etc.), as well as issues related to longevity valves used for TAVI and prognosis in terms of quality and life expectancy.

[Transcatheter aortic valve implantation in patient with critical aortic stenosis in the setting of cardiogenic shock]

This article presents a clinical case of successful transcatheter aortic valve implantation in an elderly patient with critical aortic stenosis at the stage of systolic dysfunction with development of genuine cardiogenic shock. The role of transcatheter aortic valve implantation in the pathogenetic treatment of acute heart failure due to decompensated aortic stenosis was briefly discussed.

Haemodynamic Patterns of Severe Aortic Stenosis

The authors present up-to-date review of clinical pathophysiology of aortic stenosis (AS) based on differentiation of its haemodynamic patterns, and some actual issues of instrumental diagnostics and classification of AS. The variety of clinical presentations of AS is based on diverse combination of pathological changes of haemodynamics. In Russian cardiology, there is no clear pathophysiological classification of AS despite of its relevance under the progress of surgical and transcatheter treatment of AS. The authors suggest the pilot haemodynamic classification of AS which includes 6 types (0-5) based on different combination of the following variables: left ventricle ejection fraction, stroke volume, mean aortic systolic pressure gradient. Severe AS with low transaortic pressure gradient in patients with depressed systolic function of the left ventricle (so called «low flow-low» gradient phenomenon) is referred to as the most frequent, classical haemodynamic pattern of low-gradient AS. The prevalence of this variant is about 10% among European population of patients with severe AS. The inconsistence between aortic valve area and mean pressure gradient is as common as in 35-40% of patients with AS, however, in 30-50% of these cases, AS is not severe. Severe AS is a surgical disease that should be treated in a surgical way in all patients but those in whom predicted risk overbalances potential benefits of the procedure. The use of integrated clinical and instrumental approach for identification of a true sever AS is the matter of great concern, as both overestimation and underestimation can misguide the clinical decision-making process. Verification of severe AS in patients with classical and paradoxical low flow-low gradient AS with specific indications for surgical treatment regarded is further emphasized in the paper. Since transcatheter aortic valve implantation has become a commonly recognized alternative to surgical aortic valve replacement, its role in the treatment of severe AS with different haemodynamic patterns is also discussed. The authors stress on the necessity of using tailored approach for treatment of AS regarding different clinical and pathophysiological scenarios: high gradient AS with preserved ejection fraction, classical and paradoxical low flow-low gradient AS.

[Role of magnetic resonance imaging in patients with aortic stenosis before and after replacement of the valve]

Risk stratification among patients with aortic stenosis remains inadequate, and there is a clinical need for the correct identification of high-risk patients who would benefit from aortic valve intervention before developing left ventricular decompensation. Since the publication of the results of the PARTNER study, transcatheter aortic valve implantation (TAVI) has become the method of choice for aortic valve stenosis in inoperable patients and is a real alternative to conventional surgical replacement of the aortic valve in high-risk patients. In planning TAVI and postoperative monitoring of a patient from imaging methods, the leading role is played by echocardiography and multispiral computed tomography. However, in recent years, the interest of researchers in the use of magnetic resonance imaging in this category of patients has increased. The review article examines the potential role of magnetic resonance imaging in patients with aortic stenosis before and after TAVI.

[Delayed coronary obstruction of the left main artery after transcatheter aortic valve replacement]

Coronary arteries obstruction associated with transcatheter aortic valve implantation (TAVI) may occur either during the procedure or after it. In the latter coronary obstruction can be further divided into early (7 days after procedure) or delayed one (7 days). Delayed coronary obstruction (DCO) is referred as a rare but devastating complication after TAVI and is associated with the extremely high mortality. This case demonstrates the objective difficulties of timely diagnostics of DCO. Since the results of non-invasive methods are indetermined in most cases, the authors conclude that even low-specific clinical symptoms must be interpreted as the definite rationale for the implementation of invasive diagnostic and treatment strategy.

[Critical illness - related corticosteroid insufficiency in patients after cardiac surgery and cardiologic emergencies]

Critical illness - related corticosteroid insufficiency (CIRCI) is associated with elevated level of circulating biomarkers of inflammation, pro - coagulant effects, deterioration of systemic inflammatory response syndrome (SIRS) and, consequently, prolonged in - hospital stay and increased mortality of intensive care patients. Incidence of CIRCI widely varies depending on specific patient's population and applied diagnostic thresholds being as high as 30% among postoperative patients on inotropes. CIRCI is a complex clinical and pathophysiological condition with substantial influence on immediate survival and prognosis. Clinical impact of CIRCI as well as pathogenetically based therapy arouse keen interest of intensive care specialists and clinical pathologists. The specific issues of CIRCI in patients after cardiac surgery and cardiology emergencies remain largely under - recognized, so further scrutinization is needed.

[Complications After Transcatheter Aortic Valve Implantation]

PURPOSE

to assess rate of complications after transcatheter aortic valve implantation (TAVI).

MATERIAL AND RESULTS

Our study included 99 patients who underwent TAVI. Frequent complications were: bleeding not requiring surgical hemostasis (17.2%), hemopericardium (6%), novel cardiac rhythm disturbances requiring permanent pacemaker implantation (15.1%), delirium in early postoperative period (10.7%), acute kidney injury (8.0%), stroke (7%), ventricular fibrillation (5.1%), myocardial infarction (2%). There were no significant differences in rate and type of complications between transapical and transfemoral TAVI. Comparison of general and local anesthesia showed that rate of ventricular fibrillation was significantly higher among patients subjected to transfemoral TAVI under local anesthesia (p less or equal 0.012).

[DEXMEDETOMIDINE SEDATION DURING TRANSCATHETER AORTIC VALVE IMPLANTATION.]

THE AIM

to determine the efficacy and safety of dexmedetomidinefor sedation and analgesia during transcatheter aortic valve implantation (TA VI) withfemoral access.

MATERIALS AND METHODS

the study included 34 high-risk surgical patients with "critical aortic stenosis". All patients underwent TAVI with femoral access. TAVI performed under local anaesthesia: in 18 cases - with midazolam-ketamine sedetion, in 16 cases - with dexmedetomidine sedation. The depth of sedation was evaluated by Richmond agitation-sedation scale (RASS) and Ramsay scale. Assessment includes frequency of complications arising during perioperative period.

RESULTS

in dexmedetomidine group compared with a group of midazolam/ketamine was observed significantly greater median of sedation level with RASS and Ramsay scales (- 3.5 and -1.0, p=0,000004, 5.0 and 3.0, respectively, p=0,000001). There was a signficant decrease in rapid pacing episodes in dexmedetomidine group (p = 0.0005). In the structure of complications prevailed delirium, stroke, ventricularfibrillation. There were no significant differences in the incidence and nature of complications in the groups studied. Under midazolam/ ketamine trend toward increased incidence of delirium compared with a group of dexmedetomidine (6.16 % and 6.25 %, respectively, p =0.604). There was no significant difference in the duration of operation and anesthesia in the study groups (p=0.889, p=0.103). There were no significant differences in length of hospital-stay and in the length of ICU-stay in groups studied (p =0.243, p=0.899).

CONCLUSIONS

Sedation with dexmedetomidine during TA VI with femoral access demonstrates its safety and effectiveness. Dexmedetomidine provides deep level of sedation with RASS and Ramsay scales without depression of respiratory function. There is a good tolerability of operation and good conditions for long-term use of transesophageal ECHO. In the context of ECHO monitoring further reduces the need for multiple rapid pacing (p = 0.0005), which may reduce frequency of delirium in elderly patients.

[Use of an iliac branched endoprostheis in endovascular treatment for an abdominal aortic aneurysm combined with aneurysms of both common iliac arteries]

An abdominal aortic aneurysm appears to be combined with aneurysmatic lesions of the common iliac arteries in 30-40% of cases. Like abdominal aortic aneurysms, aneurysms of the common iliac arteries rarely manifest themselves clinically. The lethality rate in case of rupture is comparable to that for rupture of an abdominal aortic aneurysm. During endoprosthetic repair of abdominal aortic aneurysms combined with aneurysms of the common iliac arteries, in order to prevent endoleaks and to improve the distal zone of fixation of endografts surgeons often resort to embolization of internal iliac arteries, which may lead to ischaemic postoperative complications. One of the methods of preserving pelvic blood flow is the use of an iliac branched endograft. A series of studies evaluating long-term outcomes demonstrated that this method proved to be both safe and effective, and with the suitable anatomy is a method of choice in high surgical risk patients. The present article deals with a clinical case report concerning bilateral endoprosthetic repair of the common iliac arteries, combined with endoprosthetic repair of an abdominal aortic aneurysm, with the description of technical peculiarities of implanting an iliac branched graft.

[Monitoring of haemodynamics and function of the aortic prosthesis during transcatheter aortic valve replacement]

PURPOSE

To find an advisability of use of invasive monitoring of intracardiac haemodynamics during transfemoral transcatheter aortic valve replacement.

PATIENTS AND METHODS

The study included 12 patients underwent transfemoral transcatheter aortic valve replacement (TTAVR). All patients were monitored according to Harvard standard. Additionally, we performed a catheterization of the right heart chambers, transesophageal or transthoracic echocardiography. Pressure in the left ventricle and aorta was measured directly after implantation ofthe aortic prosthesis.

RESULTS

Cardiac output was increased authentically in comparison with baseline in all patients. There was cardiac index increasing, however the increasing was not reliable (p ≤ 0.07). In 9 cases, baseline pulmonary artery pressure (PAP) was not changed during surgery. In 3 patients, PAP and pulmonary artery wedge pressure (PAOP) before surgery were increased. In 2 of this 3 patients, PAP and PAOP were significantly decreased after surgery. In 1 case, the pressure in the pulmonary circulation stayed increased. Ejection fraction (EF) of the left ventricle was increased after surgeries in 2 patients from 30 to 40% and from 20 to 25%. The values of stroke volume and stroke index were similar in all patients before and after surgeries. Valvular regurgitation after successful implantation of the aortic prosthesis was found in 11 patients (91.6%). We calculated dia- stolic gradient of left ventricle and the aorta and aortic regurgitation index and compared this parameters with data of echocardiography. The index of aortic regurgitation was 36.5 (35; 46), and diastolic pressure gradient in the aorta and ventricle was 48.0 (40.5; 65.5) mmHg. Calculated systolic pressure gradient in the left ventricle and aorta was 5.5 (3.0; 11.5) mmHg., this data proved that there was no stenosis of aortic prosthesis.

CONCLUSION

Invasive monitoring of intracardiac haemodynamics during transfemoral transcatheter aortic valve replace-ment allows to diagnose quality of prosthesis implantation accurately and provides data about valvular regurgitation. Invasive monitoring helps to provide haemodynamic stability in patients with critical aortic stenosis during anaesthesia.

[Endovascular treatment of spontaneous rupture of the thoracic aorta]

Spontaneous rupture of the aorta is an uncommonly encountered acute surgical aortic pathology characterised by an utterly unfavourable prognosis. The article deals with a case report concerning successful endovascular treatment of spontaneous rupture of the thoracic portion of the aorta, followed by discussion of problems regarding aetiology, diagnosis, and therapeutic policy for such pathology.

[Transcatheter Treatment of Degenerative Critical Aortic Valve Stenosis in a Patient With Severe Heart Failure and Chronic Lymphocytic Leukemia]

Surgical aortic valve replacement is the standard therapy for severe aortic valve stenosis, however one third of patients are rejected because of high surgical risk. Under medical treatment alone these patients have a very poor prognosis with a high mortality rate. We present a case of 70-year-old male patient with degenerative symptomatic critical aortic stenosis and chronic lymphocytic leukemia. Due to recurrence.

[A clinical case of endovascular prosthetic repair of a gigantic abdominal aorta aneurysm]

To illustrate the present-day possibilities in treatment of aortic dissection we describe herein a clinical case report concerning successful prosthetic repair of a gigantic aneurysm of the infrarenal portion of the aorta with the Gore Excluder using an endovascular surgical approach in a patient running high risk associated with difficult anatomy of the abdominal portion of the aorta, iliac arteries, and accompanying diseases (left lung cancer, CAD, critical stenosis of the RCA. This was followed by balloon angioplasty with stenting of the RCA with Lekton stents with a good angiographic result. EVAR has become an alternative to the conventional open surgery with lower risk of complications, shorter hospital stay, and decreased mortality rate, which was confirmed by the findings of international studies.

[Problems of brain protection in aortic arch operations]

33 patients (25 men and 8 women, aged 18 to 69 years, mean age 47 +/- 12.3 years), underwent ascending aorta and aortic arch replacement. During arch replacement the authors used the following brain protection methods: profound hypothermic circulatory arrest--in 4 (12.1%) patients, retrograde brain perfusion via superior vena cava--in 11 (33.3%), antegrade perfusion via brachycephalic vessels--in 18 (54.6%) patients. Pharmacological brain protection was applied in all cases as an addition to the listed techniques. 14 (45%) patients underwent partial aortic arch replacement; in 19 (57.6%) patients total aortic arch replacement was performed, including "elephant trunk" distal anastomosis in 4 cases. Hospital mortality rate in patients who underwent operations on the aortic arch was 18.1% (6 patients). Postoperative neurological disorders, such as transient dysfunction, were observed in 8 (24%) patients; cerebral strokes or intractable neurological disorders were not recorded. The choice of a brain protection method is determined by the extent of the operation and necessary circulation arrest time.