Five-Year Follow-Up from the CoreValve Expanded Use Transcatheter Aortic Valve-in-Surgical Aortic Valve Study

Transcatheter aortic valve replacement (TAVR) provides an option for extreme-risk patients who underwent reoperation for a failed surgical aortic bioprosthesis. Long-term data on patients who underwent TAVR within a failed surgical aortic valve (TAV-in-SAV) are limited. The CoreValve Expanded Use Study evaluated patients at extreme surgical risk who underwent TAV-in-SAV. Outcomes at 5 years were analyzed by SAV failure mode (stenosis, regurgitation, or combined). Echocardiographic outcomes are site-reported. TAV-in-SAV was attempted in 226 patients with a mean age of 76.7 ± 10.8 years; 63.3% were male, the Society of Thoracic Surgeons predicted risk of mortality score was 9.0 ± 6.7%, and 87.5% had a New York Heart Association classification III or IV symptoms. Most of the failed surgical bioprostheses were stented (81.9%), with an average implant duration of 10.2 ± 4.3 years. The 5-year all-cause mortality or major stroke rate was 47.2% in all patients; 54.4% in the stenosis, 37.6% in the regurgitation, and 38.0% in the combined groups (p = 0.046). At 5 years, all-cause mortality was higher in patients with versus without 30-day severe prosthesis-patient mismatch (51.7% vs 38.3%, p = 0.026). The overall aortic valve reintervention rate was 5.9%; highest in the regurgitation group (12.6%). The mean aortic valve gradient was 14.1 ± 9.8 mm Hg and effective orifice area was 1.57 ± 0.70 at 5 years. Few patients had >mild paravalvular regurgitation at 5 years (5.5% moderate, 0.0% severe). TAV-in-SAV with supra-annular, self-expanding TAVR continues to represent a safe and lasting intermediate option for extreme-risk patients who have appropriate sizing of the preexisting failed surgical valve. Clinical and hemodynamic outcomes were stable through 5 years.

Effects of atherectomy on major adverse limb events for femoropopliteal interventions: Vascular Quality Initiative registry

BACKGROUND

Atherectomy use in treatment of femoropopliteal disease has significantly increased despite scant evidence of benefit to long-term clinical outcomes.

AIMS

We investigated the clinical benefits of atherectomy over standard treatment for femoropopliteal interventions.

METHODS

Using data from the Society of Vascular Surgery's Vascular Quality Initiative (VQI) registry, we identified patients who underwent isolated femoropopliteal interventions for occlusive disease. We compared 13,423 patients treated with atherectomy with 47,371 receiving standard treatment; both groups were allowed definitive treatment with a drug-coated balloon or stenting. The primary endpoint was major adverse limb events (MALEs), which is a composite of target vessel re-occlusion, ipsilateral major amputation, and target vessel revascularization.

RESULTS

Mean age was 69 ± 11 years, and patients were followed for a median of 30 months. Overall rates of complications were slightly higher in the atherectomy group than the standard treatment group (6.2% vs. 5.9%, p < 0.0001). In multivariable analysis, after adjusting for demographic and clinical covariates, atherectomy use was associated with a 13% reduction in risk of MALEs (adjusted odds ratio [aOR]: 0.87; 95% confidence interval [CI]: 0.77-0.98). Rates of major and minor amputations were significantly lower in the atherectomy group (3.2% vs. 4.6% and 3.3% vs. 4.3%, respectively, both p < 0.001), primarily driven by a significantly decreased risk of major amputations (aOR 0.69; 95% CI: 0.52-0.91). There were no differences in 30-day mortality, primary patency, and target vessel revascularization between the atherectomy and standard treatment groups.

CONCLUSIONS

In adults undergoing femoropopliteal interventions, the use of atherectomy was associated with a reduction in MALEs compared with standard treatment.

In hospital outcomes among diabetics undergoing transcarotid artery revascularisation vs transfemoral carotid artery stenting & carotid endarterectomy

Background

Transcarotid artery revascularisation (TCAR) is a novel procedure to intervene on carotid artery stenosis. It has previously shown to have lower rates of periprocedural adverse events compared to transfemoral carotid artery stenting (TFCAS) and carotid endartectomy (CEA). To date, no study has examined outcomes among diabetics undergoing TCAR compared to TFCAS and CEA.

Purpose

We sought to determine the rates of adverse periprocedural outcomes related to TCAR, TFCAS and CEA in diabetics.

Methods

The Vascular Quality Initiative Database was queried for all patients from March 2009 to April 2021 for diabetic patients undergoing carotid artery revascularisation via TCAR, TFCAS or CEA. Baseline demographic information as well as periprocedural outcomes were obtained.

Results

A total of 57,716 diabetic patients underwent carotid artery revascularisation. Of these 11.3% underwent TCAR (n=6569), 8.1% (n=4703) underwent TFCAS, and 80.4% (n=46,444) underwent CEA. 39% (n=22,528) were female and 87.3% (n=50,377) were white. Compared to TFCAS, TCAR demonstrated lower rates of stroke (1.6% vs 2.2%, p=0.026), stroke/transient ischemic attack (2.2% vs 3.0%, p&lt;0.001), and death (0.4% vs 1.3%, p&lt;0.001) but remained higher than CEA for both stroke (1.6% vs 1.3%), stroke/TIA (2.2% vs 1.9%) and death (0.4% vs 0.3%).

Conclusions

TCAR appears to be a safe revascularisation procedure for carotid artery stenosis with lower rates of stroke, stroke/TIA, and death in diabetics compared to TFCAS. However, rates remain higher than CEA. TCAR may thus be a viable alternative in diabetics who otherwise would be poor candidates for revascularisation via CEA.

Funding Acknowledgement

Type of funding sources: None.

Left Ventricular Mechanics Differ in Subtypes of Aortic Stenosis Following Transcatheter Aortic Valve Replacement

Background

Left ventricular (LV) mechanics are impaired in patients with severe aortic stenosis (AS). We hypothesized that there would be differences in myocardial mechanics, measured by global longitudinal strain (GLS) recovery in patients with four subtypes of severe AS after transcatheter aortic valve replacement (TAVR), stratified based upon flow and gradient.

Methods

We retrospectively evaluated 204 patients with severe AS who underwent TAVR and were followed post-TAVR at our institution for clinical outcomes. Speckle-tracking transthoracic echocardiography was performed pre- and post-TAVR. Patients were classified as: (1) normal-flow and high-gradient, (2) normal-flow and high-gradient with reduced LV ejection fraction (LVEF), (3) classical low-flow and low-gradient, or (4) paradoxical low-flow and low-gradient.

Results

Both GLS (−13.9 ± 4.3 to −14.8 ± 4.3, P < 0.0001) and LVEF (55 ± 15 to 57 ± 14%, P = 0.0001) improved immediately post-TAVR. Patients with low-flow AS had similar improvements in LVEF (+2.6 ± 9%) and aortic valve mean gradient (−23.95 ± 8.34 mmHg) as patients with normal-flow AS. GLS was significantly improved in patients with normal-flow (−0.93 ± 3.10, P = 0.0004) compared to low-flow AS. Across all types of AS, improvement in GLS was associated with a survival benefit, with GLS recovery in alive patients (mean GLS improvement of −1.07 ± 3.10, P < 0.0001).

Conclusions

LV mechanics are abnormal in all patients with subtypes of severe AS and improve immediately post-TAVR. Recovery of GLS was associated with a survival benefit. Patients with both types of low-flow AS showed significantly improved, but still impaired, GLS post-TAVR, suggesting underlying myopathy that does not correct post-TAVR.

Impact of annular and supra-annular CoreValve deployment locations on aortic and coronary artery hemodynamics

CoreValve is widely used in transcatheter aortic valve replacement, but the impact of its deployment location on hemodynamics is unexplored despite a potential role in subsequent aortic and coronary artery pathologies. The objectives of this investigation were to perform fluid-structure interaction (FSI) simulations for a 29 mm CoreValve deployed in annular vs supra-annular locations, and characterize resulting hemodynamics including velocity and wall shear stress (WSS). Patient-specific geometry was reconstructed from computed tomography scans and CoreValve was deployed using a finite element approach. FSI simulations were then performed using a boundary conforming method and realistic boundary conditions. Results showed that CoreValve deployment location impacts hemodynamics in the ascending aorta and flow patterns in the coronary arteries. During peak-systole, annularly deployed CoreValve produced a jet-like flow structure impinging on the outer-curvature of the ascending aorta. Supra-annularly deployed CoreValve having a lateral tilt of 10° led to a more centered jet impinging further downstream. At mid-systole, valve leaflets of the annularly deployed CoreValve closed asymmetrically leading to disorganized flow patterns in the ascending aorta vs those from the supra-annular position. Supra-annularly deployed CoreValve also led to high-velocity para-valvular flow supplying the coronary arteries. CoreValve in the supra-annular position significantly (P < 0.05) elevated WSS within the first few diameters of both coronary arteries as compared to the annular position for many time points quantified. These results afforded by the advanced simulation methods may have important clinical implications given the role of aortic hemodynamics in dilation and the pro-atherogenic nature of WSS alterations in the coronary arteries.

Effect of Mechanically Expanded vs Self-Expanding Transcatheter Aortic Valve Replacement on Mortality and Major Adverse Clinical Events in High-Risk Patients With Aortic Stenosis: The REPRISE III Randomized Clinical Trial

IMPORTANCE

Transcatheter aortic valve replacement (TAVR) is established for selected patients with severe aortic stenosis. However, limitations such as suboptimal deployment, conduction disturbances, and paravalvular leak occur.

OBJECTIVE

To evaluate if a mechanically expanded valve (MEV) is noninferior to an approved self-expanding valve (SEV) in high-risk patients with aortic stenosis undergoing TAVR.

DESIGN, SETTING, AND PARTICIPANTS

The REPRISE III trial was conducted in 912 patients with high or extreme risk and severe, symptomatic aortic stenosis at 55 centers in North America, Europe, and Australia between September 22, 2014, and December 24, 2015, with final follow-up on March 8, 2017.

INTERVENTIONS

Participants were randomized in a 2:1 ratio to receive either an MEV (n = 607) or an SEV (n = 305).

MAIN OUTCOMES AND MEASURES

The primary safety end point was the 30-day composite of all-cause mortality, stroke, life-threatening or major bleeding, stage 2/3 acute kidney injury, and major vascular complications tested for noninferiority (margin, 10.5%). The primary effectiveness end point was the 1-year composite of all-cause mortality, disabling stroke, and moderate or greater paravalvular leak tested for noninferiority (margin, 9.5%). If noninferiority criteria were met, the secondary end point of 1-year moderate or greater paravalvular leak was tested for superiority in the full analysis data set.

RESULTS

Among 912 randomized patients (mean age, 82.8 [SD, 7.3] years; 463 [51%] women; predicted risk of mortality, 6.8%), 874 (96%) were evaluable at 1 year. The primary safety composite end point at 30 days occurred in 20.3% of MEV patients and 17.2% of SEV patients (difference, 3.1%; Farrington-Manning 97.5% CI, -∞ to 8.3%; P = .003 for noninferiority). At 1 year, the primary effectiveness composite end point occurred in 15.4% with the MEV and 25.5% with the SEV (difference, -10.1%; Farrington-Manning 97.5% CI, -∞ to -4.4%; P<.001 for noninferiority). The 1-year rates of moderate or severe paravalvular leak were 0.9% for the MEV and 6.8% for the SEV (difference, -6.1%; 95% CI, -9.6% to -2.6%; P < .001). The superiority analysis for primary effectiveness was statistically significant (difference, -10.2%; 95% CI, -16.3% to -4.0%; P < .001). The MEV had higher rates of new pacemaker implants (35.5% vs 19.6%; P < .001) and valve thrombosis (1.5% vs 0%) but lower rates of repeat procedures (0.2% vs 2.0%), valve-in-valve deployments (0% vs 3.7%), and valve malpositioning (0% vs 2.7%).

CONCLUSIONS AND RELEVANCE

Among high-risk patients with aortic stenosis, use of the MEV compared with the SEV did not result in inferior outcomes for the primary safety end point or the primary effectiveness end point. These findings suggest that the MEV may be a useful addition for TAVR in high-risk patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02202434.

Direct Aortic Access for Transcatheter Aortic Valve Replacement Using a Self-Expanding Device

BACKGROUND

Transcatheter aortic valve replacement (TAVR) using a self-expanding valve has been shown to be superior to an open operation in high-risk patients. Extensive iliofemoral peripheral vascular disease can prohibit femoral access. In these cases, direct aortic (DA) implantation may be a suitable option.

METHODS

The current analysis compared outcomes in patients undergoing TAVR with the self-expanding CoreValve prosthesis (Medtronic, Minneapolis, MN) by direct aortic (DA) access vs iliofemoral (IF) access. Patients treated in the CoreValve US High Risk and Extreme Risk Pivotal Trials and Continued Access Study were included. Propensity score matching was used to account for differences in baseline characteristics between groups. Clinical outcomes were compared at 30 days and 1 year.

RESULTS

We identified 394 matched pairs of IF and DA patients. The all-cause mortality rate was significantly higher in the DA group than in the IF group at 30 days (10.9% vs 4.1%, p < 0.001), but this difference was reduced at 1 year (28.1% vs 23.2%, p = 0.063). All-cause mortality or major stroke was significantly higher for DA vs IF access at 30 days (13.5% vs 5.3%, p < 0.001) and at 1 year (30.4% vs 24.2%, p = 0.025). Major/life-threatening bleeding and acute kidney injury were significantly greater in the DA group at 30 days (66.7% vs 35.4% and 19.7% vs 10.0%, respectively, both p < 0.001).

CONCLUSIONS

When femoral access is not feasible, DA access allows effective delivery of the valve but incurs an increased risk of death and adverse events, potentially the result of procedural differences.

Transthoracic echocardiography is adequate for intraprocedural guidance of transcatheter aortic valve implantation

Background

While transcatheter aortic valve implantation (TAVI) has traditionally been supported intraprocedurally by transoesophageal echocardiography (TOE), transthoracic echocardiography (TTE) is increasingly being used. We evaluated echocardiographic imaging characteristics and clinical outcomes in patients who underwent TTE during TAVI (TTE-TAVI).

Methods and results

A select team of dedicated sonographers and interventional echocardiographers performed TTE-TAVI in 278 patients, all of whom underwent TAVI through transfemoral access. We implanted the Medtronic EVOLUT R valve in 258 patients (92.8%). TTE images were acquired immediately pre-procedure by a dedicated sonographer in the cardiac catheterization laboratory with the patient in the supine position. TTE was then performed post deployment of TAVI. In the procedure, TTE image quality was fair or better in 249 (89.6%) cases. Color-flow Doppler was adequate or better in 275 (98.9%) cases. In 2 cases, paravalvular regurgitation (PVL) could not be assessed confidently by echocardiography due to poor image quality; in those cases, PVL was assessed by fluoroscopy, aortic root injection and invasive hemodynamics. Both TTE and invasive hemodynamics were used in the assessment of need for post-deployment stent ballooning (n = 23, 8.3%). TTE adequately recognized new pericardial effusion in 3 cases. No case required TOE conversion for image quality. There was only 1 case of intraprocedural TTE failing to recognize moderate PVL, without clinical implication. In 99% of patients, TTE-TAVI adequately assessed PVL compared with 24-h and 1-month follow-up TTE.

Conclusions

With the current generation of TAVI, TTE-TAVI is adequate intraprocedurally when performed by specialized sonographers and dedicated cardiologists in a highly experienced TAVI center.

Bivalirudin versus unfractionated heparin during peripheral vascular interventions: A Propensity-matched Study

OBJECTIVES

This study aimed to compare the association of access site complications and the use of unfractionated heparin versus bivalirudin during subinguinal peripheral vascular intervention.

BACKGROUND

Compared to unfractionated heparin, bivalirudin has been associated with fewer bleeding complications in patients undergoing percutaneous coronary intervention but more ischemic events. The safety and efficacy of direct thrombin inhibitors in peripheral vascular interventions is not well defined.

METHODS

We compared the incidence of in-hospital access site complications and discharge status among patients in the multicenter, prospective Vascular Quality Initiative registry who underwent peripheral vascular intervention between August 2007 and January 2014 using bivalirudin or unfractionated heparin. Propensity score matching was used to obtain a balanced cohort of 1,524 patients in each treatment group.

RESULTS

Patients treated with bivalirudin had a significantly lower incidence of access site hematomas (2.4% vs. 3.9%, P = 0.018), shorter post-procedural hospitalization (1.0 vs. 1.2 days, P < 0.001) and lower rates of discharge to a nursing home or rehabilitation center rather than home (7.61% vs. 9.73%, P = 0.034) when compared with unfractionated heparin-treated patients. The incidence of in-hospital access site occlusion, distal embolization, and mortality did not differ significantly between groups.

CONCLUSIONS

Patients who received bivalirudin had lower rates of access site hematoma, shorter length of stay, and improved discharge status compared with unfractionated heparin during hospitalization for peripheral vascular intervention. Randomized comparisons of these agents are needed to confirm these findings. © 2016 Wiley Periodicals, Inc.

Native Mitral Stenosis Treated With Transcatheter Mitral Valve Replacement

Surgical treatment of mitral stenosis with extreme calcification remains a challenge. Recently, the balloon-expandable valve prosthesis, anchored by radial force, offers a new option for these patients. We present 2 cases of transcatheter mitral valve replacement in patients with severe native mitral valve stenosis and annular calcification deemed too extensive for conventional surgical techniques.

Beneficial effects of a point-of-care bleeding risk calculator on anticoagulant selection in the coronary catheterization laboratory

STUDY OBJECTIVES

To estimate periprocedural bleeding risk before elective percutaneous coronary intervention (PCI) by using a point-of-care bleeding risk calculator and to document changes in anticoagulant use and bleeding complications after implementation of use of this calculator.

DESIGN

Prospective observational pilot study with a historical control cohort.

SETTING

Tertiary care medical center.

PATIENTS

The pilot cohort consisted of 100 patients undergoing ad hoc PCI during elective cardiac catheterization procedures between January and May 2013, whose bleeding risk and accompanying PCI anticoagulant recommendations were determined by the use of a pre-PCI point-of-care bleeding risk calculator. The historical control cohort consisted of all patients who underwent elective PCI at the same facility between April 1, 2011, and March 31, 2012, before implementation of use of the bleeding risk calculator.

MEASUREMENTS AND MAIN RESULTS

The pre-PCI bleeding risk calculator distinguished patients in the pilot cohort as high risk (score 12 or higher) or low risk (lower than 12) for bleeding after a PCI procedure. The primary outcome was bivalirudin use in the pilot cohort compared with its use in the historical control cohort. Implementation of the bleeding risk calculator significantly decreased bivalirudin use compared with bivalirudin use in the historical control cohort (87% in the control cohort vs 60% in the pilot cohort, p<0.01). Bivalirudin use remained high in patients at high bleeding risk (82.2% in the pilot cohort vs 87.4% in the control cohort, p=0.3) and its use was decreased in patients at low bleeding risk (41.8% in the pilot cohort vs 87.1% in the control cohort, p<0.01). The incidence of bleeding complications in the pilot cohort was comparable with that in the control cohort (1% vs. 0.4%, p=0.37), although this pilot study was underpowered to potentially detect a significant change in the incidence of bleeding complications.

CONCLUSION

A simple bleeding risk calculator can substantially reduce overall bivalirudin use by specifically decreasing its use among patients at low bleeding risk while maintaining its use among patients at high bleeding risk. The incidence of bleeding complications remained unchanged despite decreasing bivalirudin use among patients undergoing elective coronary catheterization who were at low risk for bleeding.

Access site complications after peripheral vascular interventions: incidence, predictors, and outcomes

BACKGROUND

Access site hematomas and pseudoaneurysms are the most frequent complications of peripheral vascular intervention (PVI); however, their incidence and risk factors remain unclear.

METHODS AND RESULTS

We retrospectively analyzed data from the multicenter Vascular Quality Initiative on 22 226 patients who underwent 27 048 PVI from August 2007 to May 2013. Primary end points included incidence and predictors of access site complications (ASCs), length of postprocedural hospitalization, discharge status, and 30-day and 1-year mortality. ASC complicated 936 procedures (3.5%). Of these, 74.4% were minor complications, 9.7% were moderate requiring transfusion, 5.4% were moderate requiring thrombin injection, and 10.5% were severe requiring surgery. Predictors of ASC were age >75 years, female sex, white race, no prior PVI, nonfemoral arterial access site, >6-Fr sheath size, thrombolytics, arterial dissection, fluoroscopy time >30 minutes, nonuse of vascular closure device, bedridden preoperative ambulatory status, and urgent indication. Mean hospitalization was longer after procedures complicated by ASC (1.2±1.6 versus 1.9±1.9 days; range, 0-7 days; P=0.002). Severity of ASC correlated with higher rates of discharge to rehabilitation/nursing facilities compared with home discharge. Patients with severe ASC had higher 30-day mortality (6.1% versus 1.4%; P<0.001), and those with moderate ASC requiring transfusion had elevated 1-year mortality (12.1% versus 5.7%; P<0.001).

CONCLUSIONS

Several factors independently predict ASC after PVI. Appropriate use of antithrombotic therapies and vascular closure device in patients at increased risk of ASC may improve post-PVI outcomes.

Heparin-bonded, expanded polytetrafluoroethylene-lined stent graft in the treatment of femoropopliteal artery disease: 1-year results of the VIPER (Viabahn Endoprosthesis with Heparin Bioactive Surface in the Treatment of Superficial Femoral Artery Obstructive Disease) trial

PURPOSE

To evaluate the performance of a heparin-bonded, expanded polytetrafluoroethylene (ePTFE)-lined nitinol endoprosthesis in the treatment of long-segment occlusive disease of the femoropopliteal artery (FPA) and to identify factors associated with loss of patency.

MATERIALS AND METHODS

In a single-arm, prospective, 11-center study (VIPER [Gore Viabahn Endoprosthesis with Heparin Bioactive Surface in the Treatment of Superficial Femoral Artery Obstructive Disease] trial), 119 limbs (113 patients; 69 men; mean age, 67 y), including 88 with Rutherford category 3-5 disease and 72 with Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) C or D lesions of the FPA, underwent stent graft implantation. The mean lesion length was 19 cm; 56% of lesions were occlusions. Follow-up evaluations included color duplex ultrasonography in all patients, with patency defined as a peak systolic velocity ratio< 2.5.

RESULTS

At 12 months, Rutherford category and ankle-brachial index (ABI) were significantly improved (mean category improvement, 2.4; ABI increased from 0.6±0.2 to 0.9±0.19; P<.0001). Primary and secondary patency rates were 73% and 92%. The primary patency for devices oversized<20% at the proximal landing zone was 88%, whereas the primary patency for devices oversized by>20% was 70% (P = .047). Primary patency was not significantly affected by device diameter (5 vs 6 vs 7 mm) or lesion length (≤20 cm vs>20 cm). The 30-day major adverse event rate was 0.8%.

CONCLUSIONS

The heparin-bonded, ePTFE/nitinol stent graft provided clinical improvement and a primary patency rate of 73% at 1 year in the treatment of long-segment FPA disease. Careful sizing of the device relative to vessel landing zones is essential for achieving optimal outcomes.

Long-term results of carotid stenting versus endarterectomy in high-risk patients

BACKGROUND

We previously reported that, in a randomized trial, carotid stenting with the use of an emboli-protection device is not inferior to carotid endarterectomy for the treatment of carotid artery disease at 30 days and at 1 year. We now report the 3-year results.

METHODS

The trial evaluated carotid artery stenting with the use of an emboli-protection device as compared with endarterectomy in 334 patients at increased risk for complications from endarterectomy who had either a symptomatic carotid artery stenosis of at least 50% of the luminal diameter or an asymptomatic stenosis of at least 80%. The prespecified major secondary end point at 3 years was a composite of death, stroke, or myocardial infarction within 30 days after the procedure or death or ipsilateral stroke between 31 days and 1080 days (3 years).

RESULTS

At 3 years, data were available for 260 patients (77.8%), including 85.6% of patients in the stenting group and 70.1% of those in the endarterectomy group. The prespecified major secondary end point occurred in 41 patients in the stenting group (cumulative incidence, 24.6%; Kaplan-Meier estimate, 26.2%) and 45 patients in the endarterectomy group (cumulative incidence, 26.9%; Kaplan-Meier estimate, 30.3%) (absolute difference in cumulative incidence for the stenting group, -2.3%; 95% confidence interval, -11.8 to 7.0). There were 15 strokes in each of the two groups, of which 11 in the stenting group and 9 in the endarterectomy group were ipsilateral.

CONCLUSIONS

In our trial of patients with severe carotid artery stenosis and increased surgical risk, no significant difference could be shown in long-term outcomes between patients who underwent carotid artery stenting with an emboli-protection device and those who underwent endarterectomy. (ClinicalTrials.gov number, NCT00231270 [ClinicalTrials.gov].).

Protected carotid-artery stenting versus endarterectomy in high-risk patients

BACKGROUND

Carotid endarterectomy is more effective than medical management in the prevention of stroke in patients with severe symptomatic or asymptomatic atherosclerotic carotid-artery stenosis. Stenting with the use of an emboli-protection device is a less invasive revascularization strategy than endarterectomy in carotid-artery disease.

METHODS

We conducted a randomized trial comparing carotid-artery stenting with the use of an emboli-protection device to endarterectomy in 334 patients with coexisting conditions that potentially increased the risk posed by endarterectomy and who had either a symptomatic carotid-artery stenosis of at least 50 percent of the luminal diameter or an asymptomatic stenosis of at least 80 percent. The primary end point of the study was the cumulative incidence of a major cardiovascular event at 1 year--a composite of death, stroke, or myocardial infarction within 30 days after the intervention or death or ipsilateral stroke between 31 days and 1 year. The study was designed to test the hypothesis that the less invasive strategy, stenting, was not inferior to endarterectomy.

RESULTS

The primary end point occurred in 20 patients randomly assigned to undergo carotid-artery stenting with an emboli-protection device (cumulative incidence, 12.2 percent) and in 32 patients randomly assigned to undergo endarterectomy (cumulative incidence, 20.1 percent; absolute difference, -7.9 percentage points; 95 percent confidence interval, -16.4 to 0.7 percentage points; P=0.004 for noninferiority, and P=0.053 for superiority). At one year, carotid revascularization was repeated in fewer patients who had received stents than in those who had undergone endarterectomy (cumulative incidence, 0.6 percent vs. 4.3 percent; P=0.04).

CONCLUSIONS

Among patients with severe carotid-artery stenosis and coexisting conditions, carotid stenting with the use of an emboli-protection device is not inferior to carotid endarterectomy.

Endovascular Stent Graft Repair of Abdominal Aortic Aneurysms in High-Risk Patients:. A Single Center Experience

BACKGROUND

Endovascular stent graft (EVG) repair can be a safe alternative to open surgical repair to treat abdominal aortic aneurysms (AAA) in high-risk patients. We report our results with EVG repair in such high-risk patients at our institution.

OBJECTIVES

We wanted to show that EVG repair can be performed successfully and with a low complication rate in patients with serious comorbidities.

METHODS

All patients prospectively studied underwent EVG repair of AAA from February 2000 to July 2002.

RESULTS

Of the 60 patients studied, 45 (75%) were high-risk surgical candidates because of associated comorbidities; their aneurysms ranged from 4.5 to 10 cm (mean: 5.7 +/- 1.2 cm). Fifty-nine of 60 patients (98.3%) were treated successfully. Two (3.3%) who underwent surgical intervention for site-related complications died from postoperative complications. Hospital stay was <48 hours in 46 (77%) patients.

CONCLUSION

Our preliminary results show that EVG is safe, feasible, and yields excellent technical success even in patients at high risk for complications. Teamwork between interventional cardiologists and vascular surgeons is advised.

Current management of patients with patent foramen ovale and cryptogenic stroke: our experience and review of the literature

BACKGROUND

Patent Foramen Ovale (PFO) occurs in approximately 25% of the population and has been implicated in the etiology of cryptogenic stroke. Although the exact mechanism of PFO's role in stroke has not been defined, there is a growing body of evidence that supports both the safety and therapeutic benefit of PFO closure in cryptogenic stroke. Current methods of therapy include anticoagulation, surgical closure, and percutaneous closure.

METHODS

We completed a retrospective analysis of data from the first 20 PFO closures at our institution and evaluated the current literature on PFO treatment.

RESULTS

Percutaneous closure had a 100% technical success rate. There were no procedural complications and only 1 episode of supraventricular arrhythmia requiring therapy.

CONCLUSION

Percutaneous closure is associated with a high technical success rate, decreased morbidity compared to surgery, and equal benefits after endothelialization of the device. As the mechanisms involved in PFO are better delineated, clear guidelines can be established for the percutaneous closure and follow-up of PFO.

Prospective randomized study of N-acetylcysteine, fenoldopam, and saline for prevention of radiocontrast-induced nephropathy

The objective of this study was to compare the efficacy of N-acetylcysteine (NAC), fenoldopam, and saline in preventing radiocontrast-induced nephropathy (RCIN) in high-risk patients undergoing cardiovascular procedures. We prospectively enrolled 123 patients who were scheduled for cardiovascular procedures and had a baseline creatinine > 1.6 mg/dl or creatinine clearance of < 60 ml/min. Patients were randomly assigned to receive either saline (0.45% normal saline at 1 cc/kg) for 12 hr before and 12 hr after the procedure, or fenoldopam (0.1 microg/kg/min) plus saline for 4 hr prior and 4 hr after the procedure, or NAC orally (600 mg) plus saline every 12 hr for 24 hr prior and 24 hr after the procedure. All the patients received low-osmolality nonionic contrast. RCIN was defined as an increase in creatinine level > 0.5 mg/dl after 48 hr. The incidence of RCIN was 17.7% in the NAC group, 15.3% in the saline group, and 15.7% in the fenoldopam group (P = 0.919). Of the 20 patients who developed RCIN, 2 required dialysis. Serum creatinine decreased after 48 hr (vs. baseline) in 38% patients in the NAC group, 18% in the fenoldopam group, and 15% in the saline group. In patients with chronic renal insufficiency, NAC or fenoldopam offered no additional benefit over hydration with saline in preventing RCIN.

Extensive coronary dissection treated with endarterectomy and coronary reconstruction

Acute coronary dissection is an uncommon event, usually not related to typical coronary risk factors, usually in women, and usually diagnosed at autopsy. This report describes a young woman with extensive left anterior descending coronary artery (LAD) dissection, refused for intervention since there was no lesion to angioplasty and no artery to bypass. A long arteriotomy was made, removing under direct vision all of the torn and dissected tissue, just as would be done for extensive LAD endarterectomy. A vein was split and attached to reconstruct the artery. Normal left ventricular function was restored.

Peripheral Artery Pseudoaneurysm: Treatment by Transcutaneous Compression Guided by Ultrasonography

Pseudoaneurysm is a well-recognized complication of invasive arterial procedures that is easily diagnosed with ultrasound. While most pseudoaneurysms will be resolved spontaneously within 3 months, some may lead to limb swelling, ischemia, thromboembolism, or nerve damage. To forestall such complications, we attempted to close the lesion using ultrasound to guide application of pressure in 13 patients with pseudoaneurysms following arterial catheterizations. Successful closure averaged 64 minutes (range 20-180) with successful results achieved in 11 (85%) of the 13 patients. No complications followed the application of either manual or device-assisted pressure. We conclude that transcutaneous compression is a generally safe and successful treatment of uncomplicated pseudoaneurysm and should be used as the treatment of choice for this lesion. (ECHOCARDIOGRAPHY, Volume 13, September 1996)

Variation among cardiologists in the utilization of right heart catheterization at time of coronary angiography

To describe how often a right heart catheterization was performed at the time of coronary angiography, the patient characteristics that predicted the use of this procedure, and the variation among cardiologists in the use of this test, we reviewed all cases of coronary angiography (n = 1,282) during the first 2 mo of 1993 at two large community hospitals. Fifty-two percent of the cases received a right heart catheterization at the time of their coronary angiography. The following characteristics were associated with the receipt of a right heart catheterization in a logistic regression analysis: cardiomyopathy (odds ratio = 2.59, 95% CI = 1.01, 6.62), congestive heart failure (odds ratio = 2.07, 95% CI = 1.42, 3.01), valvular heart disease (odds ratio = 2.54, 95% CI = 1.44, 4.49), no coronary angioplasty performed at the procedure (odds ratio = 2.71, 95% CI = 2.12, 3.45), and increased age (odds ratio = 1.13 per decade, 95% CI = 1.03, 1.25). Of 37 cardiologists who performed > 10 coronary angiography procedures, the use of right heart catheterization varied from 10-90%. The cardiologists' practice variation persisted after adjustment for patient clinical characteristics. Because of the high utilization of right heart catheterization at the time of coronary angiography and the variation in use among cardiologists, even when controlling for patient characteristics, the issue of appropriate indications for this procedure needs to be addressed in a rigorous fashion.

Percutaneous balloon aortic valvuloplasty in high-risk elderly patients

From 1987 to mid-1994 we performed 16 percutaneous balloon aortic valvuloplasties. All patients (mean age 80 years; 53% female, 47% male) had significant congestive heart failure from aortic valve stenosis; the majority were categorized as New York Heart Association Class IV (shortness of breath at rest). Twelve patients were not surgical candidates; four patients refused surgery. After valvuloplasty, all patients became asymptomatic (NYHA Class I & II), the average preprocedure valvular gradient of 59 mm Hg decreased to 31 mm Hg, and valve area increased from 0.8 cm2 (0.3 cm2-0.98 cm2) to 1.3 cm2 (0.6 cm2-1.44 cm2). The only complications were two minor groin hematomas (2 patients). Within 6 months, 50% of the patients were symptomatic again; the overall survival rate was 23 months. We conclude that in the proper environment this procedure can be effective and safe--even in high-risk elderly patients. Although symptom improvement is transient, valvuloplasty provides a valuable opportunity to treat intercurrent medical conditions and possibly follow up with surgery.

Transesophageal echocardiographically guided atrial transseptal catheterization in patients with normal-sized atria: incidence of complications

The incidence of cardiac complications from atrial transseptal catheterization has never been quantified in patients with normal-sized atria. Series defining the complication rate are derived from diseased hearts with structural changes that may alter the complication rate of the procedure. The generation of a standardized incidence of perforation in a population of structurally normal atria has important implications. A total of 46 atrial transseptal catheterizations guided by transesophageal echocardiography (TEE) for radiofrequency ablation of left-sided accessory pathways was performed in 42 patients during a 3-year period (1990-1993). Clinical and echocardiographic data were analyzed, with special attention given to TEE reports pre- and post-transseptal catheterization. Only one complication occurred in the 46 procedures (2.2%): a perforation of the left atrium that led to pericardial effusion and cardiac tamponade. In a small series of patients with normal sized atria, we have demonstrated that TEE-guided transseptal catheterization in a procedure with a low complication rate.

Utilization of the Wallstent for the treatment of innominate vein obstruction: a case report

Debilitating obstruction of the large veins may occur from external compression, neointimal proliferation or thrombosis. Appropriate interventions are contingent upon the underlying etiology and the local vascular anatomy. A case of innominate vein obstruction is presented illustrating the available intravascular therapeutic options, with special emphasis placed on intravenous stenting.

High incidence of renal artery stenosis in patients with coronary artery disease

The incidence of renal artery stenosis (RAS) in patients with coronary artery disease (CAD) has not been well documented. Over a 9-month period, 196 patients who underwent coronary angiography because of clinically suspected CAD had routine nonselective renal cine or digital subtraction angiography. There were 68 females and 128 males with a mean age of 63 years (range 35-85). Angiographically significant CAD was present in 152 patients (78%). Of the total patient cohort, 29 patients (15%) had mild RAS (< 50%), and 36 patients (18%) had significant RAS (> or = 50%). In patients with normal coronary arteries, only three patients (7%) had RAS. Thirty-three patients (92%) with severe RAS also had CAD. Of these 33 patients, 45% had hypertension, 30% had hyperlipidemia, 24% had diabetes mellitus, 24% had renal insufficiency (creatinine > or = 1.5), and 51% were smokers. In addition, it was noted that 20 of these patients (61%) had two or more of the above-listed clinical parameters. However, univariate analysis using the chi-square test revealed that only CAD (22% P < 0.03) and renal insufficiency (29% P < 0.15) were reliable clinical predictors of RAS. In conclusion, RAS is a frequent finding in patients with CAD, particularly when renal insufficiency is also present.

Ablation of left free-wall accessory pathways using radiofrequency energy at the atrial insertion site: transseptal versus transaortic approach

INTRODUCTION

Transcatheter ablation of the left free-wall atrioventricular accessory pathways (AP) by delivery of radiofrequency current at the ventricular insertion site has been shown to be effective. The efficacy of such a technique targeting the atrial insertion site of the AP was evaluated.

METHODS AND RESULTS

One hundred consecutive patients with left free-wall APs and symptomatic supraventricular tachyarrhythmias were included. APs were manifest in 55 patients and concealed in 45. There were 55 men and 45 women with a mean age of 35 years. A total of 107 left free-wall APs were identified in these patients. In these 100 patients, successful ablation was accomplished in all by using a transseptal (45 patients) or transaortic (54 patients) technique. In one patient, ablation was accomplished from within the coronary sinus. Seven patients required a repeat ablative procedure, which was performed successfully. During 107 ablative procedures, six were associated with nonfatal complications including pericardial effusion (hemopericardium) in two patients, mild mitral regurgitation in two patients, swelling of the left arm in one patient, and staphylococcal bacteremia in one patient. Eighty-two (82%) patients underwent a repeat electrophysiologic study 6 to 8 weeks after successful ablation and were found to have no functioning AP or inducible supraventricular tachycardia. During a mean follow-up of 20 +/- 8 months, none of the 100 patients had a recurrence of tachyarrhythmias.

CONCLUSION

These data indicate that the atrial insertion site of the AP can be successfully ablated in the majority of patients with left free-wall APs by using either a transseptal or transaortic approach. Furthermore, both techniques are associated with minimal morbidity and no mortality.