Angela Frei

Transcatheter aortic valve implantation in nonagenarians: Effective and safe

BACKGROUND The number of nonagenarians is rising dramatically. These patients often develop severe aortic stenosis for which transcatheter aortic valve implantation (TAVI) is an attractive option. The aim of this study was to analyze the outcome of TAVI performed in a cohort of nonagenarian patients. METHODS Between August 2008 and November 2012, 23 consecutive patients in their 90th year of age or older underwent TAVI in our institution after having been assessed by the local heart team. Data concerning baseline characteristics, procedural details and outcome were prospectively entered into a dedicated database. Transthoracic echocardiography and clinical follow-up were performed pre-procedure, at discharge, at 6 and 12 months and then annually post TAVI. RESULTS Patients were male in 52% with a mean age of 90.3 ± 2.3 years. Mean logistic EuroSCORE and STS score were 26.6 ± 14.5% and 8.7 ± 2.9%, respectively. Transcatheter heart valve (THV) could be implanted in all but one patient. Mortality at 30 days was 8.7% overall and 4.8% for transfemoral approach. At 30 days the rate of stroke was 4.3%, paravalvular leak grade ≥ 2 was 8.7%, life-threatening bleeding was 13.0% and pacemaker implantation was 13%. Device success was 73.9%. The rate of all-cause mortality increased to 27.3% at one-year follow-up and 42.8% at a median follow-up of 417 days. CONCLUSIONS TAVI is safe and effective even in a selected population of nonagenarians. Consequently, these patients should not be refused such a procedure based only on their age. Multi-disciplinary assessment is essential in order to properly select candidates.

Thirty-day Outcome Following CoreValve Evolut R Transcatheter Aortic Valve Implantation: An All-comers Prospective Study

INTRODUCTION AND OBJECTIVES There are scarce clinical outcomes data on the new generation recapturable and repositionable CoreValve Evolut R. METHODS Data on all-comer patients undergoing transcatheter aortic valve implantation (TAVI) with the Evolut R for severe symptomatic aortic stenosis at a single center were prospectively collected between February 2015 and April 2016. Clinical endpoints were independently adjudicated according to the Valve Academic Research Consortium-2 criteria. Primary outcomes consisted of early safety composite endpoints and 30-day device success. The incidence of new permanent pacemaker implantation was recorded. RESULTS Among the 83 patients undergoing TAVI during this period, 71 (85.5% of the population; median age, 83.0 [interquartile range, 80.0-87.0] years; Society of Thoracic Surgeons scores, 4.8±3.5%) were suitable for Evolut R implantation and were included in the analysis. Repositioning was performed in 26.8% of the procedures. The early safety composite endpoint was observed in 11.3% of patients at 30 days, with 2.8% all-cause mortality. Device success was documented in 90.1% of patients. Paravalvular leakage was less than grade II in 98.4% of patients. The mean transvalvular aortic gradient was reduced from 42.5±14.5mmHg at baseline to 7.7±4.0mmHg at discharge (P<.0001 vs baseline). New permanent pacemaker implantation was required in 23.9% of patients. CONCLUSIONS The new generation Evolut R is suitable for most patients and shows high device success and acceptable mortality in an unbiased, consecutive, all-comer population at a single center performing TAVI exclusively with Medtronic valves.

Goal-directed hemostatic therapy using the rotational thromboelastometry in patients requiring emergent cardiovascular surgery

AIMS AND OBJECTIVES We assessed the clinical impact of goal-directed coagulation management based on rotational thromboelastometry (ROTEM) in patients undergoing emergent cardiovascular surgical procedures. MATERIALS AND METHODS Over a 2-year period, data from 71 patients were collected prospectively and blood samples were obtained for coagulation testing. Administration of packed red blood cells (PRBC) and hemostatic products were guided by an algorithm using ROTEM-derived information and hemoglobin level. Based on the amount of PRBC transfused, two groups were considered: High bleeders (≥5 PRBC; HB) and low bleeders (<5 PRBC; LB). Data were analyzed using Chi-square test, unpaired t-test and analysis of variance as appropriate. RESULTS Pre-operatively, the HB group (n = 31) was characterized by lower blood fibrinogen and decreased clot amplitude at ROTEM compared with the LB group (n = 40). Intraoperatively, larger amounts of fibrinogen, fresh frozen plasma and platelets were required to normalize the coagulation parameters in the HB group. Post-operatively, the incidence of major thromboembolic and ischemic events did not differ between the two groups (<10%) and the observed in-hospital mortality was significantly less than expected by the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM score, 22% vs. 35% in HB and 5% vs. 13% in LB group). CONCLUSIONS ROTEM-derived information is helpful to detect early coagulation abnormalities and to monitor the response to hemostatic therapy. Early goal-directed management of coagulopathy may improve outcome after cardiovascular surgery.

Downstream indication to revascularization following hybrid cardiac PET/MRI: preliminary results

Background Hybrid PET/MRI allows the acquisition of both fluorine-18-fluorodeoxyglucose (18F-FDG) PET and cardiac magnetic resonance (CMR) during one session. Whether this will result in different referral to coronary revascularization (CR) is unknown. We compared this new hybrid method with all-nuclear/all-CMR methods in the assessment of viable myocardium and in downstream referral to CR. Patients and methods Overall, 12 patients with rest perfusion defects on a single photon emission computed tomography (SPECT) were recruited for cardiac viability assessment using a PET/MRI device. Perfusion (SPECT and CMR), metabolism, late gadolinium enhancement (LGE), and contractility were compared using a 20-segments bull’s eye for agreement. The patterns of ischemia/viability were compared between all-nuclear, all-CMR, and hybrid methods. Downstream CR was proposed after correlating findings to coronary angiography. Results The SPECT and CMR perfusion denoted poor agreement [agreement rate (AR): 60%; &kgr;: 0.191, P<0.004]. The added PET metabolism concurred in reclassifying 19.2% of segments with intermediate or unassessable LGE using the hybrid method. Overall, the all-CMR method showed better agreement with the hybrid method than the all-nuclear method for findings of normal (AR: 100%, &kgr;: 1.00 vs. 65.8% %; &kgr;: 0.347, respectively; P<0.001), scar (AR: 85%; &kgr;: 0.675 vs. 80.8%; &kgr;: 0.596, respectively; P<0.001), and ischemic segments (AR: 95.8%; &kgr;: 0.881 vs. 75.8%; &kgr;: 0.168, respectively; P<0.001). Downstream CR was proposed in four, 11, and 12 vessels by the all-nuclear, all-CMR, or hybrid methods, respectively. Conclusion Compared with all-CMR, the hybrid method allowed the reclassification of 19.2% segments. Using CMR perfusion instead of SPECT perfusion had a significant impact on downstream target vessel revascularization.

Vasospastic angina: A forgotten acute coronary syndrome and the usefulness of twelve-lead electrocardiogram monitoring in diagnosis.

More than fifty-five years ago, Prinzmetal et al. described vasospastic angina (VSA) as a clinical disorder with electrocardiographic manifestations due to coronary artery spasm [1,2]. VSA is typically defined by angina, which is responsive to short-acting nitrates, with spontaneous episodes at rest, frequently between mid-night and early in the morning. In order to fulfill diagnostic criteria, either transient ischemic changes in the electrocardiogram or one spontaneous or provoked coronary artery vasospasm of more than 90% on angiographic images during an angina episode are necessary [2,3]. Transient ST elevation that quickly resolves after administration of nitrates was first described by Prinzmetal et al. [1] Subsequently different studies have also demonstrated transient ST depression and U wave changes during spontaneous VSA episodes [2,3]. Holter monitoring is included in the recommendations of the European Society of Cardiology (ESC) when VSA is suspected (IIb) [4]. R-test and twelve-lead ECG monitoring could also be helpful for VSA diagnosis. Most of the time, monitoring needs to be repeated several times until an angina episode with ischemic changes on the ECG can be objectified [3]. The following case description will illustrate the relevant diagnosis of vasospastic angina. A 36 year-old man, known for high blood pressure, active smoking of one pack per day and alcohol consumption of four units per day, had previously presentedwith ventricular fibrillation and cardiorespiratory arrest following a slight effort four years ago. He was successfully resuscitated after electric cardioversion and standard CPR. Transthoracic echocardiography showed a normal left ventricular ejection fraction and no valvulopathy. The coronary angiography

Conduction disorders using the Evolut R prosthesis compared with the CoreValve: has anything changed?

Aim We compared early postprocedural and midterm evolution of atrioventricular and intraventricular conduction disorders following implantation of the new generation Evolut R (ER) prosthesis in comparison with the previous generation CoreValve (CV) system using routinely recorded ECG up to 6-month follow-up. Methods All consecutive patients treated by transcathether aortic valve implantation (TAVI) using the Medtronic self-expanding devices for symptomatic severe aortic stenosis in a single centre between October 2011 and February 2016 were considered for inclusion. ECGs recorded at baseline, day 1 after TAVI, discharge and 6 months were retrospectively analysed. At each time-point, intrinsic rhythm, PR interval, QRS axis and duration, and atrioventricular and intraventricular conduction were analysed. Atrioventricular and intraventricular conduction following TAVI at discharge and at 6 months were compared intrasubject at the different time intervals and between patients receiving the ER versus the CV prosthesis. Results Among the 113 patients included in the analysis (51% female, 83.3±6.2 years), 60 (53%) patients received the CV and 53 (47%) patients received the ER. Compared with patients in the CV group, those in the ER group had a lower Society of Thoracic Surgeons score (6.3±3.1vs 4.8±3.6, P=0.02). Patients in the ER group in comparison with those in the CV group more frequently had postprocedural PR interval (57%vs23%, respectively, P=0.004) and QRS prolongation (76%vs50%, P=0.03) at discharge. Incidence of complete atrioventricular block was similar between both groups (9%vs18%, P=0.3) up to 6-month follow-up. No difference in term of new left bundle branch block (LBBB) (34%vs28%, P=0.8) or permanent pacemaker implantation rates (32.1%vs31.7%, P=1.0) was reported. Conclusions Patients with the ER had greater postprocedural atrioventricular and intraventricular conduction delays than those with the CV at discharge, with however similar incidence of high-degree atrioventricular block, new LBBB and permanent pacemaker implantation up to 6-month follow-up.

Transcatheter aortic valve implantation: Update in 2018

During the last 15 years, transcatheter aortic valve implantation (TAVI) has gained wide acceptance with good reproducible clinical and safety outcomes. Today, TAVI has not only overtaken conventional surgery as the standard of care for the treatment of patients with symptomatic aortic stenosis at high surgical risk, but can also be considered in selected intermediate-risk patients. This follows technological improvements, better patient assessment and increased operator experience leading to a significant reduction in most procedure-related complications and long-term mortality. In this review, we provide internists, on the one hand with current data in the TAVI field including clinical outcomes from the most recent, major trials and on the other hand, highlight the remaining pitfalls of this treatment and the gaps in evidence that need to be addressed in order to further improve clinical practice and expand its indication.