Dayimi Kaya

Treatment of an unusual complication of transfemoral TAVI with a new technique : successful occlusion of ventricular septal defect by opening the closure device in the ascending aorta : case report

Ventricular septal defect (VSD) is a rare complication of transcatheter aortic valve implantation (TAVI) via the transfemoral approach. Aetiological factors leading to VSD have been reported as post-balloon dilatation, oversized prosthesis implantation, and severe calcification of the aorta. However, we present a case of VSD occurring after TAVI with an Edwards Sapien XT prosthesis without any distinct aetiological factors. We used a new technique for closure of the significant VSD; opening the left ventricular disc of the closure device in the ascending aorta and successfully implanting the device without any damage to the bioprosthetic valve.

The Relationship between Neutrophil-To-Lymphocyte Ratio and Fragmented QRS in Acute STEMI Patients Treated with Primary PCI ☆ ☆☆

BACKGROUND No study so far investigated fragmented QRS (fQRS) and neutrophil-to-lymphocyte ratio (NLR) together in ST segment elevation myocardial infarction (STEMI). OBJECTIVE To investigate the relationship between NLR and fQRS, and determine the prognostic significance of the combined use of these two parameters in STEMI. METHODS We included 368 patients with first acute STEMI who successfully revascularized with primary percutaneous coronary intervention. RESULTS Patients with fQRS had significantly higher NLR, and in-hospital mortality rate compared to patients with no-fQRS. The best cut-off value of NLR to predict mortality was 5.47. Patients with NLR≥5.47 had a higher frequency of fQRS and in-hospital mortality rate. Multivariate analysis showed that NLR was an independent predictor of the presence of fQRS (OR: 1.095, 95% CI: 1.039-1.153, P=0.001). When patients were stratified by fQRS and cut-off value of NLR, in-hospital mortality gradually increased (P<0.001). CONCLUSION NLR is independently associated with the presence of fQRS in STEMI patients. Combined use of both parameters provides additional prognostic contribution for identifying patients at higher cardiac risk.

Single Derivation Fragmented QRS Can Predict Poor Prognosis in Successfully Revascularized Acute STEMI Patients

Background QRS fragmentation (fQRS) is classically defined as the presence of slurred QRS morphology in at least two contiguous leads, and its prognostic importance has been shown in ST elevation myocardial infarction (STEMI). However, no study has investigated the significance of single lead fQRS (sl-fQRS) in surface electrocardiography (ECG). Objectives To evaluate whether sl-fQRS is as valuable as classical fQRS in patients with acute STEMI who had successful revascularization with primary percutaneous coronary intervention (pPCI). Methods We included 330 patients with a first STEMI who had been successfully revascularized with pPCI. The patient’s electrocardiography was obtained in the first 48 hours, and the patients were divided into three groups according to the absence of fQRS (no-fQRS); fQRS presence in a single lead (sl-fQRS); and ≥2 leads with fQRS (classical fQRS). Results In-hospital mortality was significantly higher both in patients with sl-fQRS and in patients with ≥ 2 leads with fQRS compared to patients with no-fQRS. In ROC curve analysis, ≥ 1 leads with fQRS yielded a sensitivity of 75% and specificity of 57.4% for the prediction of in-hospital mortality. Multivariate analysis showed that sl-fQRS is an independent predictor of in-hospital mortality (OR: 3.989, 95% CI: 1.237-12.869, p = 0.021). Conclusions Although the concept of at least two derivations is mentioned for the classical definition of fQRS, our study showed that fQRS in only one lead is also associated with poor outcomes. Therefore, ≥1 leads with fQRS can be useful when describing the patients under high cardiac risk in acute STEMI.

Comparison of echocardiographic results of CoreValve versus Edwards Sapien valves in patients with bicuspid aortic valve

Although the first transcatheter aortic valve implantation (TAVI) was performed in a bicuspid aortic valve (BAV) stenosis, treatment of BAV with TAVI has traditionally been regarded as a relative contraindication [1,2]. Asymmetry of the valve orifice and annulus with heavily calcified leaflets and raphe could impair the expansion of transcatheter aortic valves, eventually leading to paravalvular leak and poor hemodynamic function. Nevertheless, limited number of case reports demonstrated the feasibility of TAVI in BAV stenosis [3–5]. We read with a great interest the manuscript by Watanabe et al. [6] titled “Comparison of Multislice Computed Tomography Findings Between Bicuspid and Tricuspid Aortic Valves Before and After Transcatheter Aortic Valve Implantation” published on January 9, 2015 in the Catheterization and Cardiovascular Interventions. The authors reported that the postprocedural mean transaortic gradient was significantly higher after CoreValve implantation in BAV compared to tricuspid aortic valves (TAV) while this situation was not observed with the Edwards valve. They proposed that CoreValve bioprosthesis may not fully expand in patients with heavily calcified BAV leading to a residual pressure gradient. In order to make such a conclusion in favor of balloon-expandable valve we think that a head-to-head comparison of CoreValve and Edwards valves in BAV group for post-procedural mean transaortic gradients should have been analyzed, however the authors did not mention such an analysis in their study. We suggest this gap should absolutely be filled with a revision. If there is significant difference between the bioprosthetic valves in BAV group, this result will be more interesting since in a recently published study with more participants any significant difference was not found between bioprosthetic valves in BAV [7]. Furthermore, it is plausible to think that compliance of self-expandable bioprosthesis will be greater to an oval shaped annulus because of the unique properties of nitinol in the CoreValve and the oval shape at the inflow portion of bioprosthesis is not expected to affect the valvular functions since the level of the leaflets is supra-annular. Finally, if calcification of aortic valve actually limits the self-expandable valve to expand then it will also be expected to occur in the case of calcified TAV which was not observed in any study before. In contrast, the mean post-procedural transaortic gradients were found to be lower with the effective orifice tending to be greater in CoreValve than Edwards valve [8].

The role of baseline and post-procedural frontal plane QRS-T angles for cardiac risk assessment in patients with acute STEMI

To our knowledge, no study so far investigated the importance of post‐procedural frontal QRS‐T angle f(QRS‐T) in ST segment elevation myocardial infarction (STEMI). The aim of our study was to investigate the role of baseline and post‐procedural f(QRS‐T) angles for determining high risk STEMI patients, and the success of reperfusion.

The prognostic value of the combined use of QRS distortion and fragmented QRS in patients with acute STEMI undergoing primary percutaneous coronary intervention

BACKGROUND No study has investigated the prognostic importance of the combined use of QRS distortion and fragmented QRS (fQRS) for risk stratification in acute ST segment elevation myocardial infarction (STEMI). OBJECTIVE To determine the prognostic value of the combined use of QRS distortion and fQRS in patients with acute STEMI undergoing primary percutaneous coronary intervention (pPCI). METHODS A total of 454 patients with first STEMI who underwent pPCI were included in this study. Patients were categorized into three groups according to the presence of QRS distortion and fQRS on admission electrocardiography. Group I was defined as fQRS (-) and QRS distortion (-), group 2 was defined as fQRS (+) and QRS distortion (-), or fQRS (-) and QRS distortion (+), and group 3 was defined as both fQRS (+) and QRS distortion (+). RESULTS Patients in group III had a significantly higher in-hospital mortality rate compared with patients in groups I and II. These patients also had lower left ventricular ejection fraction and ST resolution ratios, higher maximum troponin, and higher frequency of three-vessel disease. Multivariate analysis indicated that group III (OR: 8.84, 95% CI: 2.73-28.62, p<0.001) was an independent predictors of in-hospital mortality. CONCLUSION The combined use of QRS distortion and fQRS provides additional prognostic value compared with the presence of QRS distortion or fQRS alone for early risk stratification in patients with STEMI treated with pPCI.

A rare complication: an attempt of retrieval of an aortic valve wrapped with pig tail catheter during transcatheter aortic valve implantation

Transcatheter aortic valve implantation is preferred to treat high surgical risk patients with severe aort stenosis. Wrapping of a pig tail catheter with device struts during transcatheter aortic valve implantation is a very rare complication. In this report, we present the images and videos of an attempt of retrieval of an aortic valve wrapped with pig tail catheter during transcatheter aortic valve implantation in a 71-year-old man.