Gian Paolo Ussia

The impact of calcium volume and distribution in aortic root injury related to balloon-expandable transcatheter aortic valve replacement

BACKGROUNDnA detailed assessment of calcium within the aortic root may provide important additional information regarding the risk of aortic root injury during transcatheter heart valve replacement (TAVR).nnnOBJECTIVEnWe sought to delineate the effect of calcium volume and distribution on aortic root injury during TAVR.nnnMETHODSnThirty-three patients experiencing aortic root injury during TAVR with a balloon-expandable valve were compared with a control group of 153 consecutive TAVR patients without aortic root injury (as assessed by post-TAVR multidetector CT). Using commercial software to analyze contrast-enhanced pre-TAVR CT scans, calcium volume was determined in 3 regions: (1) the overall left ventricular outflow tract (LVOT), extending 10xa0mm down from the aortic annulus plane; (2) the upper LVOT, extending 2xa0mm down from the annulus plane; and (3) the aortic valve region.nnnRESULTSnCalcium volumes in the upper LVOT (median, 29 vs 0xa0mm(3); P < .0001) and overall LVOT (median, 74 vs 3xa0mm(3); Pxa0= .0001) were higher in patients who experienced aortic root injury compared with the control group. Calcium in the aortic valve region did not differ between groups. Upper LVOT calcium volume was more predictive of aortic root injury than overall LVOT calcium volume (area under receiver operating curve [AUC], 0.78; 95% confidence interval, 0.69-0.86 vs AUC, 0.71; 95% confidence interval, 0.62-0.82; Pxa0= .010). Upper LVOT calcium below the noncoronary cusp was significantly more predictive of aortic root injury compared to calcium underneath the right coronary cusp or the left coronary cusp (AUC, 0.81 vs 0.68 vs 0.64). Prosthesis oversizing >20% (likelihood ratio test, Pxa0= .028) and redilatation (likelihood ratio test, Pxa0= .015) improved prediction of aortic root injury by upper LVOT calcium volume.nnnCONCLUSIONnCalcification of the LVOT, especially in the upper LVOT, located below the noncoronary cusp and extending from the annular region, is predictive of aortic root injury during TAVR with a balloon-expandable valve.

Percutaneous management of vascular access in transfemoral transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) using stent-based bioprostheses has recently emerged as a promising alternative to surgical valve replacement in selected patients. The main route for TAVI is retrograde access from the femoral artery using large sheaths (16-24 F). Vascular access complications are a clinically relevant issue in TAVI procedures since they are reported to occur in up to one fourth of patients and are strongly associated with adverse outcomes. In the present paper, we review the different types of vascular access site complications associated with transfemoral TAVI. Moreover, we discuss the possible optimal management strategies with particular attention to the relevance of early diagnosis and prompt treatment using endovascular techniques.

Core valve implant failure in the presence of mechanical mitral prosthesis: Importance of assessing left ventricular outflow tract

Transcatheter aortic valve replacement in the presence of a mitral prosthetic valve is a technically challenging endeavor. The presence of a mitral prosthesis can alter the geometry of the landing zone for the device. A multi slice computerized tomography with comprehensive review of left ventricular outflow tract and aortic root in its entirety is critical for preventing implant failure. Technical expedients to treat implant failure involve understanding of the device as well its relationship with the mitral prosthesis.

Meta-Analysis Comparing Single Versus Dual Antiplatelet Therapy Following Transcatheter Aortic Valve Implantation

To compare dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT) as antithrombotic treatment after transcatheter aortic valve implantation (TAVI) for the prevention of ischemic events, vascular and bleeding events, and death. Data from the 3 randomized trials comparing DAPT versus SAPT post-TAVI were pooled and analyzed in a patient-level meta-analysis. The primary end point was the occurrence of death, major or life-threatening bleedings, and major vascular complications at 30-day follow-up. Events were adjudicated according to the Valve Academic Research Consortium 2 definitions. A total of 421 patients randomized to DAPT (210 patients) or SAPT (211 patients) post-TAVI were analyzed. There were no differences between groups in baseline clinical and procedural characteristics. The occurrence of the 30-day combined primary end point was higher in the DAPT group (17.6% vs 10.9%, odds ratio 1.73, 95% confidence interval 1.00 to 2.98, pu2009=u20090.050), with an increased rate of major or life-threatening bleeding events in the DAPT group (11.4% vs 5.2%, odds ratio 2.24, 95% confidence interval 1.12 to 4.46, pu2009=u20090.022). There were no differences between DAPT and SAPT groups in the incidence of death (5.2% vs 3.8%, pu2009=u20090.477), global ischemic events (3.8% vs 3.8%, pu2009=u20090.999), or stroke (2.4% vs 2.4%, pu2009=u20090.996). DAPT (vs SAPT) was associated with a higher rate of major adverse events after TAVI, mainly driven by an increased risk of major or life-threatening bleeding complications along with a lack of beneficial effect on ischemic events. These results do not support the current recommendation of DAPT as antithrombotic therapy after TAVI.

Annulus Remodeling and Double Orifice Repair Using a Multiple Clip Approach in Complex Mitral Valve Anatomy

Transcatheter repair of mitral regurgitation (MR) with the MitraClip System (Abbott Vascular, Abbott Park, Illinois) requires specific echocardiographic criteria [(1,2)][1]. Suboptimal results after standard MitraClip repair have been associated with a coaptation length <2 mm, coaptation depth ≥11

Hemodynamic complications during transcatheter MitraClip repair in presence of congenital atrial septal defect

Transcatheter edge‐to‐edge mitral valve repair with MitraClip System (Abbott Vascular, Menlo Park, CA) needs a trans‐septal access for positioning the 22‐Fr guiding catheter in the left atrium. To the best of our knowledge no data are currently available about the hemodynamic consequences of a congenital atrial septal defect (ASD) after MitraClip repair. We report a case of MitraClip repair in a patient with ostium secundum ASD and ischemic cardiomyopathy, who needed intraprocedural closure of the defect for serious hemodynamic complications, secondary to worsening of the right ventricular function, increased pulmonary pressure and inversion of the interatrial shunt in right‐to‐left direction. These events, which were exacerbated by high blood levels of PaCO2 for the anesthesiological protocol used, led to left‐side low‐output syndrome and cardiorespiratory arrest.

Cardiac resynchronization therapy before and after MitraClip implantation: An advantageous upgrading to reduce mitral regurgitation

MitraClip therapy has been proposed as therapeutic option in selected patients with degenerative or functional mitral regurgitation (FMR), leading to clinical and prognostic benefits. Previous studies demonstrated the safety and the efficacy of MitraClip therapy on symptoms and left ventricular remodeling in cardiac resynchronization therapy (CRT) non-responder patients. We report a case of a CRT non-responder patient treated with MitraClip implantation followed by a new upgrading of the CRT for persistent FMR at the follow-up. The optimization of the interventricular delay, guided by echocardiographic parameters, resulted in a significant clinical and functional benefit. Echo-guided CRT upgrading can provide additive efficacy for patients in whom MitraClip implantation does not significantly improve FMR and symptoms.

TCT-776 Safety of Axillary and TransAortic Approaches for Transcatheter Aortic Valve Replacement in patients older than 85 years old: Results from Italian CoreValve Registry

(OR-TF) and OR non-TF TAVR. Methods: A retrospective study was performed on 174 patients who underwent TAVR at a single US academic institution using the SAPIEN valve from 11/2011 to 4/ 2013. Patients were stratified into 3 groups: C-TF TAVR (n1⁄451), OR-TF TAVR (n1⁄439), and OR-non-TF TAVR (n1⁄484). All C-TF patients were performed with i.v. sedation and TTE. The OR-TF and OR-non-TF patients were performed in the hybrid OR with general anesthesia and TEE. Total variable cost, hospital payment, and contribution margin were utilized to determine the financial viability of TAVR. Results: Compared to OR-TF and OR-non-TF, C-TF had a significantly lower procedure time (p<0.001) and postop ventilator hours (p<0.001). Resource utilization in terms of ICU (p<0.001), postop (p<0.001), and total hospital LOS (p<0.001) was significantly higher in OR-non-TF patients. Total variable cost in the OR-non-TF TAVR was the highest (

Transcatheter closure of paravalvular leak secondary to left ventricular peri-annular pseudoaneurysm

57,197 23,142), but hospital payment was comparably the highest (

P745Effect of transcatheter aortic valve implantation (TAVI) in acquired von Willebrand syndrome and molecular analysis of high-molecular-weight multimers

62,647 58,826); leading to the highest contribution margin (