Jan Kovac

Predictors for permanent pacemaker requirement after transcatheter aortic valve implantation with the CoreValve bioprosthesis.

INTRODUCTION Changes in atrioventricular (AV) conduction and need for permanent pacemaker (PPM) are a recognized complication after open aortic valve replacement. We hypothesized that the need for PPM after CoreValve (Corevalve Inc, Irvine, CA) can be predicted with a combination of baseline variables. METHODS In patients undergoing transcatheter aortic valve implantation, potential clinical, electrocardiographic and echocardiographic predictors of permanent pacing requirement were studied. RESULTS Between January 2007 and March 2008, 34 patients with severe symptomatic aortic stenosis were recruited in a single center. Mean age was 84.4 years (SD 5.4, range 71-93). Of 34 cases paced at baseline, 3 (8.8%) were excluded from this analysis, as was the single periprocedural mortality. Of the remaining 30, 10 underwent permanent pacemaker implantation during the same admission (33.3%). PPM was for prolonged high-grade AV block in 4 cases, episodic high-grade AV block in 5, and sinus node disease in 1. Need for pacemaker was correlated to left axis deviation at baseline (P = .004, r = 0.508) and left bundle-branch block with left axis deviation (P = .002, r = 0.548). It was related to diastolic interventricular septal dimension on transthoracic echocardiography >17 mm (P = .045, r = 0.39) and the baseline thickness of the native noncoronary cusp (P = .002, r = 0.655). A susceptibility model was generated, and if at least one of (1) left bundle-branch block with left axis deviation, (2) interventricular septal dimension >17 mm, or (3) noncoronary cusp thickness >8 mm was present, the likelihood of PPM could be predicted with 75% sensitivity and 100% specificity and a receiver operating characteristic curve area of 0.93 +/- 0.055 (P < .001). CONCLUSIONS After transcatheter aortic valve implantation with CoreValve, permanent pacing was performed in around a third of patients and we present preliminary concepts towards a predictive model for this phenomenon.

Prosthesis-patient mismatch after transcatheter aortic valve implantation with the Medtronic-Corevalve bioprosthesis

AIMS Prosthesis-patient mismatch (P-PM) is an important determinant of morbidity and mortality following open aortic valve replacement. The aims of this study were to report its incidence and determinants following transcatheter aortic valve implantation (TAVI) with the Corevalve bioprosthesis, which have-thus far-not been described. METHODS AND RESULTS Patients with severe calcific aortic stenosis received TAVI with the Corevalve bioprosthesis via transfemoral route. Following TAVI, moderate P-PM was defined as indexed aortic valve effective orifice area (AVAi) < or =0.85 cm(2)/m(2) and severe P-PM as AVAi < or =0.65 cm(2)/m(2). Clinical, echocardiographic, and procedural factors relating to P-PM were studied. Optimal device position was defined on fluoroscopy as final position of the proximal aspect of the Corevalve stent frame 5-10 mm below the native aortic annulus. Between January 2007 and January 2009, 50 consecutive patients underwent TAVI in a single centre with the Corevalve bioprosthesis. Mean age was 82.8 years (SD 5.9; 70-93) and 48% were male. P-PM occurred in 16 of 50 cases (32%). Optimal position was achieved in 50% of cases. P-PM was unrelated to age, annulus size, LVOT size, Corevalve size, aortic angulation, ejection fraction, and sex. It was inversely correlated to optimal position (Spearman rho r = -0.34, P = 0.015). Those with optimal positioning had a 16% incidence of P-PM relative to 48% of those with suboptimal positioning (Pearson chi(2) P = 0.015). CONCLUSION The incidence of P-PM following TAVI with the Corevalve bioprosthesis is compared favourably with that seen after AVR with conventional open stented bioprostheses and its occurrence is influenced by device positioning.

Anatomic suitability for present and next generation transcatheter aortic valve prostheses: evidence for a complementary multidevice approach to treatment.

OBJECTIVES This study sought to assess the proportion of patients anatomically suitable for transcatheter aortic valve implantation by multiple access approaches. BACKGROUND The devices currently in mainstream use for transcatheter treatment of severe aortic stenosis are those of Edwards (Edwards Lifesciences, Nyon, Switzerland) and Medtronic CoreValve (M-C) (Luxembourg City, Luxembourg). The range of patients that these can presently treat requires elucidation to guide the necessary evolution of these technologies and increase their scope of therapy. METHODS A consecutive series of patients were assessed with transthoracic or transesophageal echocardiography and invasive angiography to assess anatomical suitability by different approaches. The transfemoral access requirements for Edwards and M-C (Edwards currently 22- and 24-F, soon to be 18- and 19-F; M-C 18-F) as well as the aortic valve annular criteria (18 to 25 mm and 20 to 27 mm, respectively) were incorporated in this assessment. Patients unsuitable for the transfemoral approach were considered for Edwards transapical and M-C transaxillary and direct ascending aortic access. Patients suitable for these devices and access approaches were identified. RESULTS Data were analyzed for 100 consecutive patients. Edwards suitability was 28% for Edwards-Sapien transfemoral, 78% for Edwards Novaflex transfemoral, and 88% for Edwards-Sapien transapical. Medtronic CoreValve suitability was 84% for transfemoral and 89% using additional transaxillary and direct aortic approaches. Of the 12 patients unsuitable for Edwards-based procedures, 8 were suitable for M-C. Of the 11 patients unsuitable for M-C-based techniques, 8 were suitable for Edwards. Only 3% were anatomically unsuitable for all approaches. CONCLUSIONS In this series, 97% of patients were anatomically suitable for a complementary approach to treatment.

Initial Experience of a Second-Generation Self-Expanding Transcatheter Aortic Valve: The UK & Ireland Evolut R Implanters’ Registry

OBJECTIVES The authors present the UK and Irish real-world learning curve experience of the Evolut R transcatheter heart valve. BACKGROUND The Evolut R is a self-expanding, repositionable, and fully recapturable second-generation transcatheter heart valve with several novel design features to improve outcomes and reduce complications. METHODS Clinical, procedural, and 30-day outcome data were prospectively collected for the first 264 patients to receive the Evolut R valve in the United Kingdom and Ireland. RESULTS A total of 264 consecutive Evolut R implantations were performed across 9 centers. The mean age was 81.1 ± 7.8 years, and the mean logistic European System for Cardiac Operative Risk Evaluation score was 19.9 ± 13.7%. Procedural indications included aortic stenosis (72.0%), mixed aortic valve disease (17.4%), and failing aortic valve bioprostheses (10.6%). Conscious sedation was used in 39.8% of patients and transfemoral access in 93.6%. The procedural success rate was 91.3%, and paravalvular leak immediately after implantation was mild or less in 92.3%. Major complications were rare: cardiac tamponade in 0.4%, conversion to sternotomy in 0.8%, annular rupture in 0.0%, coronary occlusion in 0.8%, major vascular in 5.3%, acute kidney injury in 6.1%, new permanent pacemaker implantation in 14.7%, and procedure-related death in 0.0%. At 30-day follow-up, survival was 97.7%, paravalvular leak was mild or less in 92.3%, and the stroke rate was 3.8%. CONCLUSIONS This registry represents the largest published real-world experience of the Evolut R valve. The procedural success rate was high and safety was excellent, comparable with previous studies of the Evolut R valve and other second-generation devices. The low rate of complications represents an improvement on first-generation devices.

Cardiac catheter complications related to left main stem disease.

OBJECTIVE: To examine the incidence and outcome of cardiac catheter complications related to left main coronary artery disease or damage using the CECCC (Confidential Enquiry into Cardiac Catheter Complications) database. SETTING: Coordinating centre for national database. DESIGN: Retrospective analysis of reports to a national multicentre database for cardiac catheter complications. Complications involving the left main coronary artery were flagged at entry. Where necessary additional information was sought from participating centres. 112,921 procedures were registered, 12,849 of which were coronary angioplasties and the remainder diagnostic studies. RESULTS: The total number of cases for which complications were recorded was 993 (0.88%). In 61 (6.14%) of the 993 cases complications were associated with left main coronary disease or damage. In 57 (93%) of these 61 cases complications were major, necessitating resuscitation or immediate coronary bypass grafting. Ten patients (16%) died in the catheter laboratory, a further 9 (15%) within 24 hours, and a total of 23 patients (38%) died within one month of the procedure. Left main stem related complications account for 17% of total mortality in the CECCC database. Urgent coronary bypass grafting was attempted in 42 patients, of whom 31 were alive at one month. In all of the six reported PTCA-related complications the cause was traumatic damage to the left main coronary artery. Operators of all grades of seniority experienced complications in similar proportions. CONCLUSIONS: The risk of a complication relating to the left main stem is relatively low, but when such complications occur they tend to be life-threatening and contribute a fifth of total catheter-related mortality. In the absence of a widely available non-invasive investigation with good predictive value for left main stem disease, the best safeguard is careful technique. Patients who do develop complications should have emergency coronary bypass grafting.

Clopidogrel induced urticarial rash in a patient with left main stem percutaneous coronary intervention: management issues

Clopidogrel, an ideal treatment for prevention of subacute stent thrombosis, may not be feasible to use in every patient. Ticlopidine (plus aspirin) is a very good alternative, although the risks of life threatening neutropenia should mandate regular monitoring of blood counts. It is proposed that patients undergoing angioplasty and stenting should carry a warning card in an effort to make the public and general practitioners aware that antiplatelet treatment after angioplasty plays an important part in ensuring successful outcome.

Comparison of Complete Versus Incomplete Stent Frame Expansion After Transcatheter Aortic Valve Implantation With Medtronic CoreValve Bioprosthesis

We sought to determine the significance of incomplete stent frame expansion after transcatheter aortic valve implantation with the Medtronic-CoreValve device. Incomplete coronary stent expansion is a well-described phenomenon. Transcatheter valves are mounted on stents; however, the incidence of incomplete stent expansion after transcatheter aortic valve implantation, its sequelae and predictors are poorly elucidated. The 18Fr CoreValve revalving system was used to treat anatomically and clinically suitable patients with severe calcific aortic stenosis. The postdeployment stent dimensions were measured on fluoroscopic images at multiple levels of the stent frame. Incomplete expansion at each was defined as <100% expected and complete expansion as ≥100%. These parameters were correlated to the hemodynamic and clinical end points. A total of 50 consecutive patients underwent transcatheter aortic valve implantation with the Medtronic-CoreValve at a single center from January 2007 to December 2008. For the inflow portion, incomplete expansion was seen in 54% of patients and was unrelated to the aortic valve area, peak or mean aortic valve gradients, or measures of aortic regurgitation, although it was paradoxically associated with a lower incidence of prosthesis-patient mismatch. Incomplete expansion of the constrained portion was seen in 62% of the patients and displayed a trend toward a greater incidence of aortic regurgitation grade 2 or greater, although this was rare. Incomplete expansion of the Medtronic CoreValve stent frame is common. For the most part, valvular hemodynamic function was satisfactory, regardless of the degree of expansion of the stent frame that carries it and a strategy of reluctant postdilation in the context of incomplete stent frame expansion was supported.

Intestinal angiodysplasia and aortic valve stenosis: let's not close the book on this association.

The association between gastrointestinal (GI) bleeding due to angiodysplasia of the large intestine and calcific aortic stenosis (AS) has been a matter of debate. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. von Willebrand factor is the strongest possible link between aortic stenosis and bleeding associated with GI angiodysplasia. Physicians should be aware of this entity when dealing with elderly patients presenting either with GI bleeding or with AS. A high index of suspicion and appropriate diagnostic procedures followed by prompt treatment could be life saving. Several questions related to the pathogenesis and optimal management remain unanswered. Aortic valve replacement appears to offer the best hope of long-term resolution of the bleeding, and should be considered in most cases. The association between chronic gastrointestinal bleeding in elderly patients and aortic stenosis becomes more relevant with the advent of transcatheter aortic valve implantation which can be offered even to elderly patients with comorbidities which could make conventional surgery impossible.

Dressler's syndrome demonstrated by late gadolinium enhancement cardiovascular magnetic resonance

A 49-year old patient presented late with an anterolateral ST-elevation myocardial infarction and was treated with rescue angioplasty to an occluded left anterior descending artery. Her recovery was complicated by low-grade pyrexia and raised inflammatory markers. Cardiovascular magnetic resonance 5 weeks after the acute presentation showed transmural infarction and global late gadolinium enhancement of the pericardium in keeping with Dresslers syndrome.

Chronic haemoptysis as delayed complication of ventricular aneurysmectomy

Two patients developed a ventriculo-pulmonary fistula several years after original resection of a left ventricular aneurysm. Both presented with chronic mild haemoptysis. In the first case mild haemoptysis lasted nearly 19 months, and despite a battery of non invasive and invasive investigations, diagnosis was ultimately made via exploratory thoracotomy. In the second case mild haemoptysis lasted four months and finally manifested as a large haemoptysis. Diagnosis was made preoperatively using echocardiography. We recommend the use of echocardiography when haemoptysis occurs in a patient with a previous history of ventricular aneurysm repair.