Luigi Biasco

Safety and Efficacy of Using the Viabahn Endoprosthesis for Percutaneous Treatment of Vascular Access Complications After Transfemoral Aortic Valve Implantation

Vascular access complications (VACs) remain one of the biggest challenges when performing transcatheter aortic valve implantation (TAVI). This study aimed to investigate the short- and medium-term safety and efficacy of the Viabahn endoprosthesis (Gore, Flagstaff, AZ) when used to treat TAVI-induced vascular injury. Over a 40-month period, 354 patients underwent true percutaneous transfemoral (TF)-TAVI using a CoreValve and Prostar-XL closure system; this was our study population. A VAC leading to acute intervention occurred in 72 patients (20.3%) - of these, 18 were managed by balloon angioplasty, 48 were treated by Viabahn stenting (technical success rate 98%), and 6 needed surgical intervention. Overall, this approach resulted in a major VAC rate of 3.1% (n = 11) in our study cohort. Length of hospitalization and 30-day mortality rates were comparable in patients with a VAC treated by Viabahn stenting versus patients without vascular complications. Two patients (4.5%) presented with new-onset claudication; one of them had the stent implanted covering the deep femoral artery (DFA). At medium-term follow-up (median 372 days; range 55 to 978 days) duplex ultrasound showed 100% patency of the Viabahn endoprostheses with no signs of stent fracture or in-stent stenosis/occlusion. In conclusion, the use of self-expanding covered stents is safe and effective in case of TF-TAVI-induced vascular injury, with good short- and medium-term outcomes. Importantly, coverage of the DFA should be avoided. If confirmed by long-term (>5 years) follow-up studies, this strategy for treating TAVI-induced VAC may be used routinely in high-risk patients.

Echocardiographic-Fluoroscopic Fusion Imaging in Transseptal Puncture: A New Technology for an Old Procedure

In an era of catheter-based structural heart disease and left-side electrophysiologic interventions, transseptal puncture (TSP) is probably the most common transcatheter procedure. Experienced interventional cardiologists and electrophysiologists may safely perform TSP using fluoroscopic guidance alone. However, at present TSP is usually the first step in complex percutaneous catheter-based structural heart disease procedures and necessitate a precise site-specific TSP. Thus, in these procedures most interventional cardiologists perform TSP under fluoroscopic and two- or three-dimensional transesophageal echocardiographic guidance. The EchoNavigator system may provide a solution by fusing fluoroscopic and transesophageal echocardiographic images. In this review, the authors describe advantages and limitations of this new imaging system in guiding TSP and suggest specific echocardiographic-fluoroscopic fusion imaging perspectives that may facilitate TSP, making it potentially easier and safer.

J-wave duration and slope as potential tools to discriminate between benign and malignant early repolarization

Yvonne Cristoforetti, MD, Luigi Biasco, MD, Carla Giustetto, MD, Ole De Backer, MD, PhD, Davide Castagno, MD, Piero Astegiano, MD, Gianpasquale Ganzit, MD, Carlo Gabriele Gribaudo, MD, Marco Moccetti, MD, Fiorenzo Gaita, MD From the Division of Cardiology, Department of Medical Science, University of Turin, Citta della Salute e della Scienza Hospital, Turin, Italy, Fondazione Cardiocentro Ticino, University of Zurich, Lugano, Switzerland, The Heart Centre, Rigshospitalet, Copenhagen, Denmark, and Institute of Sports Medicine, Turin, Italy.

Patent foramen ovale treatment strategy: an Italian large prospective study.

Aim There is still controversy regarding the benefit of percutaneous closure of patent foramen ovale (PFO) among patients with cryptogenic stroke. Here we aimed to evaluate the factors associated with treatment choice and predictors of adverse events in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO. Methods Of 418 consecutive patients with PFO and cryptogenic stroke or TIA, 262 underwent percutaneous PFO closure, whereas 156 were medically treated. Multivariable logistic regression models were developed to evaluate factors influencing the treatment strategy and predictors of outcome, a composite of stroke, TIA or all-cause mortality. Results Patients with large interatrial right-to-left shunt were more likely treated with percutaneous closure [odds ratio (OR) = 4.79, 95% confidence interval (2.73–8.42); P < 0.0001], whereas those with multiple cerebrovascular accident (CVA) risk factors were more likely treated medically [OR = 0.15 (0.03–0.60); P = 0.023]. Age greater than 55 years [OR = 2.70 (1.05–6.88); P = 0.04], previous CVAs [OR = 2.49 (1.03–6.02); P = 0.02] and atrial septal aneurism [ASA, OR = 2.64 (1.09–6.39); P = 0.02], but not percutaneous closure of PFO [OR = 1.10 (0.44–2.74); P = 0.81], were independent predictors of outcome. Conclusion Among patients with cryptogenic stroke and PFO, the presence of large interatrial right-to-left shunt and multiple CVA risk factors influenced the treatment choice. Older age, multiple previous CVAs and ASA, but not PFO closure, independently predicted the composite outcome of cryptogenic stroke, TIA or all-cause mortality.

Acquired intracoronary ADAMTS13 deficiency and VWF retention at sites of critical coronary stenosis in patients with STEMI

von Willebrand factor (VWF) mediates platelet adhesion and agglutinationat sites of vascular injury.VWFis a largemultimericglycoprotein, which circulates in a coiled, non-adhesive conformation.When exposed to high shear stress, VWF unfolds and elongates to highly adhesive multimer strands that adhere on exposed collagen fibers, and by interacting with platelet glycoprotein Ib-a, recruit platelets to the injury site. Recent in vivo work showed that transition from laminar to turbulent flow, as observed at sites of stenotic vessels, is the most important trigger for adhesive conformational change of VWF. Additionally, the ability of VWF to tether platelets is directly proportional to its multimeric size. The latter is regulated by ADAMTS13 (a disintegrin andmetalloproteasewith thrombospondin type-1 repeats, member 13), a metalloprotease that cleaves VWFmultimers within the unfolded A2 domain, thereby reducing VWF multimer size, and by this, decreasing VWF adhesiveness. We postulated that transition from laminar to turbulent flow at sites of critical coronary stenosismay cause a local imbalance betweenVWF and ADAMTS13, which would be responsible for the presence of highly adhesive VWF multimers mediating platelet adhesion and agglutination, and ultimately responsible for acute occlusion. The aim of this investigation was to evaluate systemic and intracoronary thrombin generation, VWF, and ADAMTS13 activity in patients with acute coronary syndromes (ACS) with angiographic evidence of acute thrombotic coronary occlusion. We investigated 27 patients (24 men; median age, 65 years; interquartile range [IQR], 54-74; range, 41-84) undergoing emergency cardiac catheterization for hemodynamically stable ACS presenting with ST-elevation myocardial infarction (STEMI) who gave written informed consent. The culprit lesion was determined angiographically in two orthogonal projections and was defined by the combination of: (1) abrupt (typical) vessel occlusion; and (2) complete absence of (or severely impaired) peripheral coronary flow. Infarct localization was anterior in 9 patients, infero-posterior in 16, and lateral in 2. Maximal creatine kinase value was median 1440 U/L (IQR, 922-2262; range, 750-5800) and the extent of the underlying coronary artery disease assessed by the Syntax score was 17 6 7. All patients underwent percutaneous coronary intervention/stenting with a median time from chest pain to onset-balloon of 105 minutes (IQR, 62-150; range, 20-1140). Blood samples were obtained at 3 different sites before stenting: from the femoral vein and at the ostia of the right or left coronary artery through a coronary guiding 6 French catheter, and 1-3 cm distal to the site of occlusion with a conventional 6 French compatible thrombus aspiration catheter advanced through the lesion. In a preliminary phase, we verified that blood sampling by coronary catheter did not alter results for thrombin-generation markers, VWF, and ADAMTS13 compared with peripheral venipuncture. Additionally, care was taken to perform extra slow aspiration to avoid turbulences inside the catheter. Samples were collected into citrate test tubes, snap-frozen immediately after centrifugation, and kept at 280°C until batch analysis. Markers of thrombin generation and VWF antigen (VWF: Ag) were assessed by enzyme-linked immunosorbent assay and VWF activity (VWF:RCo) by a turbidimetric method as published. ADAMTS13 activity was measured by the fluorescence resonance energy transfer-VWF73 assay as previously described. Our results show that parameters of thrombin generation, ie, prothrombin fragments 112 (F112), thrombin-antithrombin complexes

The "Chimney Approach" for Transcatheter Aortic Valve Implantation. A Strategy for Trans Axillarian Bareback Approach in Patients With No Other Access Options

to describe the procedural steps and to report the short term follow up of our initial experience with an axillarian bareback Dacron graft based technique that could potentially reduce the rate of vascular and ischemic complications during transcatheter aortic valve implantation in patients with contraindications to trans‐femoral approach and with patent left internal mammary arterial graft to left anterior descending coronary artery (LIMA‐LAD) or small caliber axillarian/subclavian arteries.

Recovery from anemia in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation--prevalence, predictors and clinical outcome.

Introduction Preoperative anemia is common in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) and has been linked to a poorer outcome – including a higher 1-year mortality. The aim of this study was to investigate the impact of successful TAVI on baseline anemia. Methods A total of 253 patients who survived at least 1 year following TAVI were included in this study. The prevalence, predictors and clinical outcome of hemoglobin (Hb)-recovery were assessed. Results The prevalence of baseline anemia was 49% (n = 124) – recovery from anemia occurred in 40% of the anemic patients (n = 49) at 1 year after TAVI with an increase in mean Hb-level of 1.35 g/dL from baseline. This increase was not related to an improvement in renal function. At multivariate analysis, a high peak gradient (OR 4.82, P = 0.003) was shown to be an independent predictor for Hb-recovery, while blood transfusion (OR 0.31, P = 0.038) and chronic kidney disease (CKD, OR 0.33, P = 0.043) were identified as negative predictors at, respectively, one and two years after TAVI. When compared to patients without baseline anemia, those anemic patients with Hb-recovery had a similar functional improvement (OR 0.98, P = 0.975), whereas those without Hb-recovery had a significantly lower likelihood of functional improvement with ≧2 NYHA classes (OR 0.49, P = 0.034) and a higher likelihood of re-hospitalization within the first year after TAVI (OR 1.91, P = 0.024). Conclusion Recovery from anemia occurs in 40% of anemic patients at 1 year after TAVI – mainly in those with a high gradient and without CKD. Blood transfusion was found to have a transient adverse effect on this Hb-recovery. Finally, anemic patients without Hb-recovery experience less functional improvement and have a higher re-hospitalization rate within the first year after TAVI.

Evaluation of a protocol for same-day discharge after radial lounge monitoring in a southern Swiss referral percutaneous coronary intervention centre.

Aims The aim of the study was to retrospectively evaluate safety and patient satisfaction of same-day discharge after elective radial coronary angiography/percutaneous coronary intervention (PCI) after the implementation of a radial lounge facility. Methods All patients admitted to our radial lounge with a planned same-day discharge after an uncomplicated coronary angiography/PCI, having a co-living caregiver, were day enrolled in the study. Rates of same-day discharge, unplanned overnight stay, and in-hospital and first complications [death, myocardial infarction (MI), unplanned coronary angiography, access site hematoma, bleedings requiring hospitalization] were analysed; satisfaction was also evaluated through a questionnaire. Results From February 2015 to January 2016, 312 patients with a mean age of 66.6 ± 10.8 years were admitted to the radial lounge (coronary angiography, n = 232; PCIs, n = 80). Of them, 245 (78.5%) were discharged the same day. Mean radial lounge monitoring was 6:35 h (interquartile range 5:30–7:30 h). No episodes of death/MI/unplanned coronary angiography were observed both in same-day discharged and postponed patients. Reasons to postpone discharge were: PCI deemed to need prolonged monitoring in 31, patients preference in 14, femoral shift in 13, surgery in four, chest pain in four, and bleeding in one. At day 1, 11 access site hematoma and one hospitalization for access site bleeding were reported. Patients reported complete satisfaction in 97% of cases. Unplanned overnight stay was common among PCIs patients (RR 6.2, 95% CI 3.9–9.9, P < 0.001). Conclusion A low rate of minor complications was observed in elective radial coronary angiography and PCIs showing the feasibility and safety of the development of an institutional protocol for same-day discharge after the implementation of a radial lounge facility.

Tiara Valve Implantation in a Patient With Previously Implanted Mono-disk Mechanical Aortic Prosthesis

Transcatheter mitral valve replacement with the Tiara valve can be performed in inoperable patients with severe functional regurgitation. Risk of left ventricular outflow tract obstruction can be prevented using preoperative 3D imaging and 3D-printed models. However, in the case of mono-disk mechanical prostheses previously implanted in aortic position (Bjork-Shiley), there is an additional risk of mechanical interference leading to reduced leaflet motion and aortic valve dysfunction. Hereafter, we describe the case of a patient with a 27-mm mono-disk mechanical aortic valve implanted in 1978, a EuroSCORE II of 18%, and a Society of Thoracic Surgeon score (mortality) of 16% who successfully underwent a transapical Tiara valve implantation.

Invasive angiography and revascularization in patients with stable angina following prior coronary artery bypass grafting: Results from the East Denmark heart registry.

There are limited data to guide the optimum approach to patients presenting with angina after coronary artery bypass grafting (CABG). Although often referred for invasive angiography, the effectiveness of this is unknown; angina may also result from diffuse distal or micro‐vascular coronary disease and it is not known how often targets for intervention are identified.