Prakash Balan

Contrast-enhanced ultrasound imaging of atherosclerotic carotid plaque neovascularization: a new surrogate marker of atherosclerosis?

An atherosclerotic plaque requires a nutrient blood supply, which is predominantly derived from arterial vasa vasorum. A variety of factors (environmental and genetic) contribute to the initiation and growth of atherosclerosis within vessel walls. Chemotactic factors, such as tissue ischemic and hypoxic factors, stimulate the release of vascular endothelial growth factor (VEGF) proteins, resulting in vessel wall angiogenesis. These developments often precede the formation of the luminal plaque. In this report, we describe the use of contrast-enhanced carotid ultrasound (CECU) imaging for the detection and quantification of intra-plaque neovascularization. The efficacy of CECU was measured against the neovascular density observed within the tissue specimens obtained at the time of carotid endarterectomy surgery. The objective of this study was to provide a histologic correlation between CECU and carotid artery atherosclerotic plaque neovascularization. Fifteen patients with significant atherosclerotic carotid artery disease received a CECU examination prior to undergoing a carotid endarterectomy (CEA). Two patients received bilateral endarterectomies, resulting in a total of 17 cases. At the time of surgery, carotid plaque samples were surgically removed and stained with specific vascular markers (CD31, CD34, von Willebrand factor, and hemosiderin) designed to identify the presence and degree of neovascularization. The intra-plaque neovascularization recorded on preoperative CECU was correlated with the degree of neovascularization noted in the tissue specimens. The CECU neovascularization was correlated to CD31-stained tissue specimens. This correlation value was 0.68 using Spearmans rank method. When CECU results were correlated with the other histologic markers (CD34, von Willebrand factor, and hemosiderin), a correlation of 0.50 was obtained. In conclusion, contrast-enhanced carotid ultrasound correlated to the presence and degree of intra-plaque neovascularization as determined from histology specimens.

Percutaneous device closure of congenital and iatrogenic ventricular septal defects in adult patients

Objectives: We report our 10‐year experience with percutaneous closure of adult congenital and acquired (non‐post‐infarct) ventricular septal defects (VSDs) using different types of Amplatzer occluder devices. Background: Adult congenital and acquired VSDs may produce significant morbidity and mortality. Furthermore, such VSDs pose a significant surgical challenge. Methods: Between February 2000 and August 2009, data were retrospectively reviewed from 28 patients who underwent 29 procedures for percutaneous device closure of hemodynamically significant VSDs. Seventeen had unrepaired congenital VSDs, 10 had post‐operative VSDs (5 with residual patch‐margin defects, 4 post‐aortic valve replacement, 1 post‐myomectomy), and one had an acquired traumatic VSD. Indications for closure included: symptoms related to significant shunt (dyspnea on exertion); unexplained deterioration of LV function, and/or LV dilation; recurrent endocarditis, and pulmonary hypertension. Outcome parameters were procedural success, procedure‐related complications, evidence of residual shunt by echocardiography, and improvement in the signs/symptoms for which the procedure was performed. The mean follow‐up interval was 68 months. Results: Of the 28 patients studied, a single VSD was present in 26 patients, while one patient had two defects, and one patient had one defect on the LV side with three openings at the RV side. The median size of the defects by echocardiography was 6 mm. A device was successfully implanted in 28 of 29 (97%) procedures and 28 of 28 (100%) patients. Procedure‐related complications occurred in two cases: one involving an access site hematoma not requiring transfusion as well as nonsustained ventricular tachycardia that resolved spontaneously and the other involving acute mitral regurgitation due to inadvertent trapping of the anterior mitral valve leaflet between the left ventricular disk and the septum that was resolved by recapturing of the disk. There was immediate complete closure in 20 patients (71%). In six cases there was trivial residual shunt and in two patients the residual shunt was mild. At the latest follow‐up, four of the eight with a residual shunt had no shunt and in the remaining four the residual shunt was trivial. Among symptomatic patients 18 (64%), there was marked improvement in symptoms and for those patients 17 (61%) for whom the procedure was performed to address left ventricular enlargement, there was reduction or stabilization in LV size on serial echoes. Conclusions: Percutaneous closure of VSDs in the adult patient appears to be safe and effective.

Clinical trends in surgical, minimally invasive and transcatheter aortic valve replacement†

OBJECTIVES Transcatheter aortic valve replacement (TAVR) and minimally invasive aortic valve replacement (MIAVR) have emerged as alternatives to surgical aortic valve replacement (SAVR) via traditional sternotomy. However, their effect on clinical practice remains unclear. The studys objective is to describe clinical trends between TAVR, MIAVR and SAVR in patients with severe aortic stenosis (AS). METHODS This retrospective observational study analyzed trends in isolated severe aortic valve replacement (AVR) among three high volume TAVR, MIAVR and SAVR centres in the United States. The cohort included 2571 patients from 2011 through 2014 undergoing SAVR ( n  = 842), MIAVR ( n  = 699) and TAVR ( n  = 1030) further stratified into transapical (TA-TAVR) and trans-femoral (TF-TAVR). RESULTS Total AVR volume increased +107% with increases in TF-TAVR (+595%) and MIAVR (+57%). However, SAVR (-15%) and TA-TAVR (-49%) decreased from 2013 to 2014. In the final year, risk stratification by age ≥ 80, redo AVR, patients receiving dialysis and STS score >8% revealed increases in TF-TAVR and MIAVR, while SAVR decreased for all groups. CONCLUSIONS TF-TAVR and MIAVR increased while SAVR and TA-TAVR trended down in the latter periods, which underscore a paradigm shift in the treatment of severe AS and the importance of surgeon adoption of TF-TAVR and MIAVR techniques. As the demand for minimally invasive modalities increases, further studies comparing MIAVR versus TF-TAVR in low and intermediate risk patients are warranted.

Ischemic time is a better predictor than door‐to‐balloon time for mortality and infarct size in ST‐elevation myocardial infarction

Current guidelines for ST‐elevation myocardial infarction (STEMI) recommend early revascularization with optimal ischemic time (IT) < 120 min and door‐to‐balloon (D2B) time < 90 min. The focus of most studies has been D2B time, while IT is not frequently reported. We tested the hypothesis that total IT is a better predictor than D2B time for mortality and infarct size.

Early readmissions after transcatheter and surgical aortic valve replacement

We aimed to determine and compare the prevalence, and predictors of readmissions after the transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).

Transcatheter and Surgical Aortic Valve Replacement in Patients With End-Stage Renal Disease

Data on comparative outcomes and readmissions after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with end-stage renal disease (ESRD) are scarce because these patients were excluded from major TAVR trials [(1)][1]. We conducted retrospective

Traditional Sternotomy Versus Minimally Invasive Aortic Valve Replacement in Patients Stratified by Ejection Fraction

Objective Low ejection fraction (EF < 40%) portends adverse outcomes in patients undergoing valvular heart surgery. The role of traditional median sternotomy aortic valve replacement (SAVR) compared with minimally invasive aortic valve replacement (MIAVR) in this cohort remains incompletely understood. Methods A multi-institutional retrospective review of 1503 patients who underwent SAVR (n = 815) and MIAVR via right anterior thoracotomy (n = 688) from 2011 to 2014 was performed. Patients were stratified into two groups: EF of less than 40% and EF of 40% or more. In each EF group, SAVR and MIAVR patients were propensity matched by age, sex, body mass index, race, diabetes, hypertension, dyslipidemia, dialysis, cerebrovascular disease, cardiovascular disease, cerebro-vascular accident, peripheral vascular disease, last creatinine level, EF, previous MI and cardiogenic shock, and the Society for Thoracic Surgeons (STS) score. Results Among patients with an EF of 40% or more (377 pairs), patients who underwent MIAVR compared with SAVR had decreased intensive care unit hours (56.8% vs 84.6%, P < 0.001), postoperative length of stay (7.1 vs 7.9 days, P = 0.04), incidence of atrial fibrillation (18.8% vs 38.7%, P < 0.001), bleeding (0.8% vs 3.2%, P = 0.04), and a trend toward decreased 30-day mortality (0.3% vs 1.3%, P = 0.22). The STS scores were largely equivalent in patients undergoing MIAVR compared with SAVR (2.4% vs 2.6%, P = 0.09). In patients with an EF of less than 40% (35 pairs), there was no difference in intensive care unit hours (69% vs 72.6%, P = 0.80), postoperative length of stay (10.3 vs 7.2 days, P = 0.13), 30-day mortality (3.8% vs 0.8%, P = 0.50), or the STS score (3.3% vs 3.2%, P = 0.68). Conclusions Minimally invasive aortic valve replacement in patients with preserved EF was associated with improved short-term outcomes compared with SAVR. In patients with left ventricular dysfunction, short-term outcomes between MIAVR and SAVR are largely equivalent.

Comparison of outcomes for patients ≥75 years of age treated with pre-hospital reduced-dose fibrinolysis followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction.

A coordinated system of care for patients with ST-segment elevation myocardial infarctions that includes prehospital administration of reduced-dose fibrinolytic agents coupled with urgent percutaneous coronary intervention (PCI), termed FAST-PCI, has been shown to be at least as effective as primary PCI (PPCI) alone. However, this reduced-dose fibrinolytic strategy could be associated with increased bleeding risk, especially in elderly patients. The purpose of this study was to examine 30-day outcomes in patients aged ≥75 years with ST-segment elevation myocardial infarctions treated with either strategy. Data from 120 patients aged ≥75 years treated with FAST-PCI were compared with those of 94 patients aged ≥75 years treated with PPCI. The primary comparator was mortality at 30 days. Stroke, reinfarction, and major bleeding were also compared. The groups were well matched for age, cardiac risk factors, and ischemic times. At 30 days, mortality was lower with FAST-PCI than with PPCI (4.2% vs 18.1%, p <0.01). Rates of stroke, reinfarction, and major bleeding (4% vs 2%) were similar in the 2 groups. The FAST-PCI cohort had lower rates of cardiogenic shock on hospital arrival (15% vs 26%, p = 0.05) and completely occluded infarct arteries (Thrombolysis In Myocardial Infarction [TIMI] grade 0 flow, 35% vs 61%, p <0.01). In conclusion, for patients aged ≥75 years with ST-segment elevation myocardial infarctions, a FAST-PCI strategy in a coordinated system of care was associated with reduced 30-day mortality, earlier infarct artery patency, and lower incidence of cardiogenic shock at arrival compared with PPCI, without apparent bleeding, stroke, or reinfarction penalties.

TCT-724 Permanent Pacemaker Implantation after Transcatheter Aortic Valve Replacement – National Experience

METHODS We enrolled 231 consecutive pts who underwent successfully transfemoral TAVI in local anesthesia using the ESV-3 valve (23,26,29mm). CT-imaging including the Heart Navigator algorithm was used for prosthesis size and implantation plane selection. Serving the mid-balloon marker as reference, 107 pts underwent deep implantation (0.5, 500/o of the crimped valve above annulus level), 124 underwent high implantation (0.6-0.7, 60-70% of the crimped valve above annulus level). Clinical events and post-TAVI PVL was evaluated after 30 days and one year according to the VARC-II criteria.

Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction

We investigated whether prehospital, reduced dose fibrinolysis coupled with urgent percutaneous coronary intervention (FAST‐PCI) reduces mortality and cardiac magnetic resonance (CMR) measures of infarct size, compared with primary percutaneous coronary intervention (PPCI), in patients with ST‐elevation myocardial infarction (STEMI).