Sarah Zaman

Outcomes of Early Risk Stratification and Targeted Implantable Cardioverter-Defibrillator Implantation After ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

BACKGROUNDnMethods to identify high-risk patients and timing of implantable cardioverter-defibrillator (ICD) therapy after ST-elevation myocardial infarction need further optimization.nnnMETHODS AND RESULTSnWe evaluated outcomes of early ICD implantation in patients with inducible ventricular tachycardia. Consecutive patients treated with primary percutaneous coronary intervention for acute ST-elevation myocardial infarction underwent early left ventricular ejection fraction (LVEF) assessment. Patients with LVEF >40% were discharged (group 1); patients with LVEF < or =40% underwent risk stratification with electrophysiological study. If no ventricular tachycardia was induced, patients were discharged without an ICD (group 2). If sustained monomorphic ventricular tachycardia (> or =200-ms cycle length) was induced, an ICD was implanted before discharge (group 3). Follow-up was obtained up to 30 months in all patients and up to 48 months in a subgroup of patients with LVEF < or =30% without an ICD. The primary end point was total mortality. Group 1 (n=574) had a mean LVEF of 54+/-8%; group 2 (n=83), 32+/-6%; and group 3 (n=32), 29+/-7%. At a median follow-up of 12 months, there was no significant difference in survival between the 3 groups (P=0.879), with mortality rates of 3%, 3%, and 6% for groups 1 through 3, respectively. In the subgroup of group 2 patients with LVEF < or =30% and no ICD (n=25), there was 9% mortality at a median follow-up of 25 months. In group 3, 19% had spontaneous ICD activation resulting from ventricular tachycardia.nnnCONCLUSIONSnEarly ICD implantation limited to patients with inducible ventricular tachycardia enables a low overall mortality in patients with impaired LVEF after primary percutaneous coronary intervention for ST-elevation myocardial infarction.

Pre - Transcatheter Aortic Valve Implantation Workup in the Cardiac Catheterisation Laboratory

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving field with exponential growth worldwide in TAVI numbers. One of the principle methods in improving outcomes with a new technique such as TAVI is to ensure that patients undergo efficient pre-procedural evaluation. Standard TAVI workup includes clinical assessment, surgical and frailty risk scoring, blood investigations, echocardiography, pulmonary function tests, computed tomography (CT) angiography and cardiac catheterisation. Patients sent to the cardiac catheterisation laboratory (CCL) for TAVI workup require a systematic and thorough approach. This can include iliofemoral angiography, aortography, aortic valve crossing, haemodynamic evaluation, coronary angiography and right heart catheterisation. In addition, several key steps are required to evaluate suitability for the percutaneous transfemoral TAVI approach. This is the first review to systematically describe steps to evaluate pre-TAVI patients in the CCL. Due to the rapidly rising TAVI numbers, this workup will likely be performed not only by TAVI operators but also by the general interventional cardiologist.

Programmed Ventricular Stimulation to Risk Stratify for Early Cardioverter-Defibrillator Implantation to Prevent Tachyarrhythmias following Acute Myocardial Infarction (PROTECT-ICD): Trial Protocol, Background and Significance

The Programmed Ventricular Stimulation to Risk Stratify for Early Cardioverter-Defibrillator Implantation to Prevent Tachyarrhythmias following Acute Myocardial Infarction (PROTECT-ICD) trial is an Australian-led multicentre randomised controlled trial targeting prevention of sudden cardiac death in patients who have at least moderately reduced cardiac function following a myocardial infarct (MI). The primary objective of the trial is to assess whether electrophysiological study to guide prophylactic implantation of an implantable cardioverter-defibrillator (ICD) early following MI (first 40 days) will lead to a significant reduction in sudden cardiac death and non-fatal arrhythmia. The secondary objective is to assess the utility of cardiac MRI (CMR) in assessing early myocardial characteristics, and its predictive value for both inducible ventricular tachycardia (VT) at EPS and SCD/ non-fatal arrhythmia at follow-up.

Incidence and predictors of permanent pacemaker implantation following treatment with the repositionable Lotus™ transcatheter aortic valve

Objectives nTo determine the incidence and predictors of permanent pacemaker (PPM) requirement following transcatheter aortic valve replacement (TAVR) with the mechanically expanded LotusTM Valve System (Boston Scientific). n nBackground nPacemaker implantation is the most common complication following TAVR. Predictors of pacing following TAVR with the Lotus valve have not been systematically assessed. n nMethods nConsecutive patients with severe aortic stenosis who underwent Lotus valve implantation were prospectively recruited at a single-centre. Patients with a pre-existing PPM were excluded. Baseline ECG, echocardiographic and multiple detector computed tomography as well as procedural telemetry and depth of implantation were independently analyzed in a blinded manner. The primary endpoint was 30-day incidence of pacemaker requirement (PPM implantation or death while pacing-dependent). Multivariate analysis was performed to identify independent predictors of the primary endpoint. n nResults nA total of 104 consecutive patients underwent TAVR with the Lotus valve with 9/104 (9%) with a pre-existing PPM excluded. New or worsened procedural LBBB occurred in 78%. Thirty-day incidence of the primary pacing endpoint was 28%. The most common indication for PPM implantation was complete heart block (CHB) (69%). Independent predictors of the primary endpoint included pre-existing RBBB (hazard ratio [HR] 2.8, 95% CI 1.1–7.0; Pu2009=u20090.032) and depth of implantation below the noncoronary cusp (NCC) (HR 2.4, 95% CI 1.0–5.7; Pu2009=u20090.045). n nConclusions nAlmost a third of Lotus valve recipients require pacemaker implantation within 30 days. The presence of pre-existing RBBB and the depth of prosthesis implantation below the NCC were significant pacing predictors.

Impact of routine crossover balloon occlusion technique on access-related vascular complications following transfemoral transcatheter aortic valve replacement.

Objectives n nTo determine the impact of incorporating routine crossover balloon occlusion technique (CBOT) for vascular access closure following transcatheter aortic valve replacement (TAVR) on major access-site-related complications. n n n nBackground n nVascular complications are associated with increased mortality following TAVR. The CBOT involves passage of a balloon catheter from the contralateral femoral artery to enable controlled closure of large-sheath access-sites. n n n nMethods n nConsecutive patients who underwent transfemoral TAVR as part of three clinical trials were prospectively recruited. Patients who had routine CBOT (CBOT group, nu2009=u200955) were compared to preceding patients who did not undergo CBOT (control group, nu2009=u200943). The primary endpoint was 30-day occurrence of access-site-related Valve Academic Research Consortium (VARC)−2 defined major vascular and/or bleeding complications. n n n nResults n nCBOT was successfully performed in 96% with 2% occurrence of a minor CBOT-related complication. At 30-days access-site-related major vascular and/or bleeding occurred in 5.5% and 18.6% of the CBOT and control group, respectively (Pu2009=u20090.042). This consisted of VARC-2 major vascular events in 3.6% and 16.3% (Pu2009=u20090.036) and VARC-2 major/life-threatening bleeding events in 5.5% and 14.0% (Pu2009=u20090.137) of the CBOT and control group, respectively. Transfusion of ≥2 units of packed red blood cells were required in 10.9% and 30.2% of the CBOT and control group, respectively (Pu2009=u20090.016). There was no significant difference in contrast load, procedure time, and kidney injury between the two groups. n n n nConclusions n nRoutine CBOT for TAVR access-site closure has a high success rate and is associated with a significant reduction in VARC-2 major vascular and bleeding complications compared to TAVR performed without CBOT.

Safety and efficacy of valve repositioning during transcatheter aortic valve replacement with the Lotus Valve System.

OBJECTIVEnTo determine the safety and efficacy of valve repositioning following transcatheter aortic valve replacement (TAVR) with the Lotus Valve System (Boston Scientific, Marlborough, MA, USA).nnnINTRODUCTIONnTAVR is a well-established treatment for severe aortic stenosis. The Lotus Valve System is fully repositionable and retrievable. Valve repositioning has the potential to minimize TAVR-related complications caused by valve malposition; however, the effect on adverse event rates such as stroke is unknown.nnnMETHODSnConsecutive patients with severe aortic stenosis treated with the Lotus Valve System (n=125) were prospectively recruited. Patients who did not require valve repositioning (Group A) were compared to patients who required one or more valve repositions (Group B). The primary end-point was 30-day occurrence of major adverse cardiovascular and cerebrovascular events (MACCE). Secondary end-points included each component of the primary end-point, new pacemaker insertion, and procedural or 30-day major adverse events, defined according to VARC-2 definitions.nnnRESULTSnValve repositioning was utilized in 60.8% (76/125) of patients including 17.1% (13/76) who required full valve resheathing. The most frequent indications for valve repositioning were altering the depth and angulation of initial implantation (69.7%), reducing paravalvular regurgitation (13.2%), and attempt to correct new or worsened heart block (7.9%). Baseline characteristics were similar in both groups. The primary end-point occurred in 12.2% and 6.6% of Group A and B, respectively (p=0.10). Thirty-day new pacemaker implantation was 34.1% and 18.8% in Group A and B, respectively (p=0.06). The secondary end-point measures were not significantly different between the groups.nnnCONCLUSIONnRepositioning facilitated correct anatomical positioning of all devices leading to optimal prosthesis hemodynamics and a trend to lower pacemaker rate without increased risk of MACCE.

Persistent type III cavity-spilling coronary perforation due to covered stent malapposition

Coronary perforations are a rare but potentially catastrophic complication of percutaneous coronary intervention. We report a rare case of a large cavity-spilling perforation from the left anterior descending coronary artery into the left ventricle, which was successfully treated with a covered stent. However, repeating angiography 1xa0week later demonstrated persistence of the perforation due to stent malapposition.

Sudden Death Risk-Stratification in 2018–2019: The Old and the New

Sudden Cardiac Death (SCD) is a major public health issue, accounting for half of all cardiovascular deaths world-wide. The implantable cardioverter-defibrillator (ICD) has been solidified as the cornerstone therapy in primary prevention of SCD in ischaemic and non-ischaemic cardiomyopathy. However, what has become increasingly clear is that the left ventricular ejection fraction (LVEF) is an inadequate tool to select patients for a prophylactic ICD, despite its widespread use for this purpose. Use of LVEF alone has poor specificity for arrhythmic versus non-arrhythmic death. In addition, the vast majority of sudden deaths occur in patients with more preserved cardiac function. Alternate predictors of sudden death include electrophysiology study, non-invasive markers of electrical instability, myocardial fibrosis, genetic and bio-markers. The challenge for the future is finding a risk stratification test, or combination of tests, that adequately select patients at high risk of SCD with low competing risk of non-sudden death.

Transcatheter Aortic Valve Replacement and Atrial Fibrillation: Impact of Antithrombotic Strategy on Clinical Outcomes

BACKGROUNDnAntithrombotic recommendations following transcatheter aortic valve replacement (TAVR) are largely based on previous trial protocols. The efficacy and risk of anticoagulation has not been systematically assessed. The aim of this study was to determine the efficacy and safety of oral anticoagulation in patients with atrial fibrillation (AF) following TAVR with the Lotus Valve System (Boston Scientific, Marlborough, MA, USA).nnnMETHODSnConsecutive patients with severe aortic stenosis who underwent Lotus valve implantation were prospectively recruited (n=164). Atrial fibrillation patients prescribed oral anticoagulation (standard AF therapy) were compared to non-AF patients prescribed aspirin and clopidogrel (standard non-AF therapy). Twenty (20) of 164 patients were excluded, as they were not prescribed standard therapy. The primary endpoint was 6-month incidence of death, myocardial infarction, stroke/transient ischaemic attack (TIA) or major/life-threatening bleeding. Secondary endpoints included each component of the primary endpoint, defined according to VARC-2.nnnRESULTSnOverall, the primary endpoint occurred in 20.8% and 17.7% of the standard AF and standard non-AF therapy groups respectively (p=0.82). There was no statistically significant difference in bleeding (12.5% versus 9.4%, p=0.77) or stroke/TIA (2.1% versus 8.3%, p=0.27) between the standard AF and standard non-AF therapy groups respectively.nnnCONCLUSIONSnThis study supports the safety of anticoagulation in AF patients, which did not result in excess risk of bleeding or stroke/TIA compared with dual antiplatelet therapy in non-AF patients.

Long-term pacemaker dependency and impact of pacing on mortality following transcatheter aortic valve replacement with the LOTUS valve

To determine permanent pacemaker (PPM) dependency following transcatheter aortic valve replacement (TAVR) with the Lotus™ valve system (Boston Scientific), and the impact of PPM implantation on long‐term morbidity and mortality.