Uri Landes

Incidence and outcomes of emergent cardiac surgery during transfemoral transcatheter aortic valve implantation (TAVI): insights from the European Registry on Emergent Cardiac Surgery during TAVI (EuRECS-TAVI)

AimsnLife-threatening complications occur during transcatheter aortic valve implantation (TAVI) which can require emergent cardiac surgery (ECS). Risks and outcomes of patients needing ECS during or immediately after TAVI are still unclear.nnnMethods and resultsnIncidence, risk factors, management, and outcomes of patients requiring ECS during transfemoral (TF)-TAVI were analysed from a contemporary real-world multicentre registry. Between 2013 and 2016, 27xa0760 patients underwent TF-TAVI in 79 centres. Of these, 212 (0.76%) patients required ECS (age 82.4u2009±u20096.3u2009years, 67.5% females, logistic EuroSCORE: 17.1%, STS-score 5.8%). The risk of ECS declined from 2013 (1.07%) to 2014 (0.70%) but remained stable since. Annual TF-TAVI numbers have more than doubled from 2013 to 2016. Leading causes for ECS were left ventricular perforation by the guidewire (28.3%) and annular rupture (21.2%). Immediate procedural mortality (<72u2009h) of TF-TAVI patients requiring ECS was 34.6%. Overall in-hospital mortality was 46.0%, and highest in case of annular rupture (62%). Independent predictors of in-hospital mortality following ECS were ageu2009>u200985u2009years [odds ratio (OR) 1.87, 95% confidence interval (95% CI) (1.02-3.45), Pu2009=u20090.044], annular rupture [OR 1.96, 95% CI (0.94-4.10), Pu2009=u20090.060], and immediate ECS [OR 3.12, 95% CI (1.07-9.11), Pu2009=u20090.037]. One year of survival of the 114 patients surviving the in-hospital period was only 40.4%.nnnConclusionnBetween 2014 and 2016, the need for ECS remained stable around 0.7%. Left ventricular guidewire perforation and annular rupture were the most frequent causes, accounting for almost half of ECS cases. Half of the patients could be salvaged by ECS-nevertheless, 1 year of all-cause mortality was high even in those ECS patients surviving the in-hospital period.

Temporal trends in transcatheter aortic valve implantation, 2008-2014: patient characteristics, procedural issues, and clinical outcome.

About a decade past the first transcatheter aortic valve implantation (TAVI), data are limited regarding temporal trends accompanying its evolution from novel technology to mainstream therapy. We evaluated these trends in a large multicenter TAVI registry.

Type 2 myocardial infarction: A descriptive analysis and comparison with type 1 myocardial infarction

BACKGROUNDnWhile plaque rupture is the paradigm of type 1 myocardial infarction (T1MI), T2MI is myocardial necrosis secondary to oxygen supply-demand mismatch. Being a heterogeneous and rather newly defined group, data are lacking about T2MI.nnnMETHODSnA retrospective review of medical records of patients diagnosed with T2MI in the Rabin Cardiology Center, Israel between the years 2007 and 2012 was performed. Following a descriptive analysis, we used multivariate time dependent models to estimate the association of T2MI with the risk for 30-day, 1-year, and 5-year all-cause-mortality and major adverse cardiovascular events (MACE), and compared it to a T1MI group matched for age, gender and electrocardiographic changes.nnnRESULTSnThe study included 107 T2MI (and 107 T1MI) patients. Sepsis, anemia, and atrial fibrillation were the most common etiologies. Triple anti-thrombotic therapy was given to 22% of T2MI patients (vs. 82% of T1MI patients, p<0.001). Twenty-five percent were managed using urgent percutaneous coronary intervention. Angiography unmasked acute plaque rupture in 29% of T2MI patients group. Compared to T1MI, T2MI was associated with higher all-cause-mortality rate: adjusted-hazard-ratio 7.14 (1.31-38.9) at 30 days, 3.42 (1.51-7.75) at 1 year, and 2.08 (1.14-3.81) at 5 years follow-up. MACE risk was consistent between T2 and T1MI patients.nnnCONCLUSIONSnThe most common T2MI triggers are sepsis, anemia, and atrial fibrillation. Compared to a T1MI population, T2MI is associated with higher short- and long-term mortality rates but equal cardiovascular mortality and MACE risk. As many as 30% may harbor plaque rupture and in fact have T1MI.

Urgent Transcatheter Aortic Valve Implantation in Patients With Severe Aortic Stenosis and Acute Heart Failure: Procedural and 30-Day Outcomes.

BACKGROUNDnTranscatheter aortic valve implantation (TAVI) is recommended for patients with severe symptomatic aortic stenosis (AS) who are at prohibitive/high risk for surgical aortic valve replacement (SAVR). Patients with severe AS may experience acute decompensated heart failure (HF) that is resistant to medical therapy. We report our TAVI experience in treating patients with unstable AS who require urgent intervention for their aortic valve disease.nnnMETHODSnPatients were restrictively included in the urgent TAVI registry if they were admitted with acute refractory and persistent HF despite medical therapy and had TAVI performed during the same hospital stay. All others were included in the elective TAVI group.nnnRESULTSnBetween November 2008 and April 2015, 410 consecutive patients underwent TAVI at our centre-27 (6.6%) urgently. Patients operated on urgently were more likely to be frail and carry higher SAVR mortality risk based on The Society of Thoracic Surgeons Predicted Risk of Mortality/logistic EuroSCORE (LES) measures. Pulmonary edema was the most common clinical presentation. Preprocedural assessment used fewer imaging modalities, yet implantation success remained high and reached 96.3% using an additional valve (valve-within-valve) required in 3 patients, with no difference in periprocedural complications according to the Valve Academic Research Consortium-2 definitions. Although 30-day functional capacity was reduced, patients had similar 30-day mortality and major adverse cardiovascular event rates compared with patients who underwent elective TAVI.nnnCONCLUSIONSnShort-term outcome after urgent TAVI appears to be reasonable. For patients with severe AS who experience acute decompensated HF that is recalcitrant to optimal medical therapy and who are at high risk with SAVR, urgent TAVI may be a viable treatment strategy. Larger prospective studies and data on long-term outcomes are needed.

In vitro evaluation of implantation depth in valve-in-valve using different transcatheter heart valves

AIMSnTranscatheter heart valve (THV) implantation in failed bioprosthetic valves (valve-in-valve [ViV]) offers an alternative therapy for high-risk patients. Elevated post-procedural gradients are a significant limitation of aortic ViV. Our objective was to assess the relationship between depth of implantation and haemodynamics.nnnMETHODS AND RESULTSnCommercially available THVs used for ViV were included in the analysis (CoreValve Evolut, SAPIEN XT and the Portico valve). THVs were implanted in small surgical valves (label size 19 mm) to simulate boundary conditions. Custom-mounted pulse duplicators registered relevant haemodynamic parameters. Twenty-eight experiments were performed (13 CVE, 5 SXT and 10 Portico). Ranges of depth of implantation were: CVE: -1.2 mm to 15.7 mm; SXT: -2.2 mm to 7.5 mm; Portico: 1.4 mm to 12.1 mm. Polynomial regression established a relationship between depth of implantation and valvular mean gradients (CVE: p<0.001; SXT: p=0.01; Portico: p=0.002), as well as with EOA (CVE: p<0.001; SXT: p=0.02; Portico valve: p=0.003). In addition, leaflet coaptation was better in the high implantation experiments for all valves.nnnCONCLUSIONSnThe current comprehensive bench testing assessment demonstrates the importance of high device position for the attainment of optimal haemodynamics during aortic ViV procedures.

BIOFLOW-III satellite—One year clinical outcomes of diabetic patients treated with a biodegradable polymer sirolimus-eluting stent and comprehensive medical surveillance

BACKGROUNDnDrug-eluting stents with biodegradable polymer might be particularly useful in diabetic patients who are at increased risk for target lesion/target vessel revascularization. We therefore aimed at assessing the safety and performance of a biodegradable polymer sirolimus-eluting stent (BP-SES) in combination with comprehensive optimal medical therapy following coronary interventions.nnnMETHODSnThis prospective, multicenter registry was conducted at six centers in Israel. Aside of stent treatment, we aimed for an LDL-C level<70mg/dl; at one and six months post-intervention a diabetic consultancy was required, and follow-up data were collected at six and twelve months. The primary outcome measure was target vessel failure, a composite of cardiac death, target-vessel myocardial infarction and clinically driven target vessel revascularization. Secondary outcomes were target lesion failure, its individual components, and stent thrombosis.nnnRESULTSnFrom August 2013 until May 2014, 120 diabetic patients with 158 lesions were treated with a BP-SES. Mean age was 63.9±9.2years, 27.5% were insulin dependent, 28.3% had a history of myocardial infarction, and 47.5% had prior coronary interventions. By visual estimation, lesions were 3.0±0.5mm in diameter and 15.2±7.4mm long; mean stent diameter and length were 3.0±0.5mm and 19.2±6.8mm. Target vessel failure and target lesion failure at 12months occurred in seven (6.4% [95% CI: 3.1-13.0]) and four patients (3.5% [95% CI: 1.3-9.2]), respectively, and definite stent thrombosis in one patient (1.0% [95% CI: 0.1-7.0]).nnnCONCLUSIONnTreatment with a BP-SES demonstrated excellent target-vessel and target-lesion revascularization rates in a high-risk diabetic patient population undergoing catheter-based revascularization followed by intensified medical care.nnnANNOTATED TABLE OF CONTENTSnIn 120 high-risk diabetic patients with coronary artery stenosis, treatment with the Orsiro sirolimus-eluting stent with biodegradable polymer and comprehensive antidiabetic therapy resulted in excellent clinical outcomes. Target vessel revascularization occurred in 6.4% of patients and target lesion revascularization in 3.5%.

Temporal trends in percutaneous coronary interventions thru the drug eluting stent era: Insights from 18,641 procedures performed over 12‐year period

The last decade, regarded as the DES era in PCI, has witnessed significant advances in the management of coronary disease. We aimed to assess temporal trends in the practice and outcome of percutaneous coronary intervention (PCI) during the drug eluting stent (DES) era.

Usefulness of the CHA2DS2-VASc Score to Predict Outcome in Patients Who Underwent Transcatheter Aortic Valve Implantation

Risk assessment for transcatheter aortic valve implantation (TAVI) patients remains challenging, especially in elderly and high-risk candidates. Although several risk factors contribute to increased morbidity and mortality after TAVI, simple risk scores for routine use are lacking. Applying the CHA2DS2-VASC (congestive heart failure, hypertension, ageu2009≥u200975 years, diabetes, prior stroke, vascular disease, age 65-74 years, sex [female] category) score as a novel risk stratification tool for conditions other than atrial fibrillation and stroke prevention has been previously examined; however, its usefulness in a population of patients with aortic stenosis after TAVI has not been established. Thus, we investigated 633 consecutive patients who underwent TAVI between November 2008 and May 2017, and calculated the CHA2DS2-VASC score. Patients were stratified according to their CHA2DS2-VASC score into 3 categories (0 to 3, 4 to 6, 7 to 9), and the association between CHA2DS2-VASC score and 1-year clinical outcomes (stroke, all-cause mortality, and combined outcome of stroke or mortality) was evaluated. We found that both stroke and mortality at 1 year were significantly more frequent with increasing CHA2DS2-VASC score (pu2009=u20090.012 and pu2009=u20090.025, respectively). Each single-point rise in CHA2DS2-VASC score was associated with a 38% increase in the 1-year combined outcome of mortality or stroke (pu2009=u20090.022; C index 0.615). In conclusion, CHA2DS2-VASC score can be used as a simple and effective tool to predict 1-year clinical outcomes including death and stroke in patients who underwent TAVI.

TRANSCATHETER AORTIC VALVE REPLACEMENT IN ONCOLOGY PATIENTS WITH AORTIC STENOSIS

Patients with malignancy and severe aortic stenosis (AS) are often denied from surgical aortic valve replacement (AVR). Transcatheter AVR (TAVR) may be a better option for these patients, but was not yet systematically evaluated.nnAn international TAVR in Oncology Patients with AS (TOP AS) registry

Iliofemoral artery lumen volume assessment with three dimensional multi-detector computed tomography and vascular complication risk in transfemoral transcatheter aortic valve replacement

BACKGROUNDnTransfemoral Transcatheter Aortic Valve Replacement (TAVR) carries a risk of Vascular Complications (VCs) at the access site. The currently used measures for assessing the risk for VCs are not accurate enough, and sometimes fail to predict them. We therefore aimed to examine whether Iliofemoral artery lumen volume (IFV) assessment with 3-dimensional computed tomography (CT) predicts VCs after transfemoral TAVR.nnnMETHODSnWe identified 45/560 trans-femoral TAVR patients with VC, then performed nearest neighbor 1:1 matching for patients with no VC, matching for age, sex, TAVR year, valve size and type, closure-device, sheath size and peripheral vascular disease. IFV, minimal diameter, tortuosity, and calcification were measured, and their diagnostic performance assessed.nnnRESULTSnThe final analysis included 45 patients with and 45 patients without VCs. The two groups were well balanced. For all patients, median IFV was 8.65u202fml (IQR 6.5-11.95). IFV was lower in patients with VC compared to patients without VC: 7.10u202fml (IQR 5.4-9.0) vs. 10.10u202fml (IQR 8.3-13.3), pu202f<u202f0.001. VC risk had marginal association with iliofemoral artery minimal diameter (pu202f=u202f0.06) and no association with tortuosity or calcification. Compared with other measurements, IFV had the most favorable receiver operating curve for the prediction of VC, with an area under the curve (AUC) of 0.78.nnnCONCLUSIONnIFV measurement using 3-dimensional CT is significantly associated with VCs in transfemoral TAVR patients and might be superior to currently accepted parameters. IFV should be further studied among extended cohorts of TAVR treated patients as a novel tool for VC risk assessment prior to transfemoral TAVR.