Victor-Xavier Tadros

Initial clinical experience with the GORE(®) CARDIOFORM ASD occluder for transcatheter atrial septal defect closure.

To report the initial clinical experience with a novel atrial septal defect (ASD) closure device, the GORE® CARDIOFORM ASD Occluder (GCO).

From tricuspid to double orifice Morphology: Percutaneous tricuspid regurgitation repair with the MitraClip device in congenitally corrected-transposition of great arteries.

Edge to edge transcatheter mitral valve repair with MitraClip (Abbott Vascular, Menlo Park, CA) is increasing for high‐risk surgical patients with significant mitral regurgitation. Patients with congenitally corrected transposition of the great arteries (CCTGA) presenting with tricuspid valve regurgitation of a systemic right ventricle may represent particularly challenging candidates for MitraClip given their anatomy. We report the case of a 67‐year‐old gentleman with CCTGA and severe tricuspid regurgitation who was referred for MitraClip implantation after heart team consensus. Successful implantation of one clip was performed, achieving a significant reduction of the regurgitation. Similarly, favorable findings were confirmed at 6 months, 1 and 2 years follow‐up and the patient had no recurrent heart failure admissions after 2‐year follow‐up. We describe the technical considerations and the importance of 3D‐transoesophageal echocardiography for performing the MitraClip of a trileaflet systemic atrioventricular valve.

Triple Antithrombotic Therapy in Atrial Fibrillation Patients With an Indication for Oral Anticoagulation Undergoing Percutaneous Coronary Intervention A Case-Based Review of the Current Evidence

Atrial fibrillation (AF) is a growing problem, affecting 5.2 million people in the United States in 2010, with a prevalence that is expected to increase to over 12 million by 2030.1,2 The standard of care for stroke prevention in such patients at increased risk, as indicated by a congestive heart failure, hypertension, age ≥75 y (doubled), diabetes mellitus, prior stroke or TIA or thromboembolism (doubled), vascular disease, age 65–74 y, sex category (CHA2DS2-VASc) score3 ≥1, is anticoagulation with a vitamin K antagonist (VKA) or novel oral anticoagulant (NOAC).4 In addition, patients with AF have a high risk of concomitant coronary artery disease (CAD), and when percutaneous coronary intervention (PCI) is required, treatment with aspirin and a platelet P2Y12 receptor inhibitor also becomes indicated.5–7 In such cases, the risk of thromboembolic events and stent thrombosis (ST) after PCI must be weighed against the risk of major bleeding.8–11 Newer, more potent antiplatelet therapy and novel anticoagulants have emerged, thus, making the decision of triple therapy (TT) even more challenging. The optimal antithrombotic therapy for AF patients undergoing PCI is as yet unknown. For many primary care physicians and general cardiologists, the duration, benefits, and bleeding risks of TT in AF patients is unclear. We describe a clinical case of a patient with AF undergoing PCI and discuss medical management for such patients with an emphasis on the recent available data. A 77-year-old woman with permanent AF, diabetes mellitus, dyslipidemia, who was receiving warfarin to prevent stroke presented to the outpatient clinic with progressive chest pain for the past 3 months. She was a former smoker and was carefully taking her medication, which included β-blockers, statins, metformin, and warfarin, with stable international normalized ratio (INR) results. Her ECG …

Clampless myocardial revascularization on a healed iatrogenic aortic dissection

Iatrogenic aortic dissection is an infrequent complication of cardiac catheterization (0.03-0.06%) associated with up to 19% of mortality at 30 days. It was reported to mostly occur when using a 6-Fr guiding catheter to cannulate the right coronary artery. This life-threatening complication usually requires early surgical management and close imaging monitoring and control of systolic blood pressure. This case report describes a patient with iatrogenic aortic dissection during cardiac catheterization in symptomatic coronary artery disease. Conservative management of the limited non-progressive aortic dissection was chosen followed by surgical revascularization with a clampless technique, despite the recent aortic injury.

Simplifying the assessment of coronary artery stenosis by enhancing instantaneous wave free ratio

Background Instantaneous wave free ratio (iFR) does not require adenosine, but has a relatively wide intermediate range where functional assessment remains inconclusive. In this pilot study, we sought to enhance iFR through with the use of intracoronary (IC) saline (iFRs) and contrast media (iFRc) and determine whether these techniques correlated well with fractional flow reserve (FFR). Methods Patients with coronary artery stenosis (CAS) associated with an iFR in the intermediate zone (≥0.86 and ≤0.93) were prospectively assessed with resting distal coronary pressure/aorta pressure (Pd/Pa), iFR, iFRs, iFRc and FFR. Results A total of 40 coronary lesions were studied (40 patients). Pearson correlation coefficients for FFR and iFR, FFR and iFRs, FFR and iFRc were respectively: 0.57 (P=0.0002), 0.80 (P<0.0001) and 0.77 (P<0.0001). Receiver-operating characteristic (ROC) curve analysis showed similar area under the curve (AUC) of iFRs and iFR [0.90 (95% CI: 0.76-1) vs. 0.89 (95% CI: 0.79-0.99), P=0.89]. Youdens index established cut-off values of ≤0.90 for iFR (sensitivity =91%, specificity =74%) and ≤0.78 for iFRs (sensitivity =73%, specificity =100%). In contrast, the AUC of iFRc was superior to the AUC of iFR [0.99 (95% CI: 0.98-1), P=0.049]. iFRc showed excellent accuracy and established cut-off values of ≤0.81 in predicting an FFR value of ≤0.80 (sensitivity =100%, specificity =93%). Conclusions When iFR is in the intermediate zone, functional assessment of CAS by iFR is enhanced with the use of contrast media but not saline. This pilot study could be hypothesis generating for further study to enhance iFR specificity and sensibility.

Clinical outcomes of bioresorbable vascular scaffold to treat all-comer patients. Are patients with acute coronary syndrome better candidate for bioresorbable vascular scaffold?

BACKGROUND Scaffold thromboses (ST) and adverse events and have been associated with bioresorbable vascular scaffolds (BVS) at long-term, but their mechanism remains unclear. We sought to evaluate patient and lesion characteristics associated with mid- to long-term outcomes in patients treated with BVS. METHODS This is an observational single-center, single-arm, retrospective study evaluating the performance of BVS in an all-comer population, including complex lesions (chronic total occlusions, long lesions), small vessels, and acute coronary syndromes (ACS). RESULTS From May 2013 to June 2015, we included 482 patients (580 lesions) that were treated with BVS implantation including 71.2% treated for ACS in the present analysis. Mean follow-up period was 816.2 ± 242.6 days. The primary endpoint was device oriented cardiac events (DOCE), defined as a composite of target-lesion revascularization (TLR), ST, target vessel myocardial infarction (TVMI) and cardiac death. Using Kaplan-Meier methods, the DOCE and ST rates at 36 months were 9.4% and 2.3%, respectively. No ST occurred between 2 and 3 years and ST occurred after 3 years, in one patient. Using multivariate analysis, ACS was the only significant predictor of lower rates of DOCE (p = 0.04, HR: 0.47, 95% CI: 0.23-0.96). CONCLUSIONS In this large all-comers real-world cohort, lesions treated with BVS had non-negligible rates of DOCE and ST, in line with previous published randomized trials. The occurrence of very late event was very low after 24 months. ACS patients had lower rates of DOCE.

Bioresorbable vascular scaffold to treat in‐stent restenosis: Single‐center experience

AIMS The management of patients with in-stent restenosis (ISR) is still a major clinical challenge even in the era of drug-eluting stents (DES). Recent studies have demonstrated acceptable clinical outcomes for the everolimus-eluting bioresorbable vascular scaffold (BVS) ABSORB™ in patients with stable coronary artery disease but data are scarce on its use in patients with ISR. We report the long-term results of our preliminary experience with this novel approach at our institution. METHODS AND RESULTS We investigated the safety and efficacy of BVS implantation to treat ISR. 34 consecutive patients (37 lesions) underwent PCI for ISR with BVS implantation between May 2013 and June 2015 at our institution and were included in the current analysis. Follow-up was available in 91.9% of the patients. Mean follow-up period was 801.9 ± 179 days. One patient had definite scaffold thrombosis (ScT) 2 months after stent implantation which was treated with DES. Five patients (six lesions) experienced target lesion revascularization (TLR). The composite endpoint rate of TLR, ScT, myocardial infarction, and death occured in 6/37 lesions at follow-up (16.2%). CONCLUSIONS These real-world data using BVS in patients with ISR demonstrates that ISR treatment with ABSORB™ BVS is feasible but could have slightly higher target lesion failure rates as compared to DES. This proof of concept could be hypothesis-generating for larger randomized controlled studies.

Réparation mitrale à l’aide du MitraClip après échec précoce d’une réparation chirurgicale

Mitral repair using the MitraClip device is on ongoing expansion and has been evaluated in different patterns of mitral regurgitation. Nevertheless, surgical approaches to mitral regurgitation remain the standard of care, at least in absence of contraindication. We report the first Canadian experience of mitral valve repair with the MitraClip following surgical mitral annuloplasty failure. Therapeutic considerations and potential challenges are discussed.

Atrial septal defect closure with left ventricular dysfunction.

Atrial septal defects are one of the most common congenital heart diseases in adults that may result in significant left to right shunt. Secundum atrial septal defects can remain unrecognised until adult age and cause haemodynamic changes with or without symptoms. Transcatheter ASD closure is the gold standard; however, in those patients with left ventricular dysfunction there may be increased risk of complications due to acute changes in left-sided pressures. In this review, we discuss the clinical aspects of ASD closure in the setting of LV dysfunction and discuss methods to evaluate risk and strategies to minimise complications.