Volker Geist

Anatomic and procedural predictors of paravalvular aortic regurgitation after implantation of the Medtronic CoreValve bioprosthesis.

OBJECTIVES The purpose of this study was to determine the predictors of aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). BACKGROUND TAVI has been associated with a high rate of paravalvular regurgitation, usually mild. Nevertheless, moderate to severe regurgitations still occur and may have negative clinical consequences. METHODS Fifty patients with severe aortic stenosis were recruited and underwent successful TAVI with the Medtronic CoreValve bioprosthesis through the transfemoral route. The end point of this study is the early occurrence of significant AR, defined as the occurrence of grade II or more AR by post-procedural aortography. RESULTS The study populations mean age was 80.5 ± 7.9 years, with a mean aortic valve area of 0.64 ± 0.17 cm². Post-procedural AR was absent in 3 patients and was grade I in 27 patients, grade II in 13 patients, and grade III in 7 patients. Using univariate analysis, the chance of significant AR increased with increasing angle of left ventricular outflow tract to ascending aorta (∠LVOT-AO) (odds ratio: 1.24, p < 0.001). For the depth of the device in relation to the noncoronary cusp, there was a minimum chance of AR corresponding to depth = 9.5 mm (odds ratio: 1.1, p = 0.01). Using multivariate analysis, we found a greater chance of significant AR with a greater angle (odds ratio: 1.24, p = 0.001), and that the chance of significant AR is a minimum when depth of the device in relation to the noncoronary cusp is ∼10 mm (odds ratio: 1.1, p = 0.024). A predictive model was generated, and if 2 ×∠LVOT-AO + (depth to noncoronary cusp - 10)² ≥ 50, the likelihood of occurrence of significant AR could be predicted with a sensitivity of 85% and a specificity of 87%. CONCLUSIONS The occurrence of significant AR after TAVI can be predicted by anatomic and procedural variables. A model such as that presented can be used to select suitable patients for this procedure and guide operators during implantation of the device.

High-Speed Rotational Atherectomy Before Paclitaxel-Eluting Stent Implantation in Complex Calcified Coronary Lesions: The Randomized ROTAXUS (Rotational Atherectomy Prior to Taxus Stent Treatment for Complex Native Coronary Artery Disease) Trial

OBJECTIVES This study sought to determine the effect of rotational atherectomy (RA) on drug-eluting stent (DES) effectiveness. BACKGROUND DES are frequently used in complex lesions, including calcified stenoses, which may challenge DES delivery, expansion, and effectiveness. RA can adequately modify calcified plaques and facilitate stent delivery and expansion. Its impact on DES effectiveness is widely unknown. METHODS The ROTAXUS (Rotational Atherectomy Prior to TAXUS Stent Treatment for Complex Native Coronary Artery Disease) study randomly assigned 240 patients with complex calcified native coronary lesions to RA followed by stenting (n = 120) or stenting without RA (n = 120, standard therapy group). Stenting was performed using a polymer-based slow-release paclitaxel-eluting stent. The primary endpoint was in-stent late lumen loss at 9 months. Secondary endpoints included angiographic and strategy success, binary restenosis, definite stent thrombosis, and major adverse cardiac events at 9 months. RESULTS Despite similar baseline characteristics, significantly more patients in the standard therapy group were crossed over (12.5% vs. 4.2%, p = 0.02), resulting in higher strategy success in the rotablation group (92.5% vs. 83.3%, p = 0.03). At 9 months, in-stent late lumen loss was higher in the rotablation group (0.44 ± 0.58 vs. 0.31 ± 0.52, p = 0.04), despite an initially higher acute lumen gain (1.56 ± 0.43 vs. 1.44 ± 0.49 mm, p = 0.01). In-stent binary restenosis (11.4% vs. 10.6%, p = 0.71), target lesion revascularization (11.7% vs. 12.5%, p = 0.84), definite stent thrombosis (0.8% vs. 0%, p = 1.0), and major adverse cardiac events (24.2% vs. 28.3%, p = 0.46) were similar in both groups. CONCLUSIONS Routine lesion preparation using RA did not reduce late lumen loss of DES at 9 months. Balloon dilation with only provisional rotablation remains the default strategy for complex calcified lesions before DES implantation.

Multi-vessel stenting during primary percutaneous coronary intervention for acute myocardial infarction. A single-center experience.

BackgroundRecanalization of the culprit lesion is the main goal of primary angioplasty for acute ST-segment elevation myocardial infarction (STEMI). Patients presenting with acute myocardial infarction and multivessel disease are, therefore, usually subjected to staged procedures, with the primary percutaneous coronary intervention (PCI) confined to recanalization of the infarct-related artery (IRA). Theoretically at least, early relief of stenoses of non-infarctrelated arteries could promote collateral circulation, which could help to limit the infarct size. However, the safety and feasibility of such an approach has not been adequately established.MethodsIn this single-center prospective study we examined 73 consecutive patients who had an acute STEMI and at least one or more lesions ≥ 70% in a major epicardial vessel other than the infarctrelated artery. In the first 28 patients, forming the multi-vessel (MV) PCI group, all lesions were treated during the primary procedure. In the following 45 patients, forming the culprit-only (CO) PCI group, only the culprit lesion was treated during the initial procedure, followed by either planned-staged or ischemiadriven revascularization of the non-culprit lesions. Fluoroscopy time and contrast dye amount were compared between both groups, and patients were followed up for one year for major adverse cardiac events (MACE) and other significant clinical events.ResultsThe two groups were well balanced in terms of clinical characteristics, number of diseased vessels and angiographic characteristics of the culprit lesion. In the MV-PCI group, 2.51 lesions per patient were treated using 2.96 ± 1.34 stents (1.00 lesions and 1.76 ± 1.17 stents in the CO-PCI group, both p < 0.001). The fluoroscopy time increased from 10.3 (7.2–16.9) min in the CO-PCI group to 12.5 (8.5–19.3) min in the MV-PCI group (p = 0.22), and the amount of contrast used from 200 (180–250) ml to 250 (200–300) ml, respectively (p = 0.16). Peak CK and CK-MB were significantly lower in patients of the MV-PCI group (843 ± 845 and 135 ± 125 vs 1652 ± 1550 and 207 ± 155 U/l, p < 0.001 and 0.01, respectively). Similar rates of major adverse cardiac events at one year were observed in the two groups (24% and 28% in multi-vessel and culprit treatment groups, p = 0.73). The incidence of new revascularization in both infarct- and noninfarct-related arteries was also similar (24% and 28%, respectively, p = 0.73).ConclusionWe may state from this limited experience that a multi-vessel stenting approach for patients with acute STEMI and multi-vessel disease is feasible and probably safe during routine clinical practice. Our data suggest that this approach may help to limit the infarct size. However, larger studies, perhaps using drug-eluting stents, are still needed to further evaluate the safety and efficiency of this procedure, and whether it is associated with a lower need of subsequent revascularization and lower costs.

Comparison of Hospital Mortality With Intra-Aortic Balloon Counterpulsation Insertion Before Versus After Primary Percutaneous Coronary Intervention for Cardiogenic Shock Complicating Acute Myocardial Infarction

Primary percutaneous coronary intervention (PCI) and intra-aortic balloon pump counterpulsation (IABP) are established treatment modalities in acute myocardial infarction complicated by cardiogenic shock. We hypothesized that the insertion of the IABP before primary PCI might result in better survival of patients with cardiogenic shock compared to postponing the insertion to after primary PCI. We, therefore, retrospectively studied 48 patients who had undergone primary PCI with IABP because of cardiogenic shock complicating acute myocardial infarction (26 patients received the IABP before and 22 patients after primary PCI). No significant differences were present in the baseline clinical characteristics between the 2 groups. The mean number of diseased vessels was greater in the group of patients treated with the IABP before primary PCI (2.8 +/- 0.5 vs 2.3 +/- 0.7, p = 0.012), but the difference in the number of treated vessels was not significant. The peak creatine kinase and creatine kinase -MB levels were lower in patients treated with the IABP before primary PCI (median 1,077, interquartile range 438 to 2067 vs median 3,299, interquartile range 695 to 6,834, p = 0.047, and median 95, interquartile range 34 to 196 vs median 192, interquartile range 82 to 467, p = 0.048, respectively). In-hospital mortality and the overall incidence of major adverse cardiac and cerebrovascular events were significantly lower in the group of patients receiving the IABP before primary PCI (19% vs 59% and 23% vs 77%, p = 0.007 and p = 0.0004, respectively). Multivariate analysis identified renal failure (odds ratio 15.2, 95% confidence interval 3.13 to 73.66) and insertion of the IABP after PCI (odds ratio 5.2, 95% confidence interval 1.09 to 24.76) as the only independent predictors of in-hospital mortality. In conclusion, the results of the present study suggest that patients with cardiogenic shock complicating acute myocardial infarction who undergo primary PCI assisted by IABP have a more favorable in-hospital outcome and lower in-hospital mortality than patients who receive IABP after PCI.

Long-term clinical outcome of rotational atherectomy followed by drug-eluting stent implantation in complex calcified coronary lesions

To assess long‐term outcome after rotational atherectomy (RA) is followed by drug‐eluting stent (DES) implantation in complex calcified coronary lesions.

Successful percutaneous coronary intervention after implantation of a CoreValve percutaneous aortic valve.

Background: The association between aortic valve disease and coronary atherosclerosis is common. In the recent era of percutaneous aortic valve replacement (PAVR), there is little experience with coronary artery intervention after valve implantation. Case report: To our knowledge, this is the first case of successful percutaneous coronary intervention after implantation of a CoreValve percutaneous aortic valve. We report a case of a 79‐year‐old female patient who underwent successful coronary artery intervention few months after a CoreValves percutaneous implantation for severe aortic valve stenosis. Verifying the position of the used wires (crossing from inside the self expanding frame) is of utmost importance before proceeding to coronary intervention. In this case, crossing the aortic valve, coronary angiography, and multivessel stenting were successfully performed. Conclusion: Percutaneous coronary intervention in patients with previous CoreValve is feasible and safe.

Aortic Regurgitation and Left Ventricular Remodeling After Transcatheter Aortic Valve Implantation A Serial Cardiac Magnetic Resonance Imaging Study

Background—Aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) has been associated with poor outcomes, but little is known about how it evolves over time. We evaluated left ventricular (LV) function, remodeling, and the occurrence and evolution of AR after TAVI by using cardiac MRI. Methods and Results—Forty-three patients treated with transfemoral TAVI underwent cardiac MRI 1 week and 6 months after TAVI. LV volumes and function were assessed by using standard cine MRI sequences. Phase-contrast imaging was performed to quantify the degree of AR. The mean age of the evaluated patients was 80 years, and 65% of patients were women. At baseline MRI, the median LV ejection fraction was 58.1%, which improved significantly at follow-up to 63.4% (P<0.0001). A significant reduction of LV end-diastolic volume (149.7±41.4–140.1±43.9 mL; P=0.014) and of LV mass (156.3±32.8–142.7±39.3 g; P<0.001) was observed. Over time, aortic regurgitant fraction increased slightly but significantly from 5.2% to 7.8% (P=0.04). Subgroup analysis revealed that significant changes of LV ejection fraction, volumes, and mass only occurred in patients with no or mild AR at baseline MRI, whereas those parameters remained unchanged in patients with AR more than or equal to grade II. Conclusions—By using cardiac MRI in patients with TAVI, a significant improvement of LV function, volume, and mass can be documented. Mild-to-moderate AR is commonly seen, and AR shows a small increase over time. More-than-mild AR seems to prevent LV functional and structural recovery after TAVI.

Early hemodynamic and neurohormonal response after transcatheter aortic valve implantation

BACKGROUND The conventional surgical aortic bioprostheses used for treatment of aortic stenosis (AS) are inherently stenotic in nature. The more favorable mechanical profile of the Medtronic CoreValve bioprosthesis may translate into a better hemodynamic and neurohormonal response. PATIENTS AND METHODS The early hemodynamic and neurohormonal responses of 56 patients who underwent successful transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve bioprosthesis for severe symptomatic AS were compared with those of 36 patients who underwent surgical aortic valve replacement (SAVR) using tissue valves in the same period. RESULTS At baseline, patients in the TAVI and SAVR group had comparable indexed aortic valve area (0.33 ± 0.1 vs 0.34 ± 0.1 cm² , respectively; P = .69) and mean transvalvular gradient (51.1 ± 16.5 vs 53.1 ± 14.3 mm Hg, respectively; P = .56). At 30-day follow-up, mean transvalvular gradient was lower in the TAVI group than in the SAVR group (10.3 ± 4 vs 13.1 ± 6.2 mm Hg, respectively; P = .015), and the indexed aortic valve area was larger in the TAVI group (1.0 ± 0.14 vs 0.93 ± 0.13 cm²/m²; P = .017). There was a trend toward a higher incidence of moderate patient-prosthesis mismatch in the surgical group compared with the TAVI group (30.5% vs 17.8%, respectively; P = .11). The overall incidence of prosthetic regurgitation (any degree) was higher in the TAVI group than in the SAVR group (85.7% vs 16.7%, respectively; P < .00001). The left ventricular mass index decreased after TAVI (175.1 ± 61.8 vs 165.6 ± 57.2 g/m²; P = .0003) and remained unchanged after SAVR (165.1 ± 50.6 vs 161 ± 64.8 g/m²; P = .81). Similarly, NT-ProBNP decreased after TAVI (3,479 ± 2,716 vs 2,533 ± 1,849 pg/mL; P = .033) and remained unchanged after SAVR (1,836 ± 2,779 vs 1,689 ± 1,533 pg/mL; P = .78). There was a modest correlation between natriuretic peptides and left ventricular mass index in the whole cohort (r = 0.4, P = .013). CONCLUSION In patients with severe AS, TAVI resulted in lower transvalvular gradients and higher valve areas than SAVR. Such hemodynamic performance after TAVI may have contributed to early initiation of a reverse cardiac remodeling process and a decrease in natriuretic peptides.

Longitudinal Deformation of Contemporary Coronary Stents: An Integrated Analysis of Clinical Experience and Observations from the Bench

OBJECTIVE  To report clinical experience with longitudinal stent deformation (LSD) and observations from the bench. BACKGROUND  LSD was recently reported with thin-strut coronary stents. Whether it is related to a particular stent or constitutes a class-effect remains debatable. METHODS After 2 cases of LSD were reported, information was sent to operators to warn of this event and identify possible cases. All cases were reviewed to ensure LSD had occurred. Simultaneously, bench testing was conducted to identify the susceptibility of stents to longitudinal compression and whether LSD detection is influenced by fluoroscopic stent visibility. RESULTS  Between July 2010 and November 2011, 2,705 coronary interventions were performed with 4,588 stents (Promus Element = 41.6%, Xience Prime = 24.4%). Six patients with LSD were identified, all with Promus Element (0.31%). Wire bias was a predisposing factor in 4 cases. All patients were treated with postdilatation and/or additional stenting. No adverse events occurred (mean 5.8 months). In bench testing, LSD occured in all examined stents, but at different levels of applied force (weight). Most shortening at 50 g was observed with Promus Element (38.9%), as was the best visibility of LSD on x-ray images. With postdilatation all stents showed some re-elongation. CONCLUSION In our practice LSD was a rare observation only seen with the Promus Element stent. When subjected to longitudinal compression in a bench test all contemporary stents can be compressed. Compression of Promus Element occurs at a lower force, but it is the only stent where deformations are detected with x ray. Postdilatation can partially improve LSD.

Retrograde Typ-A-Dissektion nach endovaskulärem Stentgrafting einer Typ-B-Dissektion

Acute aortic dissection is a disease with high mortality. Whereas acute dissection of the ascending aorta (Stanford type A) is treated surgically, acute dissection of Stanford type B (descending aorta) is principially treated conservatively, but surgically in case of complications. Recently, another therapeutical option for the treatment of type B dissection has been developed using endovascular stent-grafts. We report on a 64-year-old woman with typical signs of acute aortic dissection. Computer tomography and transesophageal echocardiography demonstrated Stanford type B dissection. The patient was treated with an endovascular stent-graft, because of malperfusion of the right leg and chest pain. After successful closure of the entry by the stent, the patient developed acute right-sided hemiplegia one day after the intervention due to retrograde dissection into the aortic arch and ascending aorta. Upon immediate operation, the origin of the initially type B dissection was still sufficiently occluded by the endovascular stent-graft; however, there was another entry between the innominate artery and the left carotic artery near one proximal end of the stent’s strut. Using deep hypothermia and selective antegrade cerebral perfusion, the ascending aorta and proximal arch were replaced with a 28mm Dacron-Velour tube and the aortic root was remodelled with a tongue-shaped Dacron graft preserving the valve cusps according to a modified Yacoub procedure. After the operation, neurological symptoms diminished and the patient could walk on the ward on day eleven.    This case demonstrates retrograde type A dissection as a complication after interventional treatment of type B dissection using an endovascular stent-graft. The reason for this delayed complication is speculative. Aortic wall damage during stent inserting could be a possible cause. It is also likely that the patient initially had type B dissection with retrograde dissection of the distal part of the aortic arch. Therefore, one of the straight struts of the proximal end of the stent may have caused additional damage to the vulnerable dissected aortic wall in the arch, leading to retrograde type A dissection. Careful patient selection, detailed diagnosis of the aortic arch, improved stent designs and materials, especially regarding the stent’s ends and careful insertion of the stent into the aortic arch, could contribute to prevention of the described problems. Die folgende Kasuistik berichtet von einer 64-jährigen Patientin mit typischen Zeichen einer akuten Stanford Typ-B-Dissektion. Die Behandlung erfolgte mit einem endovaskulärem Stentgraft. Die Okklusion des Dissektionsentrys durch den Stentgraft war erfolgreich. Am Tage nach der Intervention entwickelte die Patientin eine akute rechtsseitige Halbseitensymptomatik aufgrund einer retrograden Stanford Typ-A-Dissektion. Die Aorta ascendens und der proximale Aortenbogen wurden durch eine 28mm Dacron-Velourprothese ersetzt und die Aortenklappe mittels einer modifizierten Yacoub-Operation resuspendiert. Nach der Operation verschwanden die neurologischen Symptome. Mögliche Ursachen der Typ-A-Dissektion als Komplikation einer, mit einem endovaskulärem Stentgraft behandelten Typ-B-Dissektion werden diskutiert.