Balloon aortic valvuloplasty with or without percutaneous coronary intervention in the TAVR era.

Introduction The role of balloon aortic valvuloplasty (BAV) amid the era of transcatheter aortic valve replacement (TAVR) remains a topic of debate. We sought to study the safety and feasibility of combined balloon aortic valvuloplasty and percutaneous coronary intervention (BAV-PCI). Methods Between November 2009 and July 2020, all patients undergoing BAV were identified and divided into three groups: combined BAV-PCI (group A), BAV with significant unrevascularised CAD (group B) and BAV without significant CAD (group C). Procedural outcomes, 30-day and one-year mortality were compared. Results A total of 264 patients were studied (n = 84, 93 and 87 patients in group A, B and C, respectively). The STS score was 10.2 ±8, 13.3 ±19 and 8.1 ±7, p = 0.026, in group A, B and C, respectively. VARC-3 adjudicated complications were similar among groups (11%, 13% and 5%, respectively, p = 0.168, respectively). Thirty-day and one-year mortality were 9.8% (n =26) and 32% (n = 86) of the entire cohort. The differences among groups did not reach statistical significance. Using univariate Cox regression analysis, group B were at higher risk of dying compared to group A patients (HR 1.58, 95% CI 1.11 - 2.25, p = 0.010). With multivariate Cox regression analysis, the predictors of mortality were STS score, cardiogenic shock, and mode of presentation and lack of subsequent definitive valve intervention. Conclusion In high-risk patients with aortic valve stenosis, combined BAV-PCI is safe and feasible with comparable outcomes to BAV with and without significant CAD.

Factors affecting knowledge and attitude of healthcare workers towards basic life support in Khyber Teaching Hospital, Peshawar, Pakistan: a cross-sectional analysis.

OBJECTIVE: This study was conducted to assess the knowledge and attitude of healthcare workers towards basic life support (BLS) in Khyber Teaching Hospital, Peshawar, and to investigate the factors affecting them. DESIGN: Cross-sectional study. SETTING: This study was carried out in a tertiary care hospital in Peshawar, Pakistan. PARTICIPANTS: 201 healthcare professionals were recruited for this study through simple convenience sampling which included house officers (HOs), trained medical officers, postgraduate residents, professors, specialty registrars and nurses. Healthcare professionals who were reluctant to give consent were excluded from the study. RESULTS: Among the chosen participants, only 16.4% had good knowledge whereas 63% had a good attitude towards BLS. Knowledge of participants was found to be positively associated with less time elapsed between the training sessions (p=0.041). On the other hand, factors such as age(p=0.004), designation (p=0.05), number of BLS sessions attended (p=0.012) and the time elapsed since the last BLS session attended (p=0.015), were positively associated with the attitude of healthcare professionals. CONCLUSION: The level of knowledge and attitude towards BLS by healthcare professionals was suboptimal. Those individuals who had attended BLS training sessions frequently had better knowledge and attitude as compared with their counterparts.

Dedicated Next Day Discharge Post Minimalist TAVI: The Tasmanian Experience.

OBJECTIVES: To assess the safety, feasibility and independent predictors of next day discharge (NDD) in patients undergoing minimalist transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) in a real-world Australian population. METHODS: This single centre study reviewed 135 consecutive patients who underwent minimalist transfemoral TAVI from June 2020 to February 2022. Baseline demographics, procedural characteristic and outcomes were obtained. All patients were assessed by the local protocol for NDD. Patients were then divided into two groups: those who achieved next day discharge (NDD) and those requiring >1 overnight hospital stay. Univariate, bivariate and stepwise multivariate logistic regression modelling was used to identify the predictors of successful next day discharge. RESULTS: The mean age of the cohort was 82.9±5.7 years with 62.3% patients male, the average STS score was 4.1±2.4. All 135 patients underwent a successful transfemoral TAVI procedure, with 131 (97%) receiving a balloon-expandable valve. Ninety-seven (97) (71.9%) patients achieved NDD. Thirty (30)-day outcomes were excellent with a 30-day mortality of 0.7%, transient ischaemic attack/cardiovascular accident (TIA/CVA) 1.5%, major vascular complication 1.5% and 11.4% need for permanent pacemaker (PPM). In patients not achieving NDD, the average length of stay (LOS) was 3.0 days. Baseline characteristics demonstrated pre-existing first degree atrioventricular (AV) block and right bundle branch block (RBBB) as statistically significant negative predictors of NDD on univariate analysis. Next day discharge was achievable in only 50% of patients who suffered any minor or major procedural complication (15/30). Stepwise multivariate logistic regression modelling demonstrated female gender (OR 3.094, 95% CI 1.141-8.391, p=0.026), smaller aortic valve area (AVA) (OR 48.265, 95% CI 2.269-102.6, p=0.013), the presence of diabetes mellitus (OR 0.594, 95% CI 0.356-0.991, p=0.046) and a longer procedure time (OR 0.960, 95% CI 0.935-0.986, p=0.002) as statistically significant negative predictors of NDD. In addition, there was no difference in 30-day readmission rates between the NDD and non-NDD cohort (7.2% vs 10.5%, p=0.386). CONCLUSION: Next day discharge is safe and feasible in almost three quarters of patients undergoing minimalist TAVI for severe AS in a predominantly balloon expandable valve cohort, with a very low rate of 30-day readmission. NDD provides advantages for hospital efficiency and improved cost-effectiveness. Female gender, smaller AVA, the presence of diabetes mellitus and a longer procedure time were independent negative predictors of successful NDD.

Optical Coherence Tomography Evaluation of Coronary Dissection and Intramural Hematoma.

Image series shows an extensive intramural hematoma causing luminal compression corresponding to the angiographic stenosis. Although intramural hematomas are identifiable on intravascular ultrasound, OCT offers superior characterization and exclusion of alternate diagnoses, such as plaque erosion.

Transradial Secondary Access to Guide Valve Implantation and Manage Peripheral Vascular Complications During Transcatheter Aortic Valve Implantation.

BACKGROUND: Vascular complications from transfemoral (TF) secondary access during transcatheter aortic valve implantation (TAVI) are common. We compare our experience of transradial (TR) versus transfemoral secondary access during TAVI and describe techniques for performing iliofemoral arterial intervention from the transradial approach. METHODS: All TAVI procedures with a single secondary access were included. Demographics, procedural details and 30-day outcomes were recorded. VARC-2 criteria were used for procedural complications. Procedures with TF primary access were stratified by the site of secondary arterial access. RESULTS: Single secondary access was used in 199 cases, of which 20 were performed via non-TF access. Of the 179 TF primary access cases, 115 (64%) used TR secondary access and 64 (36%) used TF secondary access. In the TR cohort percutaneous vascular intervention was performed from the transradial approach in 19 cases (17%). Emergent TF secondary access was not required in any case. There were no differences in procedural time, radiation dose, contrast use, bleeding complications, stroke or mortality between the groups. There was one secondary access complication in the TF cohort and none in the TR cohort. CONCLUSIONS: Transradial (TR) secondary access during TAVI is safe and feasible and may reduce the secondary access site vascular complication rate. With appropriate equipment, most peripheral vascular complications can be managed entirely via TR access avoiding unplanned femoral arterial access. TR secondary access should be considered the default approach for non-TF TAVI cases and can be considered for all TF cases as long as dedicated equipment is available.

Elevated Blood Viscosity and Microrecirculation Resulting From Coronary Stent Malapposition.

One particular complexity of coronary artery is the natural tapering of the vessel with proximal segments having larger caliber and distal tapering as the vessel get smaller. The natural tapering of a coronary artery often leads to proximal incomplete stent apposition (ISA). ISA alters coronary hemodynamics and creates pathological path to develop complications such as in-stent restenosis, and more worryingly, stent thrombosis (ST). By employing state-of-the-art computer-aided design software, generic stent hoops were virtually deployed in an idealized tapered coronary artery with decreasing malapposition distance. Pulsatile blood flow simulations were carried out using computational fluid dynamics (CFD) on these computer-aided design models. CFD results reveal unprecedented details in both spatial and temporal development of microrecirculation environments throughout the cardiac cycle (CC). Arterial tapering also introduces secondary microrecirculation. These primary and secondary microrecirculations provoke significant fluctuations in arterial wall shear stress (WSS). There has been a direct correlation with changes in WSS and the development of atherosclerosis. Further, the presence of these microrecirculations influence strongly on the local levels of blood viscosity in the vicinity of the malapposed stent struts. The observation of secondary microrecirculations and changes in blood rheology is believed to complement the wall (-based) shear stress, perhaps providing additional physical explanations for tissue accumulation near ISA detected from high resolution optical coherence tomography (OCT).

Hourglass appearance on ventriculography: insights from cardiac magnetic resonance imaging.

CLINICAL INTRODUCTION: A 75-year-old patient with hypertension and severe aortic stenosis underwent elective coronary angiography that showed mild non-obstructive disease in the mid left anterior descending artery (LAD). A left ventriculogram, however, demonstrated segmental systolic dysfunction with dilated akinetic apex (figure 1A, see online supplementary video 1). There was no history of prior myocardial infarction and the patient had not experienced any chest pain recently. A 12-lead ECG showed widespread deep symmetrical inverted T-waves with the exception of leads I, aVL and V1 (see online supplementary figure S1). Cardiac MRI (CMR) was performed to further delineate the morphology of the left ventricle (LV) and a representative frame in late gadolinium phase is shown (figure 1B). QUESTION: Above information is most likely consistent with: Takotsubo cardiomyopathyLeft ventricular pseudoaneurysmApical variant of hypertrophic cardiomyopathy (HCM) with aneurysm formationA sequel of prior myocardial infarction in the setting of aortic stenosisLeft ventricular non-compaction.

Advances in three-dimensional coronary imaging and computational fluid dynamics: is virtual fractional flow reserve more than just a pretty picture?

Percutaneous coronary intervention (PCI) has shown a high success rate in the treatment of coronary artery disease. The decision to perform PCI often relies on the cardiologist's visual interpretation of coronary lesions during angiography. This has inherent limitations, particularly due to the low resolution and two-dimensional nature of angiography. State-of-the-art modalities such as three-dimensional quantitative coronary angiography, optical coherence tomography and invasive fractional flow reserve (FFR) may improve clinicians' understanding of both the anatomical and physiological importance of coronary lesions. While invasive FFR is the gold standard technique for assessment of the haemodynamic significance of coronary lesions, recent studies have explored a surrogate for FFR derived solely from three-dimensional reconstruction of the invasive angiogram, and therefore eliminating need for a pressure wire. Utilizing advanced computational fluid dynamics research, this virtual fractional flow reserve (vFFR) has demonstrated reasonable correlation with invasive measurements and remains an intense area of ongoing study. However, at present, several limitations and computational fluid dynamic assumptions may preclude vFFR from widespread clinical use. This review demonstrates the tight integration of advanced three-dimensional imaging techniques and vFFR in assessing coronary artery disease, reviews the advantages and disadvantages of such techniques and attempts to provide a glimpse of how such advances may benefit future clinical decision-making during PCI.

Optical coherence tomography to evaluate coronary stent implantation and complications.

Coronary optical coherence tomography (OCT) is now an established imaging technique in many catheterization laboratories worldwide. With its near-histological view of the vessel wall and lumen interface, it offers unprecedented imaging quality to improve our understanding of the pathophysiology of atherosclerosis, plaque vulnerability, and vascular biology. Not only is OCT used to accurately detect atherosclerotic plaque and optimize stent position, but it can further characterize plaque composition, quantify stent apposition, and assess stent tissue coverage. Given that its resolution of 15 µm is well above that of angiography and intravascular ultrasound, OCT has become the invasive imaging method of choice to examine the interaction between stents and the vessel wall. This review focuses on the application of OCT to examine coronary stents, the mechanisms of stent complications, and future directions of OCT-guided intervention.

Treatment of hypertension in heart failure with preserved ejection fraction.

Prevalence of Heart Failure with Preserved Ejection (HFPEF) has been rising steadily in the recent past. Studies have shown that at least half of patients presenting with symptoms and signs of heart failure (HF) have preserved left ventricular ejection fraction, i.e. HFPEF, and that this portion of the HF population consists predominantly of women, older age group, and people with hypertension and other cardiovascular risk factors. The morbidity and mortality associated with HFPEF are much higher than the normal population. Chronic hypertension is the most common cause in addition to age, with suggestion of up to 60% of patients with HFPEF being hypertensive. Addressing the specific aetiology and aggressive risk factor modification remain the mainstay in the treatment of HFPEF. Current guidelines recommend the management should involve treatment of hypertension, control of heart rate, venous pressure reduction, and prevention of myocardial ischemia. This review aims to discuss the role of hypertension in the pathophysiology, risk stratification and prognosis of HFPEF, as well as the current available data on various antihypertensive options in this population.