Depth of implantation in relation to membranous septum as a predictor of conduction disturbances after transcatheter aortic valve implantation.

BACKGROUND: Conduction disturbances remain one of the most common complications occurring post TAVI. We aim to determine the predictors of cardiac conduction disturbances after Transcatheter Aortic Valve Implantation (TAVI) and propose a relevant predictive model. We included 70 consecutive patients with severe symptomatic AS who underwent TAVI using the self-expanding valve Evolut R or the balloon expandable Sapien XT valve. All patients were subjected to electrocardiographic evaluation pre- and post-TAVI and at 30 days. Clinical, echocardiographic, CT-derived, and procedural parameters were collected and analyzed. RESULTS: Conduction disturbances affected 28 patients (40%): 16 patients (22.9 %) developed Left Bundle Branch Block (LBBB), 7 patients (10%) experienced transient Complete Heart Block (CHB), and 5 patients (7.1%) experienced permanent CHB requiring Permanent Pacemaker Implantation (PPI). We classified predictors into preprocedural and procedural predictors. Multivariate logistic regression analysis of pre-procedural predictors showed that the presence of basal septal calcification is the most powerful independent predictor (OR: 28.63, 95% CI: 4.59-178.68, p < 0.001). Multivariate logistic regression analysis for pre and post procedural predictors showed that the relationship between depth of implantation at the septum and membranous septum expressed in percentage (sDIMS) with cut-off >70.42% is the most powerful independent procedural predictor (OR: 1.11, 95% CI: 1.03-1.2, p 0.006). CONCLUSION: Conduction disturbances remain a common complication of TAVI. Presence of basal septal calcification is a non-modifiable risk factor that increase patient propensity of development such complication after TAVI. A depth of implantation exceeding 70% of the membranous septal length has been found to strongly predict conduction disturbances post TAVI. sDIMS can be used in planning the depth of implantation to reduce incidence of conduction disturbances post TAVI.

Impact of prosthesis oversizing on clinical outcomes of transcatheter aortic valve implantation using a self-expandable Evolut R valve.

BACKGROUND: Transcatheter Aortic Valve Implantation (TAVI) has a growing target population after being indicated even in low-surgical-risk patients with severe symptomatic aortic stenosis. However, postoperative outcomes can be compromised due to para-valvular leakage (PVL). A lot of procedural steps have been investigated to decrease this partially avoidable operational hazard. Oversizing is a main technique to decrease the PVL, despite being itself a risky step. Many studies have been conducted to identify the optimum degree of oversizing. However, studies about oversizing by more than 20% are scarce. We aimed to evaluate the safety and efficacy of oversizing equal to or more than 20%. RESULTS: 209 patients who underwent TAVI using the self-expandable valve Evolut R were initially included. 66 patients were excluded because of the baseline conduction disturbance and lack of sufficient data, so 143 patients, 60 females and 83 males, were enrolled in our study as two groups based on the degree of oversizing: Group A included 97 patients with an oversizing index (OI) of less than 20%, and Group B included 46 patients with an OI of 20% or more. We conducted a new technique for more accurate measuring of the OI in the context of the implantation depth, and our patients were categorized using this technique. Our findings have met our primary end point in terms of the safety and efficacy of oversizing by 20% or more. There was no significant difference between both groups in terms of new-onset conduction disturbance (NOCD), with zero cases of annular rupture or coronary encroachment. In terms of efficacy, The incidence of significant PVL (grade 2 or more) in group B was less than in group A (P value 0.007). The ROC curve found that the minimum depth of implantation-derived oversizing (DIDO) to predict no significant PVL was less than 17%. CONCLUSION: Prosthesis oversizing by 20% using the self-expandable Evolut R valve is safe and effective, with no significant effect on the conduction system, coronary encroachment, or annular injury, and warrants a greater reduction in the incidence of significant PVL.

Isolation and in silico investigation of cannflavins from Cannabis sativa leaves as potential anti-SARS-CoV-2 agents targeting the Papain-Like Protease.

This study aimed to isolate and identify three prenylflavonoids (cannflavin A, B, and C) from Cannabis sativa leaves using different chromatographic techniques. The potential of the isolated compounds against SARS-CoV-2 was suggested through several in silico analysis. Structural similarity studies against nine co-crystallized ligands of SARS-CoV-2's proteins indicated the similarities of the isolated cannflavins with the SARS-CoV-2 Papain-Like Protease (PLP) ligand, Y95. Then, flexible allignment study confirmed this similarity. Docking experiments showed successful binding of all cannflavins within the active pocket of PLP, with energies comparable to Y95. Among them, cannflavin A demonstrated the most similar binding mode, while cannflavin C exhibited the best energy. Molecular dynamics (MD) simulations and MM-GPSA confirmed the accurate binding of cannflavin A to the PLP. In silico ADMET studies indicated favourable drug-like properties for all three compounds, suggesting their potential as anti-SARS-CoV-2 agents. Further In vitro and In vivo investigations are necessary to validate these findings and establish their efficacy and safety profiles.

Antitrypanosomal, Antitopoisomerase-I, and Cytotoxic Biological Evaluation of Some African Plants Belonging to Crassulaceae; Chemical Profiling of Extract Using UHPLC/QTOF-MS/MS.

In our continuous study for some African plants as a source for antitrypanosomally and cytotoxic active drugs, nine different plants belonging to the Crassulaceae family have been selected for the present study. Sedum sieboldii leaves extract showed an antitrypanosomal activity against Trypanosoma brucei with an IC50 value of 8.5 µg/mL. In addition, they have cytotoxic activities against (HCT-116), (HEPG-2) and (MCF-7), with IC50 values of 28.18 ± 0.24, 22.05 ± 0.66, and 26.47 ± 0.85 µg/mL, respectively. Furthermore, the extract displayed inhibition against Topoisomerase-1 with an IC50 value of 1.31 µg/mL. It showed the highest phenolics and flavonoids content among the other plants' extracts. In order to identify the secondary metabolites which may be responsible for such activities, profiling of the polar secondary metabolites of S. sieboldii extract via Ultra-Performance Liquid Chromatography coupled to High-Resolution QTOF-MS operated in negative and positive ionization modes, which revealed the presence of 46 metabolites, including flavonoids, phenolic acids, anthocyanidins, coumarin, and other metabolites.

The Computational Preventive Potential of the Rare Flavonoid, Patuletin, Isolated from Tagetes patula, against SARS-CoV-2.

The rare flavonoid, patuletin, was isolated from the flowers of Tagetes patula growing in Egypt. The rarity of the isolated compound inspired us to scrutinize its preventive effect against COVID-19 utilizing a multi-step computational approach. Firstly, a structural similarity study was carried out against nine ligands of nine SARS-CoV-2 proteins. The results showed a large structural similarity between patuletin and F86, the ligand of SARS-CoV-2 RNA-dependent RNA polymerase (RdRp). Then, a 3D-Flexible alignment study of patuletin and F86 verified the proposed similarity. To determine the binding opportunity, patuletin was docked against the RdRp showing a correct binding inside its active pocket with an energy of -20 kcal/mol that was comparable to that of F86 (-23 kcal/mol). Following, several MD simulations as well as MM-PBSA studies authenticated the accurate binding of patuletin in the RdRp via the correct dynamic and energetic behaviors over 100 ns. Additionally, in silico ADMET studies showed the general safety and drug-likeness of patuletin.

Prognostic impact of pre-interventional culprit artery thrombolysis in myocardial infarction (TIMI) flow in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is considered the most preferred strategy in ST-segment elevation myocardial infarction (STEMI). However, the prognostic role of spontaneous re-canalization in STEMI patients is still not clear. The purpose of this study is to evaluate the impact of pre-procedural TIMI flow grade in the culprit coronary artery on the short and long term prognosis in Egyptian patients presented with STEMI and treated with primary PCI. RESULTS: A dual center, prospective observational study that was conducted in the period from January 2019 till June 2020 and enrolled 150 STEMI patients presented within 24 h from onset of chest pain. Initial angiography was done with analysis of TIMI flow grade in the infarct related artery. Of the 150 enrolled patients; 93 patients (62%) were found to have initial TIMI flow grade 0 (group A) and 57 patients (38%) had initial TIMI flow grade I-III (group B). There was a strong association between cardiac mortality and pre-procedural TIMI flow grade. 12 mortalities (8% of total study population) were recorded during our study period; in-hospital mortality was reported in 7 patients in group A, yet no mortalities were recorded in-hospital in group B (P value = 0.033). At 1 year follow up; 5 mortalities were recorded in group A with no mortalities at all in group B (P value = 0.005). There was a trend towards an increase in acute heart failure incidence in group A yet no statistically significant value was achieved (P value = 0.112). Target lesion revascularization was reported in 8 patients in group A and in only 3 patients in group B (P value 0.446). CONCLUSIONS: Despite the evolution in primary PCI strategies and the continuous advancement in anti-thrombotic treatment; pre-interventional infarct related artery TIMI flow grade I-III is associated with better in hospital and 1 year outcome, specifically significantly lower cardiac mortality compared to patients who had TIMI flow grade 0 at initial angiography.

Traditional ancient Egyptian medicine: A review.

The ancient Egyptians practiced medicine with highly professional methods. They had advanced knowledge of anatomy and surgery. Also, they treated a lot of diseases including dental, gynecological, gastrointestinal, and urinary disorders. They could diagnose diabetes and cancer. The used therapeutics extended from different plants to include several animal products and minerals. Some of these plants are still used in the present day. Fortunately, they documented their life details by carving on stone, clay, or papyri. Although a lot of these records have been lost or destroyed, the surviving documents represent a huge source of knowledge in different scientific aspects including medicine. This review article is an attempt to understand some information about traditional medicine in ancient Egypt, we will look closely at some basics, sources of information of Egyptian medicine in addition to common treated diseases and therapeutics in this great civilization.

Early results from an Egyptian transcatheter aortic valve registry (Egy-TVR).

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a well-established and standard therapy for patients with symptomatic severe aortic stenosis at moderate or high risk for surgical aortic valve replacement. Recently, it has proven non-inferior in patients with low surgical risk. However, due to its high cost, the availability of TAVI is variable worldwide. Our aim was to assess the demographic and clinical characteristics and short-term and long-term outcome of those patients. A medical registry is believed to be an excellent tool to perform a field analysis of patients' course, documenting short, intermediate, and long-term outcomes. This is the first registry for patients who underwent TAVI in Egypt. RESULTS: Ninety-six patients were included in the study; some were retrospective, and the majority were prospective from 5 different cardiac centers from August 2012 till December 2017. The mean age of patients was 77 years SD ± 7.29; females were 52% of the patients and most of the patients were overweight (BMI 30.74, SD ± 6.83). Sixty-three percent of the patients were frail with Katz index ≤ 5. 3.5% had atrial fibrillation (AF) at presentation. General anesthesia was conducted in only 59.37% of the patients. Transfemoral access was the prevailing route of implantation (90%). The median hospital stay was 4 days. In-hospital and 30 days mortality was only 4.16%. CONCLUSION: TAVI outcome in Egypt appeared to be very promising with in-hospital complication, and mortality rates being comparable to international registries (4.16% vs. 4.0% in TVT registry) denoting the procedure as safe and beneficial. Establishing a national registry is critical to highlighting strength and weaknesses as well as identifying key areas for improvements.

Discovery of new pyrimidine-5-carbonitrile derivatives as anticancer agents targeting EGFRWT and EGFRT790M.

A new series of pyrimidine-5-carbonitrile derivatives has been designed as ATP mimicking tyrosine kinase inhibitors of the epidermal growth factor receptor (EGFR). These compounds were synthesized and evaluated for their in vitro cytotoxic activities against a panel of four human tumor cell lines, namely colorectal carcinoma (HCT-116), hepatocellular carcinoma (HepG-2), breast cancer (MCF-7), and non-small cell lung cancer cells (A549). Five of the synthesized compounds, 11a, 11b, 12b, 15b and 16a, were found to exhibit moderate antiproliferative activity against the tested cell lines and were more active than the EGFR inhibitor erlotinib. In particular, compound 11b showed 4.5- to 8.4-fold erlotinib activity against HCT-116, HepG-2, MCF-7, and A549 cells with IC50 values of 3.37, 3.04, 4.14, and 2.4 µM respectively. Moreover, the most cytotoxic compounds that showed promising IC50 values against the four cancer cell lines were subjected to further investigation for their kinase inhibitory activities against EGFRWT and EGFRT790M using homogeneous time resolved fluorescence (HTRF) assay. Compound 11b was also found to be the most active compound against both EGFRWT and mutant EGFRT790M, exhibiting IC50 values of 0.09 and 4.03 µM, respectively. The cell cycle and apoptosis analyses revealed that compound 11b can arrest the cell cycle at the G2/M phase and induce significant apoptotic effects in HCT-116, HepG-2, and MCF-7 cells. Additionally, compound 11b upregulated the level of caspase-3 by 6.5 fold in HepG-2 when compared with the control. Finally, molecular docking studies were carried out to examine the binding mode of the synthesized compounds against the proposed targets; EGFRWT and EGFRT790M. Additional in silico ADMET studies were performed to explore drug-likeness properties.

Cardiovascular risk of circulating endotoxin level in prevalent hemodialysis patients.

BACKGROUND: Cardiovascular diseases (CVDs) are a major cause of morbidity and mortality in patients with end stage renal disease (ESRD). Circulating endotoxins may have toxic effect on myocardial functions and are speculated as pathogens of accelerated atherosclerosis and hemodialysis (HD) patients. OBJECTIVE: We aimed to assess the possible relation between circulating endotoxin levels and left ventricular functions parameters, common carotid artery intimal media thickness (CIMT) in prevalent HD patients. PATIENTS AND METHODS: Forty stable prevalent HD patients with mean age (47.97 ± 14.42) year using regular conventional hemodialysis sessions in Ain shams university hemodialysis unit, Cairo, Egypt were randomly selected. Diabetics, congestive heart failure and those with history of myocardial infarction or coronary artery disease were excluded from the study. All patients were studied by CBC and routine chemistry, as well as hs CRP, Intact PTH, lipid profile and endotoxin level by ELISA before and after the HD session, Delta change of endotoxin (pre dialysis endotoxin-post dialysis endotoxin) was calculated, resting Doppler echocardiographic and carotid duplex. RESULTS: Mean of Pre-HD session serum endotoxin level was (0.356 ± 0.090) EU/mL and the mean of post -HD endotoxin levels was (0.367 ± 0.110) EU/mL. Significant positive correlation between post dialysis endotoxin, MV E/A ratio and grades of left ventricular diastolic dysfunction (P < 0.05) and significant correlation between delta change in endotoxin and EF% (r = -0.36,P = 0.02). By stepwise linear regression analysis for determinants of MVE/A post -HD endotoxin level independently associated with MV E/A ratio (ß = 0.350, P = 0.027). We did not detect any significant correlation between CCA atherosclerosis and neither pre nor post- HD endotoxin level nor with delta change of pre and post HD endotoxin levels. CONCLUSION: Acute increase in post dialytic circulating endotoxin level in prevalent HD patients may be associated with both left ventricular systolic and diastolic dysfunction and that attempts to reduce endotoxin level may have a positive impact on cardiovascular complications in HD Patients.

Impact of Remote Ischemic Postconditioning during Primary Percutaneous Coronary Intervention on Left Ventricular Remodeling after Anterior Wall ST-Segment Elevation Myocardial Infarction: A Single-Center Experience.

The role of remote ischemic postconditioning (RIPostC) in improving left ventricular (LV) remodeling after primary percutaneous coronary intervention (PCI) is not well established. To determine the efficacy and safety of RIPostC in improving LV remodeling and cardiovascular outcomes after primary PCI for anterior ST-elevation myocardial infarction (STEMI). Seventy-one patients with anterior STEMI were randomized to primary PCI with RIPostC protocol ( n = 36) versus conventional primary PCI ( n = 35). Primary outcomes included LV remodeling and LV ejection fraction (LVEF) at 6 month follow-up using transthoracic echocardiography. Secondary outcomes included infarct size, ST-segment resolution (STR) ≥70%, Thrombolysis in Myocardial Infarction (TIMI) flow grade, and myocardial blush grade (MBG). Major adverse cardiac events (MACEs) were also assessed at 6 months. Safety outcome included incidence of acute kidney injury (AKI) postprimary PCI. Sixty patients completed the study. At 6 months, there was no significant decrease in the incidence of LV remodeling with RIPostC group ( p = 0.42). Similarly, RIPostC failed to show significant improvement in LVEF. However, STR ≥ 70% after primary PCI was achieved more in the RIPostC group ( p = 0.04), with a trend toward less AKI in the RIPostC group ( p = 0.08). All other secondary end points, including MACEs at 6 months, were similar in both groups. RIPostC might be associated with better STR after reperfusion as well as less incidence of AKI in patients undergoing primary PCI for anterior wall STEMI, indicating potential benefit in those patients. Whether this role can be translated to better outcomes after primary PCI warrants further investigation.

Clinical utility of a predictive model for paravalvular aortic regurgitation after transcatheter aortic valve implantation with a self-expandable prosthesis.

BACKGROUND: A predictive model for Paravalvular aortic regurgitation (PAR) integrating the left ventricular outflow tract-to-ascending aorta angle (LVOT-AO) and depth to the non-coronary cusp (NCC) after TAVI with CoreValve prosthesis (MCP) was retrospectively identified (2 × âˆ LVOT-AO + [depth to NCC-10]2; cutoff = 50). However, the validity and clinical utility of this model remain unknown. METHODS: A total of 100 patients (79.6 ± 7 years, mean EuroScore 24.9 ± 16.3%, 41 males) constituted a validation cohort for the predictive model. Both angle (LVOT-AO) and depth to NCC were considered during patient selection and device implantation. RESULTS: Significant AR occurred in 16% (group A) vs. 84% (group B). Angle ∠LVOT-AO and depth to NCC were larger in group A compared to group B (16.4 ± 7.2 vs. 11.8 ± 4.1, p < 0.001, and 9.1 ± 4.8 mm vs. 6.6 ± 2.7 mm, p = 0.004). The model showed a sensitivity of 68.7% and a specificity of 88.1% in prediction of PAR. Comparing the derivation cohort (initial experience, n = 50) and validation cohort (later experience, n = 100) it is showed that the ∠LVOT-AO, valve depth and PAR were significantly lower (12.5 ± 4.9 and 6.9 ± 3.2 mm vs. 19.7 ± 7.9 and 10.4 ± 3.7 mm, 40% vs. 16% respectively, all p < 0.001) in the validation cohort. CONCLUSION: The predictive model for significant PAR after TAVI using MCP is valid with a reassuring specificity and an acceptable sensitivity. A strategy incorporating these anatomical and procedural variables improves PAR after TAVI.

New triterpenoidal saponins from Koelreuteria paniculata.

Bioassay guided fractionation and chemical investigation of the ethanolic extract of the aerial parts of Koelreuteria paniculata Laxm. (Sapindaceae), resulted in the isolation and identification of three new triterpenoid saponins 1-3 named Paniculatosoid A-C, along with eleven known compounds. The structures of the isolated compounds were elucidated using 1D and 2D NMR experiments, HRESIMS, and comparison with literature data. The occurrence of tridesmosidic saponin is reported for the first time from family Sapindaceae, as well as it is rarely found in natural saponins. Compounds 4-13 were evaluated for their antibacterial, antifungal, antimalarial and antileishmanial activities. Compound 12 showed weak antibacterial activity against Escherichia coli with an IC50 value of 101 µM. Compounds 12 and 13 showed antimalarial activity against chloroquine-sensitive (D6) Plasmodium falciparum protozoan with IC50 values of 6.46 and 6.95 µM, and against chloroquine-resistant (W2) Plasmodium falciparum protozoan with IC50 values of 9.34 and 4.18 µM.

Acute kidney injury after transcatheter aortic valve implantation: Impact of contrast agents, predictive factors, and prognostic importance in 203 patients with long-term follow-up.

BACKGROUND: Acute kidney injury (AKI) frequently occurs following transcatheter aortic valve implantation (TAVI) and has been related to a worse outcome. We investigated the importance of contrast medium composition, either iso-osmolar (IOCM) or low-osmolar (LOCM) and assessed predictors for AKI after TAVI. METHODS AND RESULTS: We assessed AKI in 203 TAVI patients treated mainly with trans-femoral implantation and analgosedation. A total of 100 patients received IOCM and 103 LOCM. AKI was defined according to the Valve Academic Research Consortium. Following TAVI, 39 patients (19.2%) developed AKI; 17.0% of the IOCM and 21.4% of the LOCM group (p=0.43). The only independent predictor for AKI was baseline serum creatinine [odds ratio (OR) 0.26, 95% confidence interval (CI) 0.01-0.64, p=0.002]. Patients with advanced AKI (stages 2 and 3) post-TAVI had significantly higher mortality at 2 years (log rank p<0.001), whereas patients with AKI stage 1 had a similar long-term outcome to non-AKI patients. CONCLUSIONS: Following TAVI, we observed no difference in the occurrence of AKI between IOCM and LOCM. Baseline creatinine was the only independent predictor of AKI, and patients who developed advanced AKI had significantly higher mortality at 2 years.

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.

Symptomatic abnormal vessel wall reaction after implantation of the first generation sirolimus-eluting stent: a case series.

AIMS: Expansive vessel wall remodeling has been previously reported after implantation of drug-eluting stents. These abnormal vessel wall reactions (AVWR), though uncommon may be associated with serious clinical events. We report on a series of patients in whom symptoms developed despite patent stents. METHODS AND RESULTS: We report a series of 10 consecutive patients with evidence of AVWR on angiography and/or intravascular ultrasonography after implantation of sirolimus-eluting stents (age 39-90 years, 4 females) during a period of 4 years. All patients were symptomatic despite patent stents in coronary angiographies done because of persistent chest pain. Four patients subsequently developed very late stent thrombosis (VLST). These 4 patients were only on aspirin monotherapy prior to the VLST. Of the remaining 6 patients, 3 patients underwent coronary interventions (with or without stenting) while the remaining 3 patients were managed conservatively. All 6 were advised for life-long dual antiplatelet therapy. CONCLUSION: Though uncommon, AVWR might precede VLST. In our series, all patients were symptomatic despite patent stents. Additional studies are required to identify patients at risk and to determine the best treatment modality for this challenging new entity. Until further data become available, these patients should stay on dual antiplatelet therapy after an AVWR has been identified.

Treatment of coronary bifurcation lesions with drug-eluting stents: insights from the first phase of the prospective multicenter german drug-eluting stent registry.

BACKGROUND: Controversy exists about the impact of treating bifurcations on overall outcome of coronary interventions using drug-eluting stents (DES). We sought to investigate 1-year outcome of the treatment of bifurcation lesions using DES in a large "real-world" cohort. METHODS AND RESULTS: Among 5,126 patients enrolled in phase I of the multicenter German Drug-Eluting Stent Registry, 814 (16%) were treated for a bifurcation lesion. Patients with bifurcations were compared to those without bifurcations in terms of baseline characteristics, major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR) at 1 year. Usage of sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES) was also evaluated. In total, 1,021 and 5,189 stents were implanted in the bifurcation (1.25 stents/patient) and nonbifurcation (1.2 stents/patient) group, respectively, but 64.5% of bifurcation lesions were treated with a single stent. More complex lesion and procedural characteristics were observed in the bifurcation group. However, there was no difference in 1-year MACCE rates (a composite of death, myocardial infarction, and stroke) between the bifurcation group and nonbifurcation group (8.1% vs. 8.3%, P = 0.85). Rates of TVR (11.2% vs. 10.8%, P = 0.75) and Academic Research Consoritum-defined definite stent thrombosis (0.9% vs. 0.8%, P = 0.67) were also comparable. MACCE and TVR rates remained similar after adjustment for differences in baseline characteristics. MACCE and TVR in SES patients were 7.2% and 12.6% versus 8.7% and 10.2% in PES patients (P = 0.46 and P = 0.30, respectively). CONCLUSION: In this large multicenter registry, treatment of bifurcation lesions with DES appears effective and safe. The presence of bifurcations did not affect 1-year outcomes after DES implantation. The outcomes for SES and PES were similar.

Comparison of outcomes in patients having isolated transcatheter aortic valve implantation versus combined with preprocedural percutaneous coronary intervention.

Coronary artery disease negatively affects the outcome of patients undergoing surgical aortic valve replacement and practice guidelines recommend revascularization at time of surgery. In patients undergoing transcatheter aortic valve implantation (TAVI), the impact of preprocedural percutaneous coronary intervention (PCI) on TAVI outcome has not been examined. We aimed in the present study to assess the feasibility and safety of performing PCI before TAVI and to evaluate procedural, 30-day, and 6-month clinical outcomes. We retrospectively analyzed 125 patients who underwent successful TAVI at a single institution and divided them into an isolated TAVI and a PCI + TAVI group. During the study period, a strategy of preprocedural PCI of all significant (>50%) lesions in major epicardial vessels was adopted. Study end points were adjudicated in accordance with the Valve Academic Research Consortium consensus on event definition. All patients were treated with the Medtronic CoreValve prosthesis (n = 55 with PCI + TAVI and n = 70 with isolated TAVI). Thirty-day mortality was 2% versus 6% for patients treated with PCI + TAVI versus isolated TAVI, respectively (p = 0.27). Neither periprocedural nor spontaneous myocardial infarction occurred in either group. Rates of 30-day stroke, major bleeding, major vascular complications, and the Valve Academic Research Consortium-defined combined safety end point (11% vs 13%, p = 0.74) did not differ between the 2 groups. Patients' symptoms significantly improved in the first month after TAVI, and extent of improvement did not differ between groups. Adverse events at 6 months were comparable. In conclusion, PCI before TAVI appears feasible and safe. Based on these early results revascularization should become an important consideration in patients with coronary artery disease undergoing TAVI.

Clinical outcome of percutaneous treatment of in-stent restenosis with drug-eluting stents: results from the first phase of the prospective multicentre German DES.DE registry.

AIMS: Treatment of in-stent restenosis (ISR) was historically considered the Achilles heel of percutaneous coronary intervention (PCI) and has been associated with worse clinical outcome than PCI of de novo lesions. However, comparative data on ISR and de novo lesions using drug-eluting stents (DES) are scarce. Therefore, we aimed to assess the impact of ISR on procedural and long-term outcome in patients treated with DES. METHODS AND RESULTS: We analysed data from 5,144 patients enrolled in the prospective multicentre German Drug-Eluting Stent Registry (DES.DE). The registry included 872 patients (17%) treated for ISR with follow-up data (median 12.4 months) available for 817 patients (94%). Of the ISR patients, 37.1% (n=323) presented with acute coronary syndromes. In total, 1,027 DES were used (528 sirolimus-eluting stents and 499 paclitaxel-eluting stents), with successful implantation in 97.7% of patients. In the ISR cohort, myocardial infarction (MI) during hospitalisation was observed in 1.6% of patients (n=14) and in-hospital mortality was only 0.3% (n=3). Major adverse cardiac and cerebrovascular events (MACCE) rate at follow-up (defined as a composite of death, MI and stroke) was 8.7% (n=71) versus 8.2% (n=325) in patients treated for de novo lesions (p=0.63). Target vessel revascularisation (TVR) rate was 12.7% (n=100), numerically higher than in patients with de novo lesions (10.5%, p=0.07). Ten patients (1.3%) suffered from ARC definite stent thrombosis versus 0.7% observed in patients with de novo lesions (p=0.13). After adjustment for differences in baseline characteristics, TVR rates were statistically higher in the ISR cohort (OR 1.27, 95%CI 1.01-1.61, p=0.04), while MACCE rates remained comparable (OR 1.10, 95%CI 0.83-1.44, p=0.51). The type of stent used (sirolimus vs. paclitaxel-eluting stent) did not impact the rate of MACCE, TVR or definite stent thrombosis at one year. CONCLUSIONS: Results from this large prospective multicentre registry confirm that treatment of ISR with DES is effective and safe, with similar procedural outcome but slightly higher revascularisation rates at one year compared to patients treated for de novo lesions, with no differences in outcome between sirolimus- and paclitaxel-eluting stents.