Clinical and neurocognitive outcomes after transcatheter aortic valve implantation (TAVI) with cerebral protection: initial experience with a novel dual-filter device in Southeast Asia.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is increasingly performed in patients with severe aortic stenosis. A novel dual-filter system to reduce cerebral embolism during TAVI recently became available. We aimed to assess the feasibility, safety, and clinical and neurocognitive outcomes of TAVI with cerebral protection in Asian patients. METHODS: 40 consecutive patients undergoing TAVI with cerebral protection were enrolled. All procedures were performed via femoral access using the self-expanding Evolut R/PRO or Portico, or the balloon-expandable SAPIEN 3 bioprostheses. Baseline characteristics, procedural and clinical outcomes were recorded. Cognition was assessed at baseline and 30 days using the abbreviated mental test (AMT). RESULTS: The mean age of the patients (75% male) was 76.4 ± 8.4 years. TAVI was uncomplicated in all patients. The filter device was successfully deployed in 38 (95.0%) patients without safety issues. There was no stroke or death at 30 days, and the survival rate at nine months was 95.0%. There was no overall cognitive change (baseline vs. 30-day AMT: 9.2 ± 1.1 vs. 9.0 ± 1.5, p = 0.12), and only 1 (2.5%) patient developed impaired cognition at 30 days. Patients with a decreased AMT score at 30 days were significantly older than those without (82.1 ± 4.5 vs. 74.4 ± 7.7 years, p = 0.019). All patients with decreased AMT scores were aged ≥ 76 years. CONCLUSION: In this early Asian experience of TAVI under cerebral protection, the filter device was successfully deployed in 95% of patients, with 100% procedural success. There were no filter-related complications and no stroke or mortality at 30 days. Overall cognition was preserved, although increased age was associated with a decline in AMT score.

Percutaneous transcatheter aortic valve implantation for degenerated surgical bioprostheses: the first case series in Asia with one-year follow-up.

INTRODUCTION: Percutaneous transcatheter aortic valve implantation (TAVI) has become an established therapy for inoperable and high-surgical-risk patients with severe aortic stenosis. Although TAVI in patients with degenerated surgical aortic bioprostheses (i.e. valve-in-valve TAVI) is increasingly reported in Western studies, such data is lacking in Asian patients. We describe the initial experience of valve-in-valve TAVI in Asia. METHODS: Eight patients who underwent valve-in-valve TAVI due to degenerated aortic bioprostheses were enrolled. The mechanism of bioprosthetic valve failure was stenotic, regurgitation or mixed. All procedures were performed via transfemoral arterial access, using the self-expanding CoreValve prosthesis or balloon-expandable SAPIEN XT prosthesis. RESULTS: The mean age of the patients was 71.6 ± 13.2 years and five were male. Mean duration to surgical bioprosthesis degeneration was 10.2 ± 4.1 years. Valve-in-valve TAVI was successfully performed in all patients. CoreValve and SAPIEN XT prostheses were used in six and two patients, respectively. There were no deaths, strokes or permanent pacemaker requirement at 30 days, with one noncardiac mortality at one year. All patients experienced New York Heart Association functional class improvement. Post-procedure mean pressure gradients were 20 ± 11 mmHg and 22 ± 8 mmHg at 30 days and one year, respectively. Residual aortic regurgitation (AR) of more than mild severity occurred in one patient at 30 days. At one year, only one patient had mild residual AR. CONCLUSION: In our experience of valve-in-valve TAVI, procedural success was achieved in all patients without adverse events at 30 days. Good clinical and haemodynamic outcomes were sustained at one year.

Electrocardiographic changes in acute perimyocarditis.

Pericarditis and myocarditis are characterised by electrocardiographic changes and elevated cardiac enzymes, respectively, and patients with perimyocarditis often complain of chest discomfort. These findings are nonspecific and often lead to diagnostic difficulties, as ST-elevation myocardial infarction commonly presents in a similar fashion. Clinical differentiation between perimyocarditis and myocardial infarction are especially important because adverse side effects can occur if reperfusion therapy is administered for a patient with acute pericarditis or if a diagnosis of acute myocardial infarction is missed. We herein describe a case of perimyocarditis with ST elevation and raised cardiac markers, which led to two emergency coronary angiographies that were subsequently found to be normal. We include the three serial electrocardiographies (ECGs) performed to show the characteristic features of perimyocarditis and further discuss the importance of identifying typical and atypical ECG features of pericarditis.

First transcatheter aortic valve implantation for severe pure aortic regurgitation in Asia.

Transcatheter aortic valve implantation (TAVI) has become the standard of care for inoperable patients with symptomatic severe aortic stenosis (AS), and an alternative to open aortic valve replacement for patients at high surgical risk. TAVI has also been performed in several groups of patients with off-label indications such as severe bicuspid AS, and as a valve-in-valve therapy for a degenerated surgical bioprosthesis. Although TAVI with CoreValve® prosthesis is technically challenging, and global experience in the procedure is limited, the procedure could be a treatment option for well-selected patients with severe pure aortic regurgitation (AR). Herein, we report Asia's first case of TAVI for severe pure AR in a patient who was at extreme surgical risk, with good clinical outcome at six months.

Percutaneous mitral valve repair with MitraClip for severe functional mitral regurgitation.

A 67-year-old Chinese woman with comorbidities of chronic obstructive lung disease, hypertension and prior coronary artery bypass surgery presented with severe functional mitral regurgitation (MR) and severely depressed left ventricular function. She was in New York Heart Association (NYHA) Class II-III. Due to high surgical risk, she was referred for percutaneous treatment with the MitraClip valve repair system. This procedure is typically performed via the femoral venous system and involves a transseptal puncture. A clip is delivered to grasp the regurgitant mitral valve leaflets and reduce MR. This was performed uneventfully in our patient, with reduction of MR from 4+ to 1+. She was discharged on post-procedure Day 2 and her NYHA class improved to Class I. This was the first successful MitraClip procedure performed in Asia and represents a valuable treatment option in patients with severe MR, especially those with functional MR or those at high surgical risk.