Triggered RNAi Therapy Using Metal Inorganic Nanovectors.

The administration of small interfering RNA (siRNA) is a very interesting therapeutic option to treat genetic diseases such as Alzheimer's or some types of cancer, but its effective delivery still remains a challenge. Herein, Au nanorod (GNR)-based platforms functionalized with polyelectrolyte layers were developed and analyzed as potential siRNA nanocarriers. The polymeric layers were successfully assembled on the particle surfaces by means of the layer-by-layer assembly technique through the alternating deposition of oppositely charged poly(styrene)sulfonate, PSS, poly(lysine), PLL, and siRNA biopolymers, with a final hyaluronic acid layer in order to provide the nanoconstructs with a potential targeting ability as well as colloidal stability in physiological medium. Once the hybrid nanocarriers were obtained, the cargo release, their colloidal stability in physiological-relevant media, cytotoxicity, cellular internalization and uptake, and knockdown activity were studied. The present hybrid particles release the genetic material inside cells by means of a protease-assisted and/or a light-triggered release mechanism in order to control the delivery of the oligonucleotides on demand. In addition, the hybrid nanovectors were observed to be nontoxic to cells and could efficiently deliver the genetic material in the cell cytoplasms. The GNR-based nanocarriers proposed here can provide a suitable environment to load and protect a sufficient amount of the genetic material to allow an efficient and sustained knockdown gene expression for long (up to 93% for 72 h), thanks to the slow degradation of PLL, without the observation of adverse side toxic effects. It was also found that the silencing activity was enhanced with the number of siRNA layers assembled in the nanoplatforms.

Efficacy and safety of transcatheter valve-in-valve replacement for Mitroflow bioprosthetic valve dysfunction.

OBJECTIVES: Bioprostheses with pericardial leaflets mounted externally on the stent pose a high risk for valve-in-valve (ViV) procedures. This study analyzed the efficacy and safety of ViV procedures for treating structural valve deterioration (SVD) in Mitroflow bioprostheses. METHODS: Between January 2012 and August 2017, 11 patients (mean age 80.3 ± 5.6 years) were treated for SVD of Mitroflow bioprostheses with transcatheter ViV procedures (six transapical [TA] and five transfemoral [TF]) using balloon expandable bioprostheses. RESULTS: All patients but one were in NYHA class III-IV. Mean STS PROM, euroSCORE I, and euroSCORE II were 8 ± 6.5%, 27.8 ± 11.5%, and 12 ± 5.9%, respectively. Two patients had a "porcelain aorta." The size of implanted valves were 23 mm in 10 cases and 26 mm in one case. One patient suffered a coronary occlusion during a TF approach. The mean volume of contrast used in TF implants was 163 ± 69.8 mL. No contrast media were used in TA procedures. There was one in-hospital death (10%). At 1 year of follow-up, peak and mean aortic gradients were 25.5 ± 5.8 mmHg and 15.5 ± 5.7 mmHg, respectively. One patient had mild paravalvular regurgitation. Cumulative survival was 90.9% at 1 year, 70.7% at 2 years, and 53% at 3 years. CONCLUSIONS: ViV procedures with balloon-expandable aortic valves provide good hemodynamic and clinical mid-term results for treating patients with a degenerated Mitroflow aortic bioprosthesis. Special care must be taken in small aortic roots, when the stented valve is in the supra-annular position to avoid coronary ostial obstruction.

Repair of Late Retrograde Type A Aortic Dissection After TEVAR: Causes and Management.

One of the most feared complications of thoracic endovascular aortic repair (TEVAR) and hybrid arch repair is retrograde type A aortic dissection (RTAD). More than two-thirds of RTAD occurs in the immediate postoperative period and first postoperative month. In presentations beyond that point, progression of the native aortopathy must be considered. We report a late presentation of an RTAD seven months after hybrid repair of an aortic intramural hematoma with an ulcer-like projection, and review the causes and management of this TEVAR complication.

Long-Term Outcomes and Durability of the Mitroflow Aortic Bioprosthesis.

BACKGROUND: This study aims to determine the incidence and causes of structural valve deterioration (SVD) among all models of Mitroflow bioprostheses (A12/LX/DL), as well as to define their long-term clinical and hemodynamic performance. METHODS AND RESULTS: We retrospectively reviewed a series of 1023 patients who underwent aortic valve replacement with Mitroflow bioprostheses between 2001 and 2014. A small aortic root was found in 22.4% of patients. There were two cases of severe patient-prosthesis mismatch. Only 31 patients developed SVD. The rate of incidence was 8.1 cases per 1000 patient-years. Cumulative incidence of SVD was 1.4% and 3% at five and 10 years, respectively. Freedom from SVD was 97.4% and 88.2% at five and 10 years, respectively. Anticalcification phospholipid reduction treatment (PRT) for model DL was a protective factor for SVD. Multivariable analysis confirmed age <70 years and use of 19 mm valve as independent predictors of SVD. Cumulative survival was 76.6% at five years and 42.3% at 10 years (mean follow-up 3.8 ± 3.1 years). In multivariable analysis, neither the use of small aortic prosthesis (p = 0.18) nor the occurrence of SVD (p = 0.85) was found to be independent predictors of long-term survival. CONCLUSIONS: Mitroflow valves demonstrate an acceptable rate of SVD and satisfactory long-term hemodynamic performance, particularly in patients with small aortic roots, age >70 years, and cases with severe left ventricular hypertrophy. PRT might contribute to improved long-term durability. doi: 10.1111/jocs.12726 (J Card Surg 2016;31:264-273).

Synchronized parallel deployment of vascular plugs for treating large aneurysms of pulmonary arteries.

We report an endovascular technique for the treatment of large neck pulmonary artery aneurysms. This technique consists of the synchronized parallel deployment of two vascular plugs.

Machine learning-based bioimpedance assessment of knee osteoarthritis severity.

This study proposes a multiclass model to classify the severity of knee osteoarthritis (KOA) using bioimpedance measurements. The experimental setup considered three types of measurements using eight electrodes: global impedance with adjacent pattern, global impedance with opposite pattern, and direct impedance measurement, which were taken using an electronic device proposed by authors and based on the Analog Devices AD5933 impedance converter. The study comprised 37 participants, 25 with healthy knees and 13 with three different degrees of KOA. All participants performed 20 repetitions of each of the following five tasks: (i) sitting with the knee bent, (ii) sitting with the knee extended, (iii) sitting and performing successive extensions and flexions of the knee, (iv) standing, and (v) walking. Data from the 15 experimental setups (3 types of measurements×5 exercises) were used to train a multiclass random forest. The training and validation cycle was repeated 100 times using random undersampling. At each of the 100 cycles, 80% of the data were used for training and the rest for testing. The results showed that the proposed approach achieved average sensitivities and specificities of 100% for the four KOA severity grades in the extension, cyclic, and gait tasks. This suggests that the proposed method can serve as a screening tool to determine which individuals should undergo x-rays or magnetic resonance imaging for further evaluation of KOA.

Prognostic impact of shock in patients with type A acute aortic syndrome. Results of a nationwide multicenter study.

OBJECTIVE: To evaluate the clinical characteristics, imaging findings, treatment, and prognosis of patients with type A acute aortic syndrome (AAS-A) presenting with shock. To assess the impact of surgery on this patient population. METHODS: The study included 521 patients with A-AAS enrolled in the Spanish Registry of Acute Aortic Syndrome (RESA-III) from January 2018 to December 2019. The RESA-III is a prospective, multicenter registry that contains AAS data from 30 tertiary-care hospitals. Patients were classified into two groups according to their clinical presentation, with or without shock. Shock was defined as persistent systolic blood pressure <80 mmHg despite adequate volume resuscitation. RESULTS: 97 (18.6%) patients with A-AAS presented with shock. Clinical presentation with syncope was much more common in the Shock group (45.4% vs 10.1%, p = 0.001). Patients in the Shock group had more complications at diagnosis and before surgery: cardiac tamponade (36.2% vs 9%, p < 0.001), acute renal failure (28.9% vs 18.2%, p = 0.018), and need for orotracheal intubation (40% vs 9.1%, p < 0.001). There were no significant differences in aortic regurgitation (51.6% vs 46.7%, p = 0.396) between groups. In-hospital mortality was higher among patients with shock (48.5% vs 27.4%, p < 0.001). Surgery was associated with a significant mortality reduction both in patients with and without shock. Surgery had an independent protective effect on mortality (OR 0.03, 95% CI (0.00-0.32)). CONCLUSION: Patients with AAS-A admitted with shock have a heavily increased risk of mortality. Syncope and pericardial effusion at diagnosis are strongly associated with shock. Surgery was independently associated with a mortality reduction in patients with AAS-A and shock.

Extended septal myectomy versus alcohol septal ablation: clinical results at a national referral centre.

OBJECTIVES: Extended septal myectomy and alcohol septal ablation are 2 invasive treatments for hypertrophic obstructive cardiomyopathy. Our goal was to compare which of these techniques achieved a higher reduction in gradients, improvement in New York Heart Association (NYHA) functional class and reduction in medical treatment. METHODS: It is a single-centre observational and retrospective analysis. We used multivariable regression analyses to assess the association of ablation/myectomy with different outcomes. The odds ratio or coefficient along with the 95% confidence interval was estimated according to the group and adjusted for the corresponding preprocedural variables and EuroSCORE II. RESULTS: A total of 78 patients underwent septal myectomy, and 25 patients underwent alcohol septal ablation. Basal and Valsalva gradients after myectomy were reduced to a higher degree in comparison to ablation: 21.0 mmHg [P < 0.001, 95% confidence interval -30.7; -11.3], and 34.3 mmHg (P < 0.001, -49.1; -19.5) respectively. Those patients who received a myectomy had a lower probability of having moderate mitral regurgitation (odds ratio = 0.18, P = 0.054). Patients after septal myectomy were more likely to be NYHA functional class I (80.4%), whereas patients after ablation were more likely to be NYHA functional class III (48%). Both groups continued with beta-blocker therapy, but disopyramide could be discontinued after the myectomy in more cases (20%-36% vs 59%-1.3%; P < 0.001), and there was a tendency to discontinue calcium channel blockers (48%-16% vs 15.4-3.8%; P = 0.054). CONCLUSIONS: After adjustment using preprocedural gradients and EuroSCORE II, myectomy achieves greater reduction in left ventricular outflow tract gradients compared to septal ablation.

Traumatic brachiocephalic trunk pseudoaneurysm.

The surgical approach to a large pseudoaneurysm of the brachiocephalic trunk may be hazardous because of its high risk of rupture. An adequate vascular control is vital before attempting to manage the pseudoaneurysm. We describe a surgical technique using deep hypothermic circulatory arrest to repair a giant pseudoaneurysm of the brachiocephalic trunk with impending rupture and severe respiratory distress and superior vena cava compression secondary to multisystem trauma.

Clinical and structural outcomes of neocommissural alignment in transaxillary and transcarotid transcatheter aortic valve implantation with a self-expandable transcatheter heart valve.

Objectives: This study analyzes neocommissural alignment and the clinical and hemodynamic outcomes after transaxillary and transcarotid implantation of the Acurate neo2 transcatheter heart valve. Methods: We performed a retrospective, single-center analysis of early outcomes after transaxillary and transcarotid implantation of the Acurate neo2 transcatheter heart valve. Primary outcomes were neocommisural alignment, in-hospital mortality, and valve hemodynamic performance. Commissural alignment between native and transcatheter heart valves was assessed by transesophageal echocardiogram before and after the procedure. Results: Between October 2021 and November 2022, 40 consecutive patients were treated with the Acurate neo2 through a transaxillary or transcarotid approach. Access was achieved via the left subclavian artery in 30 cases and the left common carotid artery in 10 cases, with a mean vessel diameter of 6.7 mm. Implants most commonly used were size M (37.5%), L (35%), and S (27.5%). On the basis of transesophageal echocardiogram analysis, there was no significant difference in mean commissural orientation between native (mean, 65.1°; SD, 41.3°) and neocommissures (mean, 64°; SD, 44.1°) (P = .661). Mean commissural orientation did not significantly differ between native and neocommissures (P = .661). Optimal alignment or mild commissural misalignment was achieved in 99.5% of cases. There were no cases of severe commissural misalignment. Postprocedural mean values for peak and mean gradients were 12.7 mm Hg and 5.2 mm Hg, respectively. There were 2 cases of moderate paravalvular leak and 4 cases of mild paravalvular leak. Conclusions: This patient-specific technique for transaxillary and transcarotid insertion of the Acurate neo2 delivery system prevents implantations with more than mild commissural misalignment and with a high device success rate.

In situ formation of one-dimensional assemblies of gold nanoparticles in confined media.

The spontaneous in situ formation of one-dimensional (1D) assemblies of gold nanoparticles (NP) in oleylamine/bis(2-ethylhexyl) sulfosuccinate sodium salt/water/octane (OAm/AOT/w/o) microemulsions by exploiting both the aurophilic bonding between OAm and gold salt, and the interactions between OAm and AOT surfactant is presented. Control on the structure of the resulting assemblies is achieved by changing in the solvent quality, the [Au]/[AOT] molar ratio and the presence of different cosolutes. A possible mechanism of the formation of the 1D parallel Au NP arrays is proposed.

Physicochemical characteristics of protein-NP bioconjugates: the role of particle curvature and solution conditions on human serum albumin conformation and fibrillogenesis inhibition.

Gold nanoparticles (Au NPs) from 5 to 100 nm in size synthesized with HAuCl(4) and sodium citrate were complexed with the plasma protein human serum albumin (HSA). Size, surface charge, and surface plasmon bands of the Au NPs are largely modified by the formation of a protein corona via electrostatic interactions and hydrogen bonding as revealed by thermodynamic data. Negative values of the entropy of binding suggested a restriction in the biomolecule mobility upon adsorption. The structure of the adsorbed protein molecules is slightly affected by the interaction with the metal surface, but this effect is enhanced as the NP curvature decreases. Also, it is observed that the protein molecules adsorbed onto the NP surface are more resistant to complete thermal denaturation than free protein ones as deduced from the increases in the melting temperature of the adsorbed protein. Differences in the conformations of the adsorbed protein molecules onto small (<40 nm) and large NPs were observed on the basis of ζ-potential data and FTIR spectroscopy, also suggesting a better resistance of adsorbed protein molecules to thermal denaturing conditions. We think this enhanced protein stability is responsible for a reduced formation of HSA amyloid-like fibrils in the presence of small Au NPs under HSA fibrillation conditions.

Traumatic aortic injuries associated with major visceral vascular injuries in major blunt trauma patients.

BACKGROUND: The objectives of this study were to report the clinical and radiological characteristics and outcomes of a series of acute traumatic aortic injuries (ATAIs) with associated injury to major aortic abdominal visceral branches (MAAVBs). METHODS: From January 2000 to August 2011, 10 consecutive major blunt trauma patients with associated ATAI and injury to MAAVBs (group A) and 42 major blunt trauma patients presenting only an ATAI without MAAVB injuries (group B) were admitted to our institution. RESULTS: Overall in-hospital mortality was 32.7%. In-hospital mortality in group A was 40% and in group B it was 31% (p = 0.86). Observed in-hospital mortality was slightly lower than the expected in-hospital mortality in both groups. Mean peak creatine phosphokinase was significantly higher in group A than in group B patients (23,008 ± 33,400 vs. 3,970 ± 3,495 IU/L; p < 0.001). Acute renal injury occurred in 50% of group A and in 26.2% of group B patients. Hemodiafiltration was required in 30% of group A and in 9.5% of group B patients. Median follow-up time was 64 months (range = 1-130 months). Group A survival was 60% at 1, 5 and 10 years. Group B survival was 69% at 1 year and 63.3% at 5 and 10 years (p = 0.15). CONCLUSIONS: Aortic injuries associated with MAAVB injuries in major trauma patients seem to present in a different clinical scenario. These patients present increased risk of rhabdomyolysis, visceral ischemia, and acute renal failure, as well as higher in-hospital mortality. A multidisciplinary approach combining endovascular and open surgical techniques for a staged treatment of these life-threatening aortic and MAAVB injuries is mandatory in this critical subset of trauma patients.

A low-cost, portable, two-dimensional bioimpedance distribution estimation system based on the AD5933 impedance converter.

This study proposes a low-cost, portable, eight-channel electrical impedance tomograph based on the AD5933 impedance converter. The patterns for current injection and voltage measurement are managed by an Arduino Mega 2560 board and four 74HC4067 Texas Instruments multiplexers. Regarding the experimental results, the errors in the impedance estimates of an electrical circuit that represents a Cole model were less than 1.14% for the magnitude and 4.15% for the phase. Furthermore, the signal-to-noise ratio measured in a resistive phantom was 55.23 dB. Additional experiments consisted of placing five spheres of different size and conductivity in a saline tank, measuring their impedance through eight electrodes, and then generating impedance maps using the Electrical Impedance Tomography and Diffuse Optical Tomography Reconstruction Software (EIDORS). These maps were different for each sphere, suggesting the proposed prototype as a promising alternative for medical applications.

Combined Therapeutics for Atherosclerosis Treatment Using Polymeric Nanovectors.

Atherosclerosis is an underlying risk factor in cardiovascular diseases (CVDs). The combination of drugs with microRNAs (miRNA) inside a single nanocarrier has emerged as a promising anti-atherosclerosis strategy to achieve the exploitation of their complementary mechanisms of action to achieve synergistic therapeutic effects while avoiding some of the drawbacks associated with current systemic statin therapies. We report the development of nanometer-sized polymeric PLGA nanoparticles (NPs) capable of simultaneously encapsulating and delivering miRNA-124a and the statin atorvastatin (ATOR). The polymeric NPs were functionalized with an antibody able to bind to the vascular adhesion molecule-1 (VCAM1) overexpressed in the inflamed arterial endothelium. The dual-loaded NPs were non-toxic to cells in a large range of concentrations, successfully attached overexpressed VCAM receptors and released the cargoes in a sustainable manner inside cells. The combination of both ATOR and miRNA drastically reduced the levels of proinflammatory cytokines such as IL-6 and TNF-α and of reactive oxygen species (ROS) in LPS-activated macrophages and vessel endothelial cells. In addition, dual-loaded NPs precluded the accumulation of low-density lipoproteins (LdL) inside macrophages as well as morphology changes to a greater extent than in single-loaded NPs. The reported findings validate the present NPs as suitable delivery vectors capable of simultaneously targeting inflamed cells in atherosclerosis and providing an efficient approach to combination nanomedicines.

Aortic valve reimplantation in patients with connective tissue syndromes: A 15-year follow-up.

OBJECTIVES: The goal of this study was to analyse early- and long-term outcomes of aortic valve reimplantation (David operation) in patients with heritable thoracic aortic disease. METHODS: This is a retrospective observational analysis using data from a prospectively maintained surgical database from March 2004 to April 2021. Patients with heritable thoracic aortic disease were included in the study. RESULTS: A total of 157 patients with aortic root aneurysm with the diagnosis of heritable thoracic aortic disease received the David procedure. Marfan syndrome was found in 143 (91.1%) patients, Loeys-Dietz in 13 and Ehler-Danlos in 1 patient. The median age was 35.0 (IQR: 17.5) years and the median ascending aorta diameter in the Valsalva sinuses was 48 mm (IQR: 4). A Valsalva graft was used in 8 patients; the David V technique was performed in the rest of the cases. The median follow-up time was 7.3 years [standard deviation: 0.58, 95% confidence interval (CI): 6.12-8.05]. Only 2 patients died during the follow-up period. The overall survival was 99% (95% CI: 95%; 99%); 98% (95% CI: 92%; 99%); and 98% (95% CI: 92%; 99%) at 5, 10 and 15 years. Freedom from significant aortic regurgitation (AR> II), reintervention and postoperative type-B dissection was 90% (95% CI: 77%; 95%), 96% (95% CI: 91%; 99%) and 87% (95% CI: 68%; 95%) at 15 years, respectively. No differences were found in any outcome between Marfan syndrome and Loeys-Dietz syndrome. No statistically significant differences in survival were found when we compared expected gender- and age-specific population survival values. CONCLUSIONS: The David operation is an excellent option for the treatment of patients with heritable thoracic aortic disease and dilatated aortic root. Surgical expertise in referral centres is essential to achieve the best long-term results.

One-dimensional magnetic nanowires obtained by protein fibril biotemplating.

Magnetic nanowires were obtained through the in situ synthesis of magnetic material by Fe-controlled nanoprecipitation in the presence of two different protein (human serum albumin (HSA) and lysozyme (Lys)) fibrils as biotemplating agents. The structural characteristics of the biotemplates were transferred to the hybrid magnetic wires. They exhibited excellent magnetic properties as a consequence of the 1D assembly and fusion of magnetite nanoparticles as ascertained by SQUID magnetometry. Prompted by these findings, we also checked their potential applicability as MRI contrast agents. The magnetic wires exhibited large r(2)* relaxivities and sufficient contrast resolution even in the presence of an extremely small amount of Fe in the magnetic hybrids, which would potentially enable their use as T(2) contrast imaging agents.

Left atrial size and risk for all-cause mortality and ischemic stroke.

BACKGROUND: Limited data are available on the relation between left atrial size and outcome among patients referred for clinically indicated echocardiograms. Our aim was to assess the association of left atrial size with all-cause mortality and ischemic stroke in a large cohort of patients referred for echocardiography. METHODS: Left atrial diameter was measured in 52 639 patients aged 18 years or older (mean age 61.8 [standard deviation (SD) 16.3] years; 52.9% men) who underwent a first transthoracic echocardiogram for clinical reasons at our institution between April 1990 and March 2008. The outcomes were all-cause mortality and nonfatal ischemic stroke. RESULTS: Based on the criteria of the American Society of Echocardiography, 50.4% of the patients had no left atrial enlargement, whereas 24.5% had mild, 13.3% had moderate and 11.7% had severe left atrial enlargement. Over a mean follow-up period of 5.5 (SD 4.1) years, 12 527 patients died, and 2314 patients had a nonfatal ischemic stroke. Cumulative 10-year survival was 73.7% among patients with normal left atrial size, 62.5% among those with mild enlargement, 54.8% among those with moderate enlargement and 45% among those with severe enlargement (p < 0.001). After adjustment in multivariable Cox proportional hazard analysis, left atrial diameter remained a predictor of all-cause mortality in both sexes (hazard ratio [HR] per 1-cm increment in left atrial size 1.17, 95% confidence interval [CI] 1.12-1.22, p < 0.001 in women, and HR 1.09, 95% CI 1.05-1.13, p < 0.001 in men) and of ischemic stroke in women (HR 1.25, 95% CI 1.14-1.37, p < 0.001). INTERPRETATION: Left atrial diameter has a graded and independent association with all-cause mortality in both sexes and with ischemic stroke in women.

Emergency surgical retrieval of a migrated LAmbre device through the mitral valve.

Left atrial appendage occlusion has become an alternative for long-term anticoagulation for patients with non-valvular atrial fibrillation. Although the procedure is safe, life-threatening complications such as embolization of the device or cardiac tamponade might occur. We present a case of a LAmbre device that migrated 4 days after being implanted and remained trapped in the mitral valve. Secondary massive mitral regurgitation with severe stenosis and haemodynamic instability required emergency surgery. The device was successfully removed, but severe damage in the anterior leaflet and chords forced a valve replacement.

Non-contrast transoesophageal echo-guided transapical transcatheter aortic valve replacement: 10-year experience of a renoprotective strategy.

OBJECTIVES: This study aims to evaluate the efficacy, safety and long-term outcomes of a renoprotective non-contrast, transoesophageal echocardiography-guided transapical (TA) transcatheter aortic valve replacement (TAVR) strategy with a balloon-expandable prosthesis, as well as to determine its impact on renal function. METHODS: Between 2009 and 2019, 200 consecutive patients underwent a non-contrast, transoesophageal echocardiography-guided TA TAVR with a balloon-expandable prosthesis. RESULTS: The device success rate was 95.5%. Transoesophageal echocardiography-guided deployment demonstrated a low rate of procedure-related complications: 9.5% of acute kidney injury, 8% postoperative bleeding, 6% low-cardiac output, 4.5% postprocedural aortic regurgitation ≥+2, 4% implantation of permanent pacemaker and 2% stroke. There were no significant differences between preoperative and on discharge estimated glomerular filtration rate (53.9 ± 22.2 vs 54.3 ± 22.9 ml/min/1.73 m2, P = 0.60). Logistic regression analysis confirmed postoperative bleeding as an independent predictor for acute kidney injury (odds ratio (OR) 11.148, 95% confidence interval 3.537-35.140, P < 0.001). In-hospital mortality was 7.5%. The mean follow-up was 48.5 ± 39.9 months. Renal function and patient's chronic kidney disease stage did not significantly vary during follow-up. Long-term cumulative survival at 1, 5 and 10 years was 84.2 ± 0.027%, 42.9 ± 0.038% and 32.5 ± 0.044%, respectively. Renal function affected on neither in-hospital mortality nor long-term survival. CONCLUSIONS: Non-contrast, transoesophageal echocardiography-guided TA TAVR is a safe and reproducible technique with a low incidence of periprocedural complications that avoids the use of contrast and mitigates the incidence of acute kidney injury.