Mechanical atherothrombectomy improves endothelial function through plaque burden reduction in PAD.

Background: Endothelial dysfunction defines outcomes and serves as a surrogate parameter for the progression of cardiovascular disease. For symptomatic peripheral artery disease (PAD) endovascular treatment is the primary revascularization strategy, which affects endothelial function. Interventional mechanical atherothrombectomy (MATH) provides advantages when treating complex atherosclerotic and thrombotic lesions. We now aimed to determine the impact and mechanisms of MATH on endothelial function. Patients and methods: Endothelial function was determined using flow-mediated dilation (FMD) before and after lower limb intervention with a six-month follow-up in the target and control vessel in 15 PAD MATH+DCB treated patients and compared to 15 non-Math controls. In a further cohort of 20 patients the impact of MATH and DCB on vascular structure and virtual histology was assessed through intravascular ultrasound (IVUS) and compared to DCB treatment alone. Results: Improved endothelial function after 6 months was observed in both groups for the target and nontarget vessel. When comparing the changes from baseline endothelial function, treatment with MATH+DCB was superior to DCB treatment in the target vessel. IVUS revealed a greater improvement in luminal area and plaque burden reduction after MATH treatment. Virtual histology disclosed MATH-associated changes in plaque composition evidenced by alterations in fibrous volume and reductions in superficial calcium. Conclusions: We demonstrate an improved endothelial function after MATH treatment as compared to DCB treatment. The improved vessel function is evidenced by MATH-related plaque burden reduction, improved luminal gain and a decrease in superficial calcification. Clinicaltrials.gov: NCT04092972.

Alternative access in high-risk patients in the era of transfemoral aortic valve replacement.

BACKGROUND: We aimed to evaluate the outcomes of transapical and transaortic transcatheter aortic valve replacement (TAVR) in high-risk patients who were not suitable for transfemoral access and had a logistic EuroSCORE-I ≥ 25% and Society of Thoracic Surgeons (STS) score >6%. 'STS/ACC TAVR In-Hospital Mortality Risk App' was evaluated. MATERIAL AND METHODS: Between January 2016 and May 2020, 126 patients at very high risk for aortic valve replacement underwent transapical (n = 121) or transaortic (n = 5) transcatheter aortic valve replacement. TAVR was performed using SAPIEN 3™ or ACURATE TA™ prosthesis. RESULTS: The logistic EuroSCORE-I was 40.6 ± 14.0%, the STS-score 7.9 ± 4.6%, and STS/ACC-score 8.4 ± 3.4%. Valve implantation was successful in all patients. Operative, in-hospital and 30-days mortality, were 0, 7.9, and 13.5%, respectively. Survival was 72% at one year and 48% at four years. Expected/observed in-hospital mortality was 1.0 for the STS-score and 1.06 for the STS/ACC-score. Renal failure, low ejection fraction, and postoperative acute kidney injury, hemorrhage, and vascular complications were identified as independent predictors for 30-day mortality. CONCLUSIONS: Transapical and transaortic TAVR in high-risk patients unsuitable for transfemoral access is still a reasonable alternative in these patients. STS and STS/ACC-score appear to be highly accurate in predicting in-hospital mortality in high-risk patients undergoing TAVR.

Simultaneous transaortic transcatheter aortic valve implantation and off-pump coronary artery bypass: An effective hybrid approach.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) techniques are increasingly being adopted into clinical routine for various risk groups. Coronary artery disease (CAD) is seen in up to 75% of patients with severe aortic valve stenosis (AS) presenting with typical angina pectoris. Due to high mortality rates and procedural complications in these patients, a hybrid concept of simultaneous transaortic TAVI and off-pump coronary artery bypass (OPCAB) can be a feasible treatment option. METHODS: Between April 2014 and July 2020, 10 consecutive high-risk patients underwent concomitant transaortic TAVI and OPCAB at our institution. All indications were discussed in Heart Team and decisions were made based on patients' comorbidities and complexity of CAD. The study endpoints were 30-day mortality, device success, and development of postoperative adverse events defined by the Valve Academic Research Consorium. RESULTS: The mean age of the patients was 77.9 ± 7.1 years old. All patients presented with multiple comorbidities (mean logistic EuroSCORE 26.5 ± 12.3%, median EuroSCORE II 5.13% [interquartile range 4.2-9.5], mean STS-Score 6.04 ± 1.6%). Five patients (50%) presented with porcelain aorta. No conversion to conventional procedures was needed. 30-day mortality occurred in one patient (10%). Complete revascularization was achieved in seven (70%) of the patients. Device success rate was 100%. No paravalvular leakage was detected. No stroke, myocardial infarction or vascular complications were observed. CONCLUSIONS: A hybrid approach combining transaortic TAVI and OPCAB might be a safe and feasible method of treatment in high-risk patients presenting with severe AS and CAD who are not eligible for conventional surgical or interventional solutions.

Early Pacemaker Implantation after Transcatheter Aortic Valve Replacement: Impact of PlasmaBlade™ for Prevention of Device-Associated Bleeding Complications.

Background and Objectives: Permanent pacemaker implantation (PPI) is frequently required following transcatheter aortic valve replacement (TAVR). Dual antiplatelet therapy (DAPT) or oral anticoagulation therapy (OAK) is often necessary in these patients since they are at higher risk of thromboembolic events due to TAVR implantation, high incidence of coronary artery diseases (CAD) with the necessity of coronary intervention, and high rate of atrial fibrillation with the need of stroke prevention. We sought to evaluate the safety, efficiency, and clinical outcomes of early PPI following TAVR using the PlasmaBlade™ (Medtronic Inc., Minneapolis, MN, USA) pulsed electron avalanche knife (PEAK) for bleeding control in patients under DAPT or OAK. Materials and Methods: This retrospective single-center study included patients who underwent PPI after transfemoral TAVR (TF) at our center between December 2015 and May 2020. All PPI were performed using the PlasmaBlade™ Device. Results: The overall PPI rate was 14.1% (83 of 587 patients; 82.5 ± 4.6 years; 45.8% male). The PPI procedures were used to treat high-grade atrioventricular block (81.9%), severe sinus node dysfunction (13.3%), and alternating bundle branch block (4.8%). At the time of the procedure, 35 (42.2%) patients received DAPT, and 48 (57.8%) patients received OAK (50% with vitamin K antagonist (VKA) and 50% with novel oral anticoagulants (NOAK)). One device-pocket hematoma treated conservatively occurred in a patient (1.2%) receiving NOAK. Two re-operations were necessary in patients due to immediate lead dislocation (2.4%). Conclusions: The results of this study illustrate that the use of PlasmaBlade™ for PPI in patients after a TAVR who require antithrombotic treatment is feasible and might result into lower rates of severe bleeding complications compared to rates reported in the literature. Use of the PlasmaBlade device may be considered in this specific group of patients because of their high risk of bleeding.

Changes in Health Perception among Patients with Aortic Diseases in a Severe COVID-19 Area in the West of Germany: A Longitudinal Study between the First and Second Wave of the COVID-19 Pandemic.

Background and Objectives: The rapid spread of the novel coronavirus disease (COVID-19) has become the most challenging global health pandemic since the 1918 flu. In Germany, more than 3.4 million cases are confirmed so far, including 83,000 deaths. Increased fatality rates among patients with pre-existing cardiovascular diseases (CVD) represent this group at particular risk. The aim of this study was to evaluate changes in health perception among patients with aortic diseases during the first (w1) and second wave (w2) of the COVID-19 pandemic in Germany. Material and Methods: Patients (n = 262) diagnosed with aortic disease participated in telephone interviews during w1 and w2. The perception of COVID-19 as a threat was examined using relevant items of the Brief Illness Perception (BIP) questionnaire. Results: The BIP score increased from 9.18 (SD = 7.132) to 14.58 (SD = 6.956) between w1 and w2 (p < 0.001). Although this population is at high risk their overall perception of COVID-19 as a threat was low in the beginning, but surged during w2. Main reasons were increased effects on personal life and elevated concerns about the pandemic, but did not include the educational aspect of COVID-19. Conclusions: Tailored risk communication strengthens the mental health of people in a public health crisis and ensures the success of governmental guidelines.

Global longitudinal strain is associated with better outcomes in transcatheter aortic valve replacement.

BACKGROUND: Parameters that mark the timing of left ventricular (LV) reverse remodeling following transcatheter aortic valve replacement (TAVR) are incompletely defined. This study aims to identify the dynamics of LV strain derived from speckle tracking echocardiography in a cohort of patients with severe aortic stenosis (AS) who underwent TAVR and its correlation with postprocedural outcomes. METHODS: We selected 150 consecutive patients (82 ± 4 years old, STS score 6.4 ± 6.2) who underwent transfemoral TAVR between 07/2016 and 12/2017 at our tertiary care center. All patients were evaluated at baseline, 1 week after TAVR, and 3 months following TAVR. RESULTS: The global longitudinal strain (GLS) 1 week following TAVR was comparable to that at baseline (- 15,9 ± 4.3 vs - 16.8 ± 4.1; p = NS) but significantly improved at 3 months following TAVR (- 15.9 ± 4.3% vs. -19.5 ± 3.5%; p < 0.001). No significant changes in global circumferential strain (GCS) and global radial strain (GRS) were detectable. The ejection fraction was significantly improved 1 week after the TAVR procedure. The baseline GLS correlated directly with the complication rate (R = 0.36, p = 0.005). The linear regression analysis showed that the main predictors of the improvement in the GLS at 3 months in our cohort were baseline GRS and GCS. CONCLUSION: GLS improves at 3 months after TAVR, while LV ejection fraction does not show a substantial change, signaling an early recovery of LV longitudinal function after the intervention. Additionally, GLS has a direct correlation with the postprocedural outcomes. GLS improvement might emerge as a valuable parameter for a tailored follow-up in TAVR patients.

Distal Stent Graft Induced New Entry: Risk Factors in Acute and Chronic Type B Aortic Dissections.

OBJECTIVES: Distal stent graft induced new entry (dSINE) is a rare complication associated with acute and chronic dissections after thoracic endovascular aortic repair (TEVAR) and is linked to a high re-intervention rate. The potential predicting risk factors for dSINE and long term outcome of patients after re-intervention were analysed. METHODS: This single centre, retrospective study included patients undergoing TEVAR. Multivariable analysis was used to test important interventional parameters such as distal oversizing (dOS), taper ratio (TR), angle between distal stent graft and aorta, acute dissection and stent graft length. Re-intervention characteristics were analysed and further long term follow up after re-intervention were evaluated. RESULTS: One hundred and eighty-five patients were analysed with acute (n = 77) and chronic (n = 108) dissections after TEVAR with an average follow up of 68.9 ± 32.5 months. During follow up, 12 (6.5%) patients developed dSINE after a median of 22.2 ± 20.7 months. Acute dissection was identified as a major predicting factor for dSINE development (15.8 fold increased odds), followed by increased dOS and TR. The re-intervention rate was higher in the dSINE group (83% vs. 20%, p = .001), but results indicated that no further re-intervention was needed and no new endoleak development occurred up to a mean follow up of 60.7 ± 54.8 months. No dSINE was seen in association with tapered stent grafts. CONCLUSIONS: Acute aortic dissection was found to be the major predicting factor for dSINE development, followed by increased dOS and TR. The use of tapered stent grafts might be beneficial for patients with high expected dOS and TR. In the rare case of dSINE occurrence, even when re-intervention is required, the long term prognosis is good.

Impact of baseline left ventricular ejection fraction on outcome after transfemoral transcatheter aortic valve implantation in patients with and without low-gradient aortic stenosis.

OBJECTIVES: To evaluate the impact of baseline left ventricular ejection fraction (LVEF) and its interaction with low-gradient aortic stenosis (LGAS) on all-cause mortality after transfemoral aortic valve implantation (TF-TAVI). METHODS: We reviewed mortality data of 624 consecutive single center TF-TAVI patients and categorized LVEF according to current ASE/EACVI recommendations (normal, mildly-, moderately-, and severely abnormal). RESULTS: Baseline LVEF was normal in 336 (53.8%), mildly abnormal in 160 (25.6%), moderately abnormal in 91 (14.6%), and severely abnormal in 37 (5.9%) patients, and 1-year mortality was 19%, 17%, 23%, and 43% (P = 0.002), respectively. Patients with LGAS had a similar 1-year mortality compared to those without LGAS in groups with normal (19% vs 19%, P = 0.899) and mildly abnormal LVEF (16% vs 17%, P = 0.898). One-year mortality of patients with LGAS was significantly greater than in those without LGAS in presence of moderately abnormal LVEF (31% vs 11%, P = 0.022), and it was numerically greater than in those without LGAS in presence of severely abnormal LVEF (48% vs 25%, P = 0.219). In multivariate analysis, only the combination of moderately/severely abnormal LVEF and LGAS predicted increased 1-year mortality (HR: 2.12, 95% CI: 1.4-3.2, P < 0.001). Other variables, including EuroSCORE I did not affect this result. CONCLUSIONS: Moderately/severely abnormal LVEF (≤40%) at baseline is associated with increased mortality after TF-TAVI, especially when the mean transvalvular aortic gradient is <40 mm Hg (LGAS), while outcomes in patients with normal and mildly abnormal LVEF are comparable regardless of the pressure gradient across the native aortic valve. (DRKS00013729).

Thoracic Endovascular Repair of Complicated Penetrating Aortic Ulcer: An 11-Year Single-Center Experience.

PURPOSE: To analyze an 11-year single-center experience of treating complicated penetrating aortic ulcer (PAU) using thoracic endovascular aortic repair (TEVAR). METHODS: This study included 63 consecutive patients (mean age 69.1±11.5 years; 40 men) with complicated PAU (42 symptomatic, 22 with rupture) who underwent TEVAR between 2002 and 2013. The PAUs were located in the aortic arch (n=11), the descending thoracic aorta (n=43), and the thoracoabdominal aorta (n=9). RESULTS: TEVAR was performed within 14 days of diagnosis in 33 (52.3%) cases (19 ruptures treated immediately); the other 30 (47.6%) patients had an average interval between diagnosis and intervention of 40±39 days. Technical success was 98.4% (62/63). One patient had a type I endoleak after stent-graft repair of a PAU in the aortic arch without great vessel transposition; another procedure was required for carotid-subclavian bypass and proximal stent-graft extension. No patient experienced spinal cord ischemia after TEVAR. Five (7.9%) patients died in-hospital; 3 had severe cardiac complications, 1 died from complications of aortic rupture, and the other succumbed to septic shock. Mean follow-up was 45.6±47.2 months, during which 12 (19.0%) patients needed a secondary intervention because of late endoleaks (n=4, 6.3%) or new complications due to disease progression. Multivariate analysis indicated that a PAU depth >15 mm was an independent predictor of mortality (hazard ratio 6.92, p=0.03). In the biomarker analysis, symptomatic patients had significantly higher D-dimer and troponin levels compared to asymptomatic patients [559.5±460.7 vs 283.2±85.2 µg/L (p=0.016) and 0.22±0.61 vs 0.02±0.03 ng/mL (p=0.04), respectively]. CONCLUSION: Patients with PAU suffer from underlying severe atherosclerotic disease and have a significant number of cardiovascular comorbidities that lead to relevant mortality and morbidity after TEVAR. As a PAU diameter >15 mm represented high risk for disease progression, these patients may be candidates for early intervention. D-dimer levels may help identify patients at risk and with progression of PAU.

Thoracic aortic aneurysm expansion due to late distal stent graft-induced new entry.

OBJECTIVES: This study analyzed the mechanism and risk factors of thoracic aortic aneurysm expansion due to late distal stent graft-induced new entry (dSINE). BACKGROUND: This late complication of thoracic endovascular aneurysm repair (TEVAR) for aortic dissection is under-recognized but potentially life-threatening. METHODS: In 142 patients who underwent TEVAR with endovascular entry sealing for acute and chronic aortic type B dissection, using commercially available straight (nontapered) stent-grafts, we examined the oversizing rate, the aortic taper ratio, and the need for reintervention. RESULTS: Nine of 142 patients developed thoracic aortic aneurysm expansion due to dSINE after TEVAR. The median follow-up was 47.5 ± 37.4 months. There was a significant difference in the distal stent-aorta angle between the patients with and without dSINE (149.08 ± 15.09° vs. 166.72 ± 12.47°, P < 0.005). Patients with dSINE showed a significantly higher taper ratio of the true lumen of the aorta (40.9 ± 14.13% vs. 25.36 ± 20.2%, P < 0.05). There was also a significant difference in the oversizing of the stent-graft in the distal landing zone (95.88 ± 49.3% vs. 55.94 ± 36.23%, P < 0.01). All patients with dSINE underwent a secondary endograft procedure without any complications or deaths. In 7 cases we used a custom-made, highly tapered stent-graft. CONCLUSIONS: Lifelong follow-up of patients is mandatory after TEVAR. A stent-graft with a tapered design should be used in aortic dissection to avoid oversizing and devastating late complications.

Validation of intravascular ultrasound for measurement of aortic diameters: Comparison with multi-detector computed tomography.

INTRODUCTION: Intravascular ultrasound (IVUS) provides real-time imaging of aortic pathology during aortic interventions. The objective of the present study was to validate IVUS measurements using computed tomography (CT) angiography in a sufficiently large cohort. MATERIAL AND METHODS: From October 2010 to February 2014, 57 consecutive patients with acute aortic syndrome underwent both IVUS and spiral CT for a total of 509 comparable thoracic aorta segments. Minimum, maximum, and mean diameters were determined at each measurement point. RESULTS: IVUS measurements of the thoracic aorta (aortic root, brachiocephalic trunk, left common carotid artery, left subclavian artery) ranged from 18-48.5 (mean 33.0) mm, versus 18-48.4 (mean 31.7) mm on CT, with a significant mean difference of 5.1% (p < 0.05). The correlation between methods was generally good, but IVUS tended toward larger diameters than CT in the aortic arch, especially the left subclavian artery. In 78% of measurement sites, total mean diameters were larger on IVUS measurements of the thoracic aorta than on CT measurements. CONCLUSION: IVUS is a reliable tool for measuring aortic diameter, especially in the descending part of the aorta. However, its pitfalls must be considered to prevent choosing an incorrectly sized stent graft in the acute setting of thoracic endovascular aortic repair.

Impact of smoking on procedural outcomes and all-cause mortality following acute myocardial infarction: A misleading early-stage pseudoparadox with ultimately reduced survival.

Background: Smoking has conflicting results on outcomes following acute myocardial infarction (AMI). We evaluated the independent influence of smoking status on patient outcomes. Methods: We included patients with AMI undergoing invasive coronary angiography with available self-reported smoking status. The incidence of death of any cause was evaluated during a median follow-up of 1.14 years (range 0.36-3.40 years). Association between smoking status and long-term mortality was evaluated using multivariable adjusted Cox regression analysis. Results: From 1612 AMI patients (aged 65.7 ± 13.3 years, 72.1 % male), 378 patients (23.4 %) were current-smokers, 311 (19.3 %) ex-smokers, and 923 (57.3 %) non-smokers. Compared with non-smokers, current-smokers were younger (68.5 ± 13.0 vs. 58.6 ± 12.5, p < 0.0001) and more frequently presented with STEMI (21.6 % vs. 35,4 %, p < 0.0001), while ex-smokers with similar frequency of STEMI-manifestation as non-smokers (22.5 %, p = 0.79) constituted an intermediate-group in terms of age (65.8 ± 11,6 years). Although smoking status was not significantly associated with long-term survival in unadjusted-analysis, active-smokers had 56 % higher long-term mortality than non-smokers when adjusting for age, gender, medications and other traditional risk factors, whereas ex-smokers possessed comparable survival probability (current-smokers: 1.56[1.14-2.14], p = 0.006, ex-smokers 1.16[0.84-1.59], p = 0.37). Current-smokers had unadjusted lower NT-proBNP and modestly higher absolute in-hospital left ventricular global longitudinal strain (LV GLS) values that did not differ among groups after the same adjustments (NT-proBNP: -0.08[-0.31; 0.15], p = 0.5, LV GLS: 0.65[-0.26; 1.55], p = 0.16). Conclusion: Active smoking is associated with increased adjusted long-term mortality, earlier onset and more frequent manifestation as STEMI, compared to non-smoking. Comparable adjusted results for LV GLS and NT-proBNP between groups support the presence of the pseudoparadox.

Screening for Occult Transthyretin Amyloidosis in Patients with Severe Aortic Stenosis and Amyloid Red Flags.

AIMS: The optimal strategy to identify transthyretin-type cardiac amyloidosis (ATTR-CA) in patients with aortic stenosis (AS) is still unclear. This study aimed to investigate if targeted screening for ATTR-CA in patients with severe AS and amyloid red flags is associated with higher detection rates. METHODS: The study prospectively enrolled patients ≥65 years with severe AS. Patients who fulfilled ≥1 major (carpal tunnel syndrome (CTS), ruptured biceps tendon, spinal stenosis, N-terminal pro B-type natriuretic peptide ≥1000 pg/mL, cardiac troponin >99th percentile) or ≥2 minor criteria (diastolic dysfunction ≥2 grade/lateral e' <10 cm/s, atrial fibrillation, atrioventricular conduction disease/pacemaker) received bone scintigraphy and biochemical analysis for light chain amyloidosis. Hypertensive patients (>140/90 mmHg) and those with interventricular septal thickness (IVSd) ≤13 mm were excluded. RESULTS: Overall, 264 patients were screened, of whom 85 were included in the analysis. Tracer uptake Perugini grade ≥1 was detected in nine patients (11%). An endomyocardial biopsy was additionally performed in four of nine patients, yielding a prevalence of 7% (n = 6). All patients with dual AS-ATTR were male. Syncope was more commonly reported in AS-ATTR patients (50% vs. 6%, p = 0.010), who also tended to have more severe hypertrophy (IVSd of 18 vs. 16 mm, p = 0.075). Pericardial effusion and CTS were more common in patients with dual pathology (67% vs. 8%, p < 0.001, and 83% vs. 24%, p = 0.003, respectively). CONCLUSION: Targeted screening for ATTR-CA in patients with AS and amyloid red flags does not yield higher detection rates than those reported previously in all comers with AS.

Acute coronary occlusion with vs. without ST elevation: impact on procedural outcomes and long-term all-cause mortality.

BACKGROUND: Acute total occlusion (ATO) is diagnosed in a substantial proportion of patients with non-ST-elevation myocardial infarction (NSTEMI). We compared procedural outcomes and long-term mortality in patients with STEMI with NSTEMI with vs. without ATO. METHODS AND RESULTS: We included patients with acute myocardial infarction (AMI) undergoing invasive coronary angiography between 2004 and 2019 at our centre. Acute total occlusion was defined as thrombolysis in myocardial infarction (TIMI) 0-1 flow in the infarct-related artery or TIMI 2-3 flow with highly elevated peak troponin (>100-folds the upper reference limit). Association between presentation and long-term mortality was evaluated using multivariable adjusted Cox regression analysis. From 2269 AMI patients (mean age 66 ± 13.2 years, 74% male), 664 patients with STEMI and 1605 patients with NSTEMI (471 [29.3%] with ATO) were included. ATO(+)NSTEMI patients had a higher frequency of cardiogenic shock and no reflow than ATO(-)NSTEMI with similar rates compared with STEMI patients (cardiogenic shock: 2.76 vs. 0.27 vs. 2.86%, P < 0.0001, P = 1; no reflow: 4.03 vs. 0.18 vs. 3.17%, P < 0.0001, P = 0.54). ATO(+)NSTEMI and STEMI were associated with 60 and 55% increased incident mortality, respectively, as compared with ATO(-)NSTEMI (ATO(+)NSTEMI: 1.60 [1.27-2.02], P < 0.0001, STEMI: 1.55 [1.24-1.94], P < 0.0001). Likewise, left ventricular ejection fraction (48.5 ± 12.7 vs. 49.1±11 vs. 50.6 ± 11.8%, P = 0.5, P = 0.018) and global longitudinal strain (-15.2 ± -5.74 vs. -15.5 ± -4.84 vs. -16.3 ± -5.30%, P = 0.48, P = 0.016) in ATO(+)NSTEMI were comparable to STEMI but significantly worse than in ATO(-)NSTEMI. CONCLUSION: Non-ST-elevation myocardial infarction patients with ATO have unfavourable procedural outcomes, resulting in increased long-term mortality, resembling STEMI. Our findings suggest that the occlusion perspective provides a more appropriate classification of AMI than differentiation into STEMI vs. NSTEMI.

Biomarkers of aortic diseases.

The development of diagnostic biomarkers of acute cardiovascular disease remains an important topic of interest given potential use to aid in early diagnosis. Cardiac biomarkers of ischemia and heart failure have already proven to be clinically useful. Biomarkers of aortic diseases are also needed, especially for life-threatening conditions such as aortic dissection. In this review, we discuss the present status of the development of biomarkers of aortic diseases. Although aortic dissection has been most vigorously pursued, there has also been notable recent progress in biomarkers of aneurysms and inflammatory aortic disease.

A new self-expandable transcatheter aortic valve for transapical implantation: feasibility in acute and chronic animal experiments.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) is currently expanding worldwide, however all available prostheses share some fundamental design drawbacks. We investigated the feasibility, safety and hemodynamic performance of the innovative transapical Acurate TA™ self-expandable device, which has the unique advantage of offering anatomically correct self-alignment within the aortic root. DESIGN: Transapical TAVI was performed in six acute swine and six chronic sheep procedures, with follow-up of 7, 14, 21, 28, 60 and 90 days. TAVI was performed under TEE and angiographic guidance without rapid pacing. RESULTS: A partial sternotomy approach was used to access the LV-apex. All valve implantations were performed as planned and all animals survived the implantation procedure. After deployment, no migration, embolization or coronary obstruction was observed during the observation period. Intraoperative TEE examination identified no signs of intravalvular leakage or valve dysfunction. Transvalvular mean pressure gradients were 5.4 ± 2.2 mmHg decreasing during follow-up (1.6 ± 0.8 mmHg, 1.8 ± 0.8 mmHg, 1.3 ± 0.2, 1.8 ± 0.7 mmHg, 1.6 ± 0.8 mmHg), with a slight increase atday 90 (4.0 ± 2.4 mmHg, P < 0.05). Macroscopic examination at necropsy showed correct anatomical positioning of the valve stent without any signs of structural valve deterioration. CONCLUSIONS: These first results of the innovative self-expandable transapical ACURATE TA™ device explore the feasibility and safety of anatomically correct off-pump implantation with optimal hemodynamic results.

Septal Microsphere Embolization in Hypertrophic Obstructive Cardiomyopathy.

Alcohol septal ablation is an established treatment for selected patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction (LVOT). The safety and efficacy of septal microsphere embolization (SME) have not been studied. We conducted a retrospective analysis of SME procedures performed at our center from 2006 to 2021 using 75-µm microspheres. The primary end point was LVOT gradient reduction. Secondary outcomes included periprocedural mortality, conduction disturbances, access site complications, and duration of hospitalization. The population comprised 76 patients (median age 61 years, men 43%). Dyspnea New York Heart Association ≥III was present in 65 patients (86%); ventricular tachycardia and previous syncope were described in 4% and 18%, respectively. Median duration of hospitalization was 13 days, and the time to first follow-up was 4 months. SME resulted in a significant reduction at rest (41 vs 12 mm Hg, mean Δ PG = -71%, p <0.001) and provoked LVOT gradients (94 vs 29 mm Hg, mean Δ PG = -75%, p <0.001). Periprocedural death occurred in 1 patient (1%) who underwent SME after transcatheter aortic valve replacement. Complete atrioventricular block was observed in 5 patients (7%). Left bundle branch block was diagnosed in 1 case (1%) and right bundle branch block in 3 (4%). Access site complications were observed in 4 patients (5%). In conclusion, SME is a safe and effective alternative to alcohol septal ablation. The potential advantages of microspheres are still to be investigated in prospective studies.

Sex-Related Differences among Adults with Hypertrophic Obstructive Cardiomyopathy Undergoing Transcoronary Ablation of Septal Hypertrophy.

(1) Background: The transcoronary ablation of septal hypertrophy (TASH) is an established therapy for hypertrophic obstructive cardiomyopathy (HOCM). Previous studies on this topic are characterised by a consistent male predominance and show a worse prognosis in females. (2) Methods: This study is a retrospective analysis of all TASH procedures conducted between 2006 and 2021 at a tertiary academic centre. A solution of 75 µm microspheres (Embozene®, Boston Scientific, Marlborough, MA, USA) was used as an embolising agent. The outcomes of interest were left ventricular outflow tract (LVOT) gradient reduction and symptom improvement among males vs. that among females. Secondarily, we analysed the sex-related differences in procedural safety outcomes and mortality. (3) Results: The study population consisted of 76 patients, with a median age of 61 years. Females comprised 57% of the cohort. We observed no sex-related differences in the baseline LVOT gradients at rest or under provocation (p = 0.560 and p = 0.208, respectively). Females were significantly older at the time of the procedure (p < 0.001), had lower tricuspid annular systolic excursion (TAPSE) (p = 0.009), presented a worse clinical status according to the NYHA functional classification (for NYHA ≥ 3, p < 0.001), and were more often on diuretics (p < 0.001). We did not observe sex-related differences in absolute gradient reduction at rest (p = 0.147) and under provocation (p = 0.709). There was a reduction in the NYHA class by a median value of 1 (p = 0.636) at follow-up for both sexes. Postprocedural access site complications were documented in four cases (two of which concerned females), and complete atrioventricular block was noted in five patients (three of which concerned females). The 10-year survival rates were comparable between the sexes (85% in females and 88% in males). The female sex was not associated with enhanced mortality according to multivariate analysis after adjusting for the confounding variables (HR 0.94; 95% CI 0.376-2.350; p = 0.895), but we observed age-related differences in long-term mortality (HR 1.035; 95% CI 1.007-1.063; p = 0.015). (4) Conclusions: TASH is safe and effective in both sexes, irrespective of their clinical differences. Women present at an advanced age and with more severe symptoms. An advanced age at the time of the intervention is an independent predictor of mortality.