Asymptomatic Stroke in the Setting of Percutaneous Non-Coronary Intervention Procedures.

Advancements in clinical management, pharmacological therapy and interventional procedures have strongly improved the survival rate for cardiovascular diseases (CVDs). Nevertheless, the patients affected by CVDs are more often elderly and present several comorbidities such as atrial fibrillation, valvular heart disease, heart failure, and chronic coronary syndrome. Standard treatments are frequently not available for "frail patients", in particular due to high surgical risk or drug interaction. In the past decades, novel less-invasive procedures such as transcatheter aortic valve implantation (TAVI), MitraClip or left atrial appendage occlusion have been proposed to treat CVD patients who are not candidates for standard procedures. These procedures have been confirmed to be effective and safe compared to conventional surgery, and symptomatic thromboembolic stroke represents a rare complication. However, while the peri-procedural risk of symptomatic stroke is low, several studies highlight the presence of a high number of silent ischemic brain lesions occurring mainly in areas with a low clinical impact. The silent brain damage could cause neuropsychological deficits or worse, a preexisting dementia, suggesting the need to systematically evaluate the impact of these procedures on neurological function.

Effects of transcatheter aortic valve implantation on left ventricular and left atrial morphology and function.

AIMS: Transcatheter aortic valve implantation (TAVI) is an alternative treatment in surgically high-risk or inoperable patients with severe aortic stenosis (AS). The objective of this study was to analyze the effects of TAVI on left ventricular (LV) and left atrial (LA) longitudinal function assessed by speckle tracking echocardiography (2DSTE) in patients with AS. METHODS: In our prospectively conducted study, a total of 55 symptomatic (New York Heart Association class II or higher) patients with severe AS, considered to be at increased risk for undergoing surgical aortic valve replacement, were recruited (age: 78.6 ± 7.4 year). Patients underwent a complete clinical and laboratory evaluation, in addition to standard echocardiography and 2DSTE. Echocardiographic analysis was performed before and 6 months after TAVI. 2DSTE measured segmental and global longitudinal strain (GLS) and radial strain. RESULTS: All the patients received the CoreValve self-expanding prosthesis. Six months after TAVI, patients showed a significant reduction in mean transaortic gradient (52.1 ± 15.8 vs. 11.2 ± 3.3 mmHg, P < 0.0001), LV mass, LA volume index, and an improvement of ejection fraction (P < 0.0001). In addition, LV GLS (-11.8 ± 3.2 vs. -16.3 ± 4.2%; P < 0.0001) and LA longitudinal strain (14.2 ± 5.4 vs. 26.6 ± 10.8%, P < 0.0001) significantly increased after TAVI. In a stepwise forward multiple logistic regression analysis, LV mass before TAVI (P < 0.001) and peak CK MB mass after TAVI (P < 0.0001) were powerful independent predictors of lower improvement of LV GLS. Moreover, LV mass index (P < 0.001) and LV GLS strain (P < 0.001) before TAVI were powerful independent predictor of LA longitudinal strain after TAVI CONCLUSIONS: TAVI in patients with AS resulted in geometric changes known as "reverse remodelling," and improved LV and LA function assessed by 2DSTE.

Treating Aortic Valve Stenosis for Vitality Improvement: The TAVI Study.

BACKGROUND: Degenerative aortic valve stenosis (AS) is the most common valvular heart disease among the elderly. Once cardiac symptoms occur, current guidelines recommend aortic valve replacement. Progressive degeneration/calcification reduces leaflet mobility with gradual cardiac output (CO) impairment. Low CO might induce abnormal brain-aging with cognitive impairment and increased risk of dementia, such as Alzheimer's disease or vascular dementia. On the contrary, cognitive improvement has been reported in patients in whom CO was restored. Transcatheter aortic valve implantation (TAVI) has proven to be a safe alternative to conventional surgery, with a similar mid-term survival and stroke risk even in low-risk patients. TAVI is associated with an immediate CO improvement, also effecting the cerebrovascular system, leading to an increased cerebral blood flow. The correlation between TAVI and cognitive improvement is still debated. The present study aims at evaluating this relationship in a cohort of AS patients where cognitive assessment before and after TAVI was available. METHODS: a total of 47 patients were retrospectively selected. A transcranial Doppler ultrasound (TCD) before and after TAVI, a quality of life (QoL) score, as well as a mini-mental state examination (MMSE) at baseline and up to 36 months, were available. RESULTS: TAVI was associated with immediate increase in mean cerebral flow at TCD. MMSE slowly increase at 36-months follow-up with improved QoL mainly for symptoms, emotions and social interactions. CONCLUSIONS: this proof-of-concept study indicates that TAVI might induce cognitive improvement in the long-term as a result of multiple factors, such as cerebral flow restoration and a better QoL.

[Prevention and management of paravalvular leak post-transcatheter aortic valve implantation]. / Prevenzione e gestione dei leak paravalvolari post-impianto transcatetere di valvola aortica.

During transcatheter aortic valve implantation (TAVI) the native valve is not removed but crushed. Thus, a slight prosthesis insufficiency is not uncommon and has been reported up to 25% of patients for both available types of percutaneous valves. However, the definition of "clinically significant" valve regurgitation is not fully established yet. In most cases, aortic insufficiency is mild and clinical acceptable; however, severe insufficiency can occur. Paravalvular insufficiency is usually prevalent, and it may be the consequence of prosthesis-patient mismatch due to an undersizing of the implanted device or an incomplete expansion of the prosthesis stent frame, or also to incorrect site of prosthesis implantation. Thus, accurate assessment of the aortic valve annulus before TAVI is mandatory in order to select the optimal valve size. The presence of large calcium burden or bicuspid valve as well as the correct implantation of the device are other key determinants of final valve insufficiency. When severe regurgitation is present, an integration of hemodynamic, angiographic, transthoracic and transesophageal echocardiography data is necessary to tailor the best clinical decision on a per-patient basis.

From Femoral to Radial Approach in Coronary Intervention.

Since the first cardiac catheterization in 1929, this procedure has evolved considerably. Historically performed via the transfemoral access, in the last years, the transradial access has been spreading gradually due to its many advantages. We have conducted a review of published literature concerning efficacy, safety, and cost-effectiveness, and we analyzed our patients' data, including the results of the recently published Minimizing Adverse hemorrhagic events by TRansradial access site and systemic implementation of angioX (MATRIX) study. This review confirmed the superiority of the transradial access compared to the femoral access, especially regarding complications related to the access site, duration of hospitalization, and comfort for the patient. The transradial approach is an excellent option for coronary angiography, and the procedure's risks are reduced by increased operator experience.

Test-re-test reproducibility of Doppler echocardiography for assessment of electromechanical dyssynchrony: implications for heart failure clinic.

BACKGROUND: Reproducibility of Doppler echocardiography for assessment of inter-ventricular and intra-left ventricular (LV) dyssynchrony, and its clinical implications, have not been established. METHODS: Twenty-eight subjects (heart failure stages A-C, 61% with QRS ≥ 120 ms, ejection fraction (EF) ≤ 35%) underwent two consecutive echo-studies within 24h to evaluate test-re-test reproducibility of inter-ventricular electromechanical delay (VV delay, by traditional pulsed-Doppler), and intra-LV electromechanical delay between opposite LV walls by color-coded Doppler tissue-velocity (COLOR-DTI), and by pulsed-Doppler tissue spectrum (PW-DTI). Reproducibility of LV internal diastolic diameter (LVIDD) and of EF (by Simpson's method) assessments was evaluated contextually for reference. RESULTS: Intra-study and inter-study reproducibility of inter-ventricular and intra-LV electromechanical dyssynchrony was in general good, and comparable to the reproducibility of LVIDD and EF assessments. Between-study reproducibility of PW-TDI method was fair, but showed poor agreement with COLOR-TDI method. In repeated studies, agreement of significant electromechanical delay by COLOR-TDI was comparable to the agreement of EF ≤ 35%. In the 5 patients who had simultaneously large QRS, EF ≤ 35%, and significant inter- and intra-ventricular dyssynchrony at study #1, 3 had EF 36-40% and 1 showed no significant dyssynchrony by study #2. CONCLUSION: In serial echocardiographic studies, Doppler echocardiography showed a good test-re-test reproducibility for the identification of significant electromechanical delay. Planimetry for EF assessment was a source of variability as relevant as Doppler echocardiography, but COLOR-DTI may add meaningful and reproducible information to QRS duration for cardiac-resynchronization therapy.