Procedural success in transaxillary transcatheter aortic valve implantation according to type of transcatheter heart valve: results from the multicenter TAXI registry.

BACKGROUND: Transaxillary (TAx) transcatheter aortic valve implantation (TAVI) is a preferred alternative access in patients ineligible for transfemoral TAVI. AIMS: This study used the Trans-AXillary Intervention (TAXI) registry to compare procedural success according to different types of transcatheter heart valves (THV). METHODS: For the TAXI registry anonymized data of patients treated with TAx-TAVI were collected from 18 centers. Acute procedural, early and 1-month clinical outcomes were adjudicated in accordance with standardized VARC-3 definitions. RESULTS: From 432 patients, 368 patients (85.3%, SE group) received self-expanding (SE) THV and 64 patients (14.8%, BE group) received balloon-expandable (BE) THV. Imaging revealed lower axillary artery diameters in the SE group (max/min diameter in mm: 8.4/6.6 vs 9.4/6.8 mm; p < 0.001/p = 0.04) but a higher proportion of axillary tortuosity in BE group (62/368, 23.6% vs 26/64, 42.6%; p = 0.004) with steeper aorta-left ventricle (LV) inflow (55° vs 51°; p = 0.002) and left ventricular outflow tract (LVOT)-LV inflow angles (40.0° vs 24.5°; 0.002). TAx-TAVI was more often conducted by right sided axillary artery in the BE group (33/368, 9.0% vs 17/64, 26.6%; p < 0.001). Device success was higher in the SE group (317/368, 86.1% vs 44/64, 68.8%, p = 0.0015). In logistic regression analysis, BE THV were a risk factor for vascular complications and axillary stent implantation. CONCLUSIONS: Both, SE and BE THV can be safely used in TAx-TAVI. However, SE THV were more often used and were associated with a higher rate of device success. While SE THV were associated with lower rates of vascular complications, BE THV were more often used in cases with challenging anatomical circumstances.

Transcatheter aortic valve implantation in patients with anomalous coronary artery.

OBJECTIVES: The aim of this review was to analyze literature and provide systematic algorithm to guide decision making during TAVI procedure. BACKGROUND: Transcatheter aortic valve implantation (TAVI) is growing in popularity and expanding to younger patients with lower risk profiles. Currently, there is no concise guideline on the management strategy during TAVI in patients with anomalous coronary artery (ACA) anatomy undergoing this procedure. METHODS: A systematic search was conducted for relevant case reports of TAVI in patients who had confirmed ACA anatomy. Twenty-four case reports, that met the criteria for this review, were identified and included in the final study size. RESULTS: TAVI was successful in 23 out of 24 cases. Half of the cases (12) described performing balloon aortic valvuloplasty (BAV) before TAVI. The majority (15) reported using angiogram Postimplantation. Only one-third of cases (8) reported performing coronary protection (with either wire, wire and stent or wire and balloon). Two-third of case reports (16/24, 67%) mentioned using Edwards SAPIEN balloon expandable transcatheter heart valves (THV). CONCLUSIONS: Preprocedural diagnostic imaging tests play important role in determining the ACA anatomy and its relation to the aortic valve. BAV with simultaneous coronary arteries angiography or aortography should be performed before implantation of THV, as it could potentially predict whether the ACA would be compressed. Using at least a coronary wire for ACA protection is recommended in case there is high risk of ACA obstruction. Management strategy should be individualized when performing TAVI in patients with ACA.

Transcatheter Interventions for Atrioventricular Dysfunction in Patients with Adult Congenital Heart Disease: An International Case Series.

INTRODUCTION: A substantial proportion of patients with adult congenital heart disease (ACHD) suffer from worsening valvular dysfunction in adulthood. Transcatheter valve interventions can offer a therapeutic alternative to surgery for those at high surgical risk. There is emerging but limited data on transcatheter interventions for atrioventricular (AV) valve dysfunction in patients with ACHD. METHODS: We compiled an international collaborative multi-center registry focusing on adult patients with congenital heart disease undergoing transcatheter AV valve interventions (repair or replacement). Included were patients from three international centers who underwent procedures between 2016 and 2022. Demographic, clinical, and procedural data were compiled. RESULTS: Nine patients with ACHD underwent AV valve interventions. The median age was 48 years (IQR (37; 56), 55% women). At baseline, seven patients (78%) were in NYHA functional class III and two (22%) were in NYHA functional class II. The diagnosis of ACHD varied. Three valve interventions were performed on the subpulmonary AV valve and six on the systemic AV valve. The primary valvular pathology was regurgitation (six patients, 78%). Five procedures were valve-in-valve interventions, and four procedures were transcatheter edge-to-edge repair procedures. There were no major complications or peri-procedural complications or peri-procedural mortality. One patient developed a suspected non-obstructive thrombus on the valve that was medically treated. One patient did not improve clinically following the procedure and underwent a heart transplant, one patient died 6 months following the procedure due to a cardiovascular implantable electronic device infection. At one year, six patients were in NYHA functional class I, and one patient was in NYHA functional class III. In conclusion, transcatheter AV heart valve interventions are feasible and safe procedures in carefully selected ACHD patients. These procedures can offer an effective treatment option in these younger patients with high surgical risk.

Impact of implantation technique on conduction disturbances for TAVR with the self-expanding portico/navitor valve.

BACKGROUND: Use of a right-left (R-L) cusp overlap view for transcatheter aortic valve replacement (TAVR) with self-expanding valves has recently been proposed aiming to reduce permanent pacemaker implantation (PPMI). An objective, data-driven explanation for this observation is missing. AIMS: To assess the impact of different implantation techniques on the risk of PPMI following TAVR with the Portico/NavitorTM transcatheter heart valve (THV; Abbott). METHODS: A TAVR-population treated with Portico/NavitorTM had the THV implanted in a right versus left anterior oblique (RAO/LAO) fluoroscopic view with no parallax in the delivery system. The impact of these different implantation views on the spatial relationship between THV and native aortic annulus and the risk of conduction disturbances and PPMI after TAVR was studied. RESULTS: A total of 366 matched TAVR patients were studied: 183 in the RAO group and 183 in the LAO group. The degree of aortic annulus plane tilt was significantly smaller in the RAO versus LAO group (median: 0° vs. 23°, p < 0.001), with no plane tilt in 105 out of 183 cases (57.3%) in the RAO group. At 30 days after TAVR, the overall PPMI and guideline-directed PPMI rates were 12.6% versus 18.0% (p = 0.15) and 8.2% versus 15.3% (p = 0.04) in the RAO versus LAO group, respectively. CONCLUSIONS: Use of a R-L cusp overlap (RAO-caudal) view for implantation of the Portico/NavitorTM valve results in less tilt of the native aortic annulus plane and a clear trend toward a lower 30-day PPMI rate as compared to TAVR using the conventional LAO implantation view.

Collateral effect of the COVID-19 pandemic on cardiology service provision and cardiovascular mortality in a population-based study: COVID-COR-LT.

BACKGROUND: Collateral damage of the COVID-19 pandemic on cardiovascular health is increasingly studied. This is a population-based study addressing multiple aspects of cardiovascular care during the pandemic in a country of Lithuania, in which pandemic waves were significantly different. METHODS: Data on cardiology outpatient care, hospitalizations and cardiovascular mortality in 2019 and 2020 were collected from Lithuanian nationwide administrative databases and registries. Weekly data and aggregated numbers of corresponding 6-week phases were analyzed comparing the numbers between 2019 and 2020. Age, sex and regional subgroup analysis was performed. RESULTS: Both cardiovascular outpatient care visits and hospitalizations decreased dramatically in 2020 compared to 2019 with a peak reduction (up to - 60% for both) during the first pandemic wave in spring of 2020. Simultaneously, cardiovascular mortality was much higher in 2020, with a pronounced peak at the end of the year compared to 2019 (up to 46%). The increase was even more staggering when analyzing home deaths, which rose up to 91% by the end of 2020. Notable differences between age groups, regions and sexes were documented. CONCLUSION: A profound indirect damage of COVID-19 pandemic on cardiovascular care was observed in this study, with striking decreases in cardiovascular care provision and concurrent increase in cardiovascular mortality, both overall and, even more dramatically, at home. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05021575 (registration date 25-08-2021, retrospectively registered).

Percutaneous vs. surgical axillary access for transcatheter aortic valve implantation: the TAXI registry.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an established management strategy for severe aortic valve stenosis. Percutaneous axillary approach for TAVI holds the promise of improving safety without jeopardizing effectiveness in comparison to surgical access. We aimed at appraising the comparative effectiveness of percutaneous vs. surgical axillary approaches for TAVI. METHODS: We performed an international retrospective observational study using de-identified details on baseline, procedural, and 1-month follow-up features. Valve Academic Research Consortium (VARC)-3 criteria were applied throughout. Outcomes of interest were clinical events up to 1 month of follow-up, compared with unadjusted and propensity score-adjusted analyses. RESULTS: A total of 432 patients were included, 189 (43.8%) receiving surgical access, and 243 (56.2%) undergoing percutaneous access. Primary hemostasis failure was more common in the percutaneous group (13.2% vs. 4.2%, P<0.001), leading to more common use of covered stent implantation (13.2% vs. 3.7%, P<0.001). Irrespectively, percutaneous access was associated with shorter hospital stay (-2.6 days [95% confidence interval: -5.0; -0.1], P=0.038), a lower risk of major adverse events (a composite of death, myocardial infarction, stroke, type 3 bleeding, and major access-site related complication; odds ratio=0.44 [0.21; 0.95], P=0.036), major access-site non-vascular complications (odds ratio=0.21 [0.06; 0.77], P=0.018), and brachial plexus impairment (odds ratio=0.16 [0.03; 0.76], P=0.021), and shorter hospital stay (-2.6 days [-5.0; -0.1], P=0.038). CONCLUSIONS: Percutaneous axillary access provides similar or better results than surgical access in patients undergoing TAVI with absolute or relative contraindications to femoral access.

TAVR With the Novel Navitor Titan™ Transcatheter Heart Valve to Treat Aortic Stenosis Patients With Large Aortic Annuli.

This case report describes the first transcatheter aortic valve replacement (TAVR) with the latest-generation Navitor Titan™ transcatheter heart valve (Abbott, USA) in a European patient with severe symptomatic aortic valve stenosis (AS). The Navitor Titan™ transcatheter heart valve has been developed to treat patients with large aortic annuli, namely aortic annulus perimeter 85 to 95 mm. In combination with the low profile FlexNav™ delivery system, the Navitor Titan™ valve offers the unique possibility to treat AS patients with large aortic annuli and suboptimal vascular access.

Cusp Symmetry and Coronary Ostial Eccentricity and its Impact on Coronary Access Following TAVR.

OBJECTIVES: The aim of this study was to assess cusp symmetry and coronary ostial eccentricity and its impact on coronary access following transcatheter aortic valve replacement (TAVR) using a patient-specific commissural alignment implantation technique. BACKGROUND: TAVR implantation techniques to obtain neocommissural alignment have been introduced. The impact of cusp symmetry and coronary ostial eccentricity on coronary access after TAVR remains unknown. METHODS: Cardiac computed tomographic scans from 200 tricuspid aortic valves (TAVs) and 200 type 1 bicuspid aortic valves (BAVs) were studied. Cusp symmetry and coronary ostial eccentricity were assessed. In addition, the right coronary cusp/left coronary cusp and right coronary artery (RCA)/left coronary artery (LCA) ostia overlap views were calculated and compared. RESULTS: Severe cusp asymmetry (>135°) was more frequent in BAVs (52.5%) than in TAVs (2.5%) (P < 0.001), with the noncoronary cusp being the most common dominant cusp. The RCA ostium was found to be more often eccentric (>20°) than the LCA ostium (28% vs 6%, respectively; P < 0.001). Considering the right/left cusp overlap view, there was <20° deviation between the right coronary cusp-left coronary cusp centered line and the RCA-LCA centered line in 95% of all patients (TAV, 97%; BAV, 93%). The right/left cusp and coronary ostia overlap view differed by <10° and <20° fluoroscopic angulation in 75% and 98% of all cases, respectively. CONCLUSIONS: Using the right/left cusp overlap view to obtain commissural alignment in TAVR is also an effective approach to implant one of the transcatheter heart valve commissures in the near center between both coronary ostia in most TAVs and type 1 BAVs. Preprocedural CT assessment remains crucial to assess cusp symmetry and coronary ostial eccentricity.

Treatment of chronic total occlusion with percutaneous coronary intervention is associated with improved survival as compared to medical treatment alone: insights from a single-centre registry.

Symptom relief is currently the main indication to perform percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). So far, none of the randomized trials for CTO treatment have demonstrated improved survival after PCI compared to optimal medical treatment (OMT) alone. We investigated whether CTO PCI in addition to OMT could improve survival over OMT alone. Data of 1004 patients with a treated CTO was analysed. Patients with acute coronary syndrome and who underwent coronary artery bypass graft surgery (CABG) were excluded, thus final study population was 378. According to the treatment received, patients were divided into two groups: CTO PCI + OMT (n = 163) and OMT alone (n = 215). The primary endpoint was all-cause mortality during follow-up. The incidence of myocardial infarction (MI), revascularization (both CTO artery and non-CTO artery related) and stroke were also analysed as a secondary outcome. The mean follow-up period was 3.55 ± 0.93 years. Multiple regression analysis was performed to identify independent predictors of all-cause mortality. Occurrence of MI and repeat revascularization (both CTO vessel related and non-CTO vessel) and stroke did not differ significantly between groups. However, all-cause mortality was more frequent in OMT (19.1%) patients than PCI (10.4%). Patients age ≤70 years (odds ratio (OR) 0.47 [0.26; 0.84], p = 0.01) and CTO PCI (OR 0.51 [0.27; 0.94], p = 0.03) were independent predictors of reduced likelihood of all-cause death. The data from our centre registry demonstrates that CTO PCI is associated with reduced all-cause mortality as compared to medical treatment alone in a real-life setting.

Increase of Myocardial Ischemia Time and Short-Term Prognosis of Patients with Acute Myocardial Infarction during the First COVID-19 Pandemic Wave.

Background and objectives: early reports showed a decrease in admission rates and an increase in mortality of patients with acute myocardial infarction (AMI) during the first wave of COVID-19 pandemic. We sought to investigate whether the COVID-19 pandemic and associated lockdown had an impact on the ischemia time and prognosis of patients suffering from AMI in the settings of low COVID-19 burden. Materials and Methods: we conducted a retrospective data analysis from a tertiary center in Lithuania of 818 patients with AMI. Data were collected from 1 March to 30 June in 2020 during the peri-lockdown period (2020 group; n = 278) and compared to the same period last year (2019 group; n = 326). The primary study endpoint was all-cause mortality during 3 months of follow-up. Secondary endpoints were heart failure severity (Killip class) on admission and ischemia time in patients with acute ST segment elevation myocardial infarction (STEMI). Results: there was a reduction of 14.7% in admission rate for acute myocardial infarction (AMI) during the peri-lockdown period. The 3-month mortality rate did not differ significantly (6.9% in 2020 vs. 10.5% in 2019, p = 0.341 for STEMI patients; 5.3% in 2020 vs. 2.6% in 2019, p = 0.374 for patients with acute myocardial infarction without ST segment elevation (NSTEMI)). More STEMI patients presented with Killip IV class in 2019 (13.5% vs. 5.5%, p = 0.043, respectively). There was an increase of door-to-PCI time (54.0 [42.0-86.0] in 2019; 63.5 [48.3-97.5] in 2020, p = 0.018) and first medical contact (FMC)-to-PCI time (101.0 [82.5-120.8] in 2019; 115 [97.0-154.5] in 2020, p = 0.01) during the pandemic period. Conclusions: There was a 14.7% reduction of admissions for AMI during the first wave of COVID-19. FMC-to-PCI time increased during the peri-lockdown period, however, it did not translate into worse survival during follow-up.

Intravascular Lithotripsy-Assisted Transfemoral TAVI: The Copenhagen Experience and Literature Review.

Transcatheter aortic valve implantation (TAVI) is currently an established therapy for elderly patients with symptomatic severe aortic valve stenosis across all surgical risk categories. Access is an important aspect when planning for and performing TAVI. The superiority of a transfemoral (TF) approach compared to a transthoracic (transapical, direct aortic) approach has been demonstrated in several studies. Recently, the introduction of intravascular lithotripsy (IVL) has made it possible to treat patients with calcified iliofemoral disease by TF approach. This article aimed to provide a comprehensive overview on the following aspects: (1) preprocedural planning for IVL-assisted TF-TAVI; (2) procedural aspects in IVL-assisted TF-TAVI; (3) outcomes of IVL-assisted TF-TAVI in an experienced TAVI center; and (4) literature review and discussion of this new emerging approach.

Patient-Specific Implantation Technique to Obtain Neo-Commissural Alignment With Self-Expanding Transcatheter Aortic Valves.

OBJECTIVES: The authors sought to investigate whether a patient-specific implantation technique during transcatheter aortic valve replacement (TAVR) can result in a safe and reproducible neo-commissural alignment of self-expanding transcatheter heart valves (THVs). BACKGROUND: To date, little attention has been paid to neo-commissural alignment during TAVR. METHODS: A fluoroscopy-based, patient- and valve-specific TAVR implantation technique was applied in 60 patients treated with 3 different self-expanding THV platforms (Evolut R/PRO, Medtronic; ACURATE neo2, Boston Scientific; and Portico, Abbott-20 patients in each group). Post-TAVR cardiac computed tomography was used to assess THV neo-commissural alignment. RESULTS: Considering all 60 patients, ≤mild commissural misalignment (CMA <30°) was obtained in 53 patients (88%) using this modified TAVR implantation technique-in 36 patients (60%), optimal commissural alignment (<15°) was obtained. In 2 patients, cardiac computed tomography revealed severe CMA (>45°) with overlap between the coronary ostia and THV commissures. Using the ACURATE neo2 platform, operators succeeded in avoiding ≥moderate CMA in all 20 cases. When analyzing those cases in which the optimal amount of THV rotation could be assessed and applied before THV expansion (n = 52; 87%), the success rate of TAVR with ≤mild CMA was 98%. No procedure- or valve-related complications occurred in this study cohort. CONCLUSIONS: A patient-specific TAVR implantation technique aiming to obtain neo-commissural alignment is feasible and safe, and aides to prevent THV implantations with overlap between the coronary ostia and THV commissures. Optimized TAVR devices and design may further improve the success rate of TAVR with neo-commissural alignment.

Think outside the coronary artery: Extremely rare case of STEMI in young man.

Acute myocardial infarction caused by a bronchogenic cyst is a very rare pathology. It occurs as a result of external compression of the coronary artery by the cyst, leading to myocardial ischemia. The present case illustrates that a bronchogenic cyst, which is generally considered to be a chronic disease entity with gradual onset of symptoms, can manifest acutely as a life-threatening condition. Timely invasive coronary intervention is critical in the acute management of this complication while multimodality imaging assessment is essential in the subsequent management of the underlying etiology.

Immediate coronary angiogram in out-of-hospital cardiac arrest patients with non-shockable initial rhythm and without ST-segment elevation - Is there a clinical benefit?

AIM: Coronary angiogram (CA) may be useful after resuscitated out-of-hospital cardiac arrest (OHCA), but data regarding its benefit in patients with non-shockable initial rhythm without ST-segment elevation is scarce. We aimed to evaluate the prevalence of acute coronary syndrome (ACS) and survival in OHCA patients with non-shockable initial rhythm without ST-segment elevation and compare them to patients with shockable initial rhythm without ST-segment elevation. METHODS: Retrospective single-centre study approved by the ethics committee of our institution, including adults successfully resuscitated from OHCA of presumed cardiac cause, undergoing routine CA on admission. Baseline characteristics, angiographic data including presence of ACS and survival were compared between patients with non-shockable and shockable initial rhythm focusing on patients without ST-segment elevation. RESULTS: Among 517 patients included between 2002 and 2018, 311 had no ST-elevation, of whom 179 had non-shockable and 132 shockable initial rhythm. Compared with shockable initial rhythm patients without ST-elevation, non-shockable initial rhythm patients without ST-elevation had longer no-flow duration, 5 (1-10) versus 2 (0-8) min, p = 0.024, more frequent shock requiring vasopressors, 72% versus 47% p < 0.0001, a lower prevalence of ACS, 2 (1%), versus 29 (22%), p < 0.001 and higher mortality, 85% versus 39% (p < 0.0001). Among ACS patients, none survived in the non-shockable without ST-elevation group, while 20 (69%) survived in the shockable rhythm without ST-elevation group. CONCLUSIONS: Prevalence of ACS in patients without ST-segment elevation and non-shockable initial rhythm is extremely low, and survival extremely poor, therefore routine emergency CA does not seem beneficial in these patients.

FFR result post PCI is suboptimal in long diffuse coronary artery disease.

AIMS: The aim of this study was to evaluate the functional result immediately post PCI and at nine-month follow-up, and to ascertain how often a functionally optimal result of >0.95 can be achieved in long coronary lesions treated with long second- or newer-generation DES. METHODS AND RESULTS: Patients receiving DES measuring ≥30 mm with FFR value ≤0.8 were included in the study. Stent length was defined as long (30 to 49 mm; L-DES) and ultra-long (≥50 mm; UL-DES). Angiographic and FFR evaluation was performed before and after PCI and at nine-month follow-up. A total of 74 patients each received a mean stent length of 50.72±14.6 mm. Mean FFR post PCI was 0.88±0.06. An optimal post PCI FFR value of >0.95 was achieved in only 9/74 patients (12.2%), and was not achieved in any UL-DES patients. Only 12/74 (16.2%) had FFR post PCI of 0.91 to 0.95; 8/74 (10.8%) patients remained ischaemic (≤0.8). FFR gradient across the stent was higher in UL-DES patients compared to L-DES patients (0.07±0.03 vs. 0.04±0.03; p=0.001). At follow-up, the angiographic restenosis rate was 4.7%, and the functional restenosis rate was 15.1%. CONCLUSIONS: The FFR result post PCI was suboptimal in the majority of patients treated with long DES and was particularly poor when the total stent length exceeded 50 mm.

FFR guided PCI on long coronary lesions: 2-year clinical results with 2nd or newer generation DES.

Background. Despite improvements in drug-eluting stent (DES) technology, treatment strategies for long coronary artery lesions remain a controversial issue. The aim of our study was to evaluate the long-term clinical results after FFR guided PCI on long coronary lesions. Materials and methods. A total of 74 consecutive patients with significant (mean FFR 0.61 ± 0.11) coronary artery lesions ≥30 mm in length were included in the prospective study. All patients were treated with FFR guided PCI implanting newer generation Biolimus, Everolimus or Zotarolimus eluting stents. Clinical endpoints - target vessel revascularization (TVR) and major adverse cardiac events (MACE) - were recorded at 1 and 2 years. Results. 100% angiographic procedure success was achieved, the mean post procedural FFR was 0.88 ± 0.06. At 2-year follow-up, 6 (8.1%) patients had ischemia driven TVR, all within the first 12 months. There were no target vessel related acute coronary syndromes and definite stent thromboses in the study group. At 2 years, the total MACE rate was 29.7%. There was a trend towards a higher TVR rate in patients with overlapping DES vs single DES implanted (9.6 vs 4.5%, p = 0.6). On regression analysis, the total stent length had no influence on the TVR rate. Conclusions. At 2 years after stenting long coronary lesions with newer generation DES the TVR rate was 8.1%, which is acceptable in the high cardiovascular risk population with diffuse coronary artery disease. The total stent length did not affect the long-term clinical outcomes.