Safety and Feasibility of Transcatheter Aortic Valve Replacement in COVID-19 Patients: A Case Series.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic has led to a decrease in interventional treatment for structural heart disease worldwide. In this context, the management of patients with symptomatic severe aortic stenosis (AS) or bioprosthetic valve dysfunction (BVD) represents a clinical challenge, as a delay in aortic valve replacement procedures may increase short-term morbidity and mortality. We report four cases of TAVR performed in patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. All of them were discharged in good clinical conditions and no adverse events were reported at 30 days follow-up. Our experience suggests that in selected patients with mild SARS-CoV-2 infection and symptomatic native AS or BVD, TAVR has a favorable short-term outcome.

Surgical redo versus transseptal or transapical transcatheter mitral valve-in-valve implantation for failed mitral valve bioprosthesis.

BACKGROUND: Redo surgical mitral valve replacement (SMVR) is the current standard of care for patients with failed bioprosthetic mitral valve (MV). Transcatheter mitral valve-in-valve replacement (TMViV) is arising as an alternative to SMVR in high risk patients. We sought to evaluate procedural safety, early and mid-term outcomes of patients who underwent transseptal TMViV (TS-TMViV), transapical TMViV (TA-TMViV), or redo-SMVR. METHODS: We identified patients with failed bioprosthetic MV who underwent TS-TMViV, TA-TMViV, or SMVR at four Italian Centers. Clinical and echocardiographic data were codified according to Mitral Valve Academic Research Consortium definition (MVARC), except for significant valve stenosis. RESULTS: Between December 2012 and September 27, 2019 patients underwent TS-TMViV, 22 TA-TMViV, and 29 redo-SMVR. TS-TMViV and TA-TMViV patients presented higher mean age and surgical risk scores compared with SMVR group (77.8 ± 12 years, 77.3 ± 7.3 years, 67.8 ± 9.4 years, p < .001; STS PROM 8.5 ± 7.2; 8.9 ± 4.7; 3.6 ± 2.6, p < .001). TS-TMViV procedure was associated with shorter intensive care unit time and total length of stay (LOS) compared with TA-TMViV and SMVR group. There were no differences in MVARC procedural success at 30-days (74.1, 72.7, and 51.7%, p = .15) and one-year all-cause mortality between groups (14.8, 18.2, and 17.2%, p = 1.0). MV mean gradient was similar between TS-TMViV, TA-TMViV, and SMVR groups at 30 days and 12 months. CONCLUSIONS: For the selected patients, TS-TMViV and TA-TMViV are to be considered a valid alternative to redo-SMVR with comparable 1-year survival. TS-TMViV is the less invasive strategy and has the advantage of shortening the LOS compared with TA-TMViV.

RANKL Expression Is Increased in Circulating Mononuclear Cells of Patients with Calcific Aortic Stenosis.

We aimed to investigate whether the expression of the OPG/RANK/RANKL triad in peripheral blood mononuclear cells (PBMC) and circulating levels of markers of ectopic mineralization (OPG, FGF-23, PPi) are modified in patients with calcific aortic valve disease (CAVD). We found that patients affected by CAVD (n = 50) had significantly higher circulating levels of OPG as compared to control individuals (p = 0.003). No differences between the two groups were found in FGF-23 and PPi levels. RANKL expression was higher in the PBMC from CAVD patients (p = 0.018) and was directly correlated with the amount of valve calcification (p = 0.032). In vitro studies showed that treatment of valve interstitial cells (VIC) with RANKL plus phosphate was followed by increase in matrix mineralization (p = 0.001). In conclusion, RANKL expression is increased in PBMC of patients with CAVD, is directly correlated with the degree of valve calcification, and promotes pro-calcific differentiation of VIC.

Transfemoral transcatheter aortic valve implantation for treatment of severe aortic regurgitation in a patient with previous aortic valve-sparing operation according to David.

The regurgitation of the native aortic valve in patient with previous David operation may represent a clinical challenge because the morbidity and mortality risk of re-operation is not negligible. Here we describe the case of a patient suffering from late severe aortic regurgitation, many years after David operation, efficaciously treated with transfemoral transcatheter aortic valve implantation. To the best of our knowledge, this is the first description of such treatment in a patient with aortic regurgitation and previous David operation.

A Nonfluoroscopic Technique for Coronary Arteries Three-Dimensional Mapping during Epicardial Ventricular Tachycardia Ablation.

When performing epicardial ablation of ventricular tachycardia (VT), caution must be taken not to damage the coronary arteries. We report a case in which a new, nonfluoroscopic technique for incorporating an accurate, real-time reconstruction of the main coronary vessels into a three-dimensional electroanatomic map was used for epicardial VT ablation.

Implanting cardiac rhythm devices during uninterrupted warfarin therapy: a prospective, single center experience.

AIM: The aim of the present study was to assess the safety of cardiac rhythm device implantation during uninterrupted oral anticoagulant therapy. METHODS: Patients at high thromboembolic risk (venous thromboembolism <3 months, nonvalvular atrial fibrillation with CHADS2 score >2, valvular atrial fibrillation, prosthetic heart valves) underwent procedures during uninterrupted warfarin (on warfarin group) and were compared to low-risk patients who underwent procedures after warfarin withdrawal (off warfarin group). Primary endpoint was a composite of hematoma requiring warfarin interruption, reoperation, or blood transfusion; death; hemothorax; and tamponade. Secondary endpoints were nonsignificant hematoma and clinical arterial thromboembolism assessed at discharge and at a 2 month follow-up. RESULTS: One hundred and ninety-one patients were enrolled, 102 in the 'on warfarin group' and 89 in the 'off warfarin group'. The majority of procedures were first implants (73% in the 'on warfarin group' vs. 87% in the 'off warfarin group', P= 0.01). Pacemakers, implantable cardioverter defibrillators, and biventricular devices were included. International normalized ratio at implant was 2 ±â€Š0.28 (range 1.6-3.2) in the 'on warfarin group' and 1.3 ±â€Š0.19 (range 1-1.6) in the 'off warfarin group' (P= 0.0001). Incidence of hemathoma was five of 102 in the 'on warfarin group' vs. three of 89 in the 'off warfarin group' (5 vs. 3%, P = not significant) and all hemathomas resolved spontaneously. There were no significant hemathomas in either group. There was no death, hemothorax, or tamponade. There were no thromboembolic events at 2 months. CONCLUSION: Cardiac rhythm device implantation during uninterrupted warfarin was not associated with increased bleeding compared with warfarin interruption.

Management strategies and outcome for prosthetic valve endocarditis.

The aim of this study was to assess the impact of an operative protocol with a multidisciplinary approach on the outcome of patients with prosthetic valve endocarditis (PVE). A formal policy for the care of PVE was introduced at our hospital in 2003 in which patients were referred to and managed by a preexisting team involving a cardiologist, a specialist in infectious diseases, and a cardiac surgeon. All patients underwent transesophageal echocardiography as soon as clinical suspicion of PVE arose. If high-risk conditions such as heart failure, ring abscess, conditions associated with impending malfunctioning of the prosthesis, or vegetations at high risk for systemic embolization were found during the initial multidisciplinary evaluation (performed within 12 hours of admission), patients were operated on within 48 hours. Stable patients were evaluated weekly by the multidisciplinary team, and on-treatment surgery was performed whenever high-risk conditions developed or when there was persistent fever/bacteremia after 1 week of adequate antibiotic therapy. Comparing the period 2003 through 2009 with 1996 through 2002 (when a multidisciplinary policy was not followed), patients with PVE were more numerous (61 vs 38), older (mean age 68.3 vs 63.1, p = 0.01), and had more co-morbidities (mean Charlson index 3.15 vs 2.42, p = 0.03). The most frequent causative organisms were Staphylococci in both periods. In the second period, fewer patients had delayed diagnosis (39% vs 71%, p = 0.03), heart failure (20% vs 45%, p = 0.01), abscess (20% vs 39%, p = 0.04), culture-negative infective endocarditis (11% vs 29%, p = 0.03), and worsened renal function (21% vs 42%, p = 0.04). A significant reduction in in-hospital mortality (53% to 23%, p = 0.04) and 3-year mortality (60% to 28%, p = 0.001) was observed, driven by the increased number of patients successfully treated with medical therapy alone (44% vs 16%, p = 0.04). In conclusion, formalized, collaborative management led to significant improvement in PVE-related mortality.

Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial.

OBJECTIVES: This study sought to determine the risk versus benefit ratio of an early aggressive (EA) approach in elderly patients with non-ST-segment elevation acute coronary syndromes (NSTEACS). BACKGROUND: Elderly patients have been scarcely represented in trials comparing treatment strategies in NSTEACS. METHODS: A total of 313 patients ≥ 75 years of age (mean 82 years) with NSTEACS within 48 h from qualifying symptoms were randomly allocated to an EA strategy (coronary angiography and, when indicated, revascularization within 72 h) or an initially conservative (IC) strategy (angiography and revascularization only for recurrent ischemia). The primary endpoint was the composite of death, myocardial infarction, disabling stroke, and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year. RESULTS: During admission, 88% of the patients in the EA group underwent angiography (55% revascularization), compared with 29% (23% revascularization) in the IC group. The primary outcome occurred in 43 patients (27.9%) in the EA group and 55 (34.6%) in the IC group (hazard ratio [HR]: 0.80; 95% confidence interval [CI]: 0.53 to 1.19; p = 0.26). The rates of mortality (HR: 0.87; 95% CI: 0.49 to 1.56), myocardial infarction (HR: 0.67; 95% CI: 0.33 to 1.36), and repeat hospital stay (HR: 0.81; 95% CI: 0.45 to 1.46) did not differ between groups. The primary endpoint was significantly reduced in patients with elevated troponin on admission (HR: 0.43; 95% CI: 0.23 to 0.80), but not in those with normal troponin (HR: 1.67; 95% CI: 0.75 to 3.70; p for interaction = 0.03). CONCLUSIONS: The present study does not allow a definite conclusion about the benefit of an EA approach when applied systematically among elderly patients with NSTEACS. The finding of a significant interaction for the treatment effect according to troponin status at baseline should be confirmed in a larger size trial. (Italian Elderly ACS Study; NCT00510185).

High take-off of the right coronary artery with intramural course associated with the persistence of the left superior vena cava.

We describe the case of a coronary artery with an intra-aortic course (a rare coronary anomaly) associated with the persistence of the left superior vena cava. The first finding could represent an important surgical risk factor and should be recognized before cardiac surgery; the latter is not yet reported in the literature. A modified surgical technique is described.

Early mobilization after percutaneous catheterization and vascular closure with a novel device (Star-Close).

Arteriotomy closure devices used to obtain hemostasis at the end of cardiac catheterization represent a valid alternative to manual compression. We are the first to report on a series of 60 patients in whom a novel system was used, Star-Close, which obtains vessel closure by deployment of a clip at the puncture site. Subsequent early (2 hours) mobilization was obtained in 55 patients (92%). Unsuccessful device deployment occurred in 5 patients. We conclude that Star-Close is a novel arteriotomy closure device that, in selected patients, is safe and allows early deambulation after diagnostic cardiac catheterization.

Spontaneous coronary artery dissection mimicking aortic dissection.

A 51-year-old woman suffered rapidly irreversible cardiogenic shock with left hemiparesis. Transesophageal echocardiography, which represents an essential imaging tool in the emergency room, ruled out aortic dissection involving branch vessels but did not allow an in vivo diagnosis of spontaneous coronary dissection. The in vivo diagnosis of spontaneous coronary dissection is rather difficult because of the dramatic clinical presentation and selective coronary angiography requirement.

[A fistula between the coronary artery and peripheral branches of the pulmonary artery: a case report]. / Fistola tra circolo coronarico e polmonare periferico: un caso clinico.

Coronary artery fistulas are occasionally found in patients who undergo a coronary angiography and they may involve any epicardial coronary artery; the natural history in asymptomatic adult patients is unknown. Besides the invasive diagnosis with cardiac catheterization, it is possible to detect significant coronary fistulas also with different non-invasive methods, but they need the presence of shunt of enough size. Therapeutic options can be surgical or percutaneous. The demonstration of a communication between the coronary and distal tract of the pulmonary artery is difficult to explain with the embryogenic theory. We report the case of a patient with aortic stenosis and a shunt between the distal tract of the left pulmonary artery and the circumflex coronary artery.