Effective Orifice Area of Balloon-Expandable and Self-Expandable Transcatheter Aortic Valve Prostheses: An Echo Doppler Comparative Study.

Published data on the size-specific effective orifice area (EOA) of transcatheter heart valves (THVs) remain scarce. Here, we sought to investigate the intra-individual changes in EOA and mean transvalvular aortic gradient (MG) of the Sapien 3 (S3), CoreValve (CV), and Evolut R (EVR) prostheses both at short-term and at 1-year follow-up. The study sample consisted of 260 consecutive patients with severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI). EOAs and MGs were measured with Doppler echocardiography for the following prostheses: S3 23 mm (n = 74; 28.5%), S3 26 mm (n = 67; 25.8%), S3 29 mm (n = 20; 7.7%), CV 23 mm (n = 2; 0.8%), CV 26 mm (n = 15; 5.8%), CV 29 mm (n = 24; 9.2%), CV 31 mm (n = 9; 3.5%), EVR 26 mm (n = 22; 8.5%), and EVR 29 mm (n = 27; 10.4%). Values were obtained at discharge, 1 month, 6 months, and 1 year from implantation. At discharge, EOAs were larger and MGs lower for larger-size prostheses, regardless of being balloon-expandable or self-expandable. In patients with small aortic annulus size, the hemodynamic performances of CV and EVR prostheses were superior to those of S3. However, we did not observe significant differences in terms of all-cause mortality according to THV type or size. Both balloon-expandable and self-expandable new-generation THVs show excellent hemodynamic performances without evidence of very early valve degeneration.

Outcome associated with prescription of cardiac rehabilitation according to predicted risk after acute myocardial infarction: Insights from the FAST-MI registries.

BACKGROUND: Cardiac rehabilitation is strongly recommended in patients after acute myocardial infarction. AIMS: To assess cardiac rehabilitation prescription after acute myocardial infarction according to predicted risk, and its association with 1-year mortality, using the FAST-MI registries. METHODS: We used data from three 1-month French nationwide registries, conducted 5 years apart from 2005 to 2015, including 13130 patients with acute myocardial infarction admitted to coronary or intensive care units. Atherothrombotic risk stratification was performed using the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P). Patients were classified into three categories: Group 1 (low risk; no or one risk indicator; score of 0 or 1); Group 2 (intermediate risk; two risk indicators; score of 2); and Group 3 (high risk; at least three risk indicators; score of≥3). RESULTS: Among the 12291 patients, cardiac rehabilitation prescription was 43.6% (49.9% in Group 1; 43.0% in Group 2; 35.2% in Group 3). Using Cox multivariable analysis, cardiac rehabilitation prescription was associated with lower mortality at 1 year in the overall population (3.8% vs. 8.2%; hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.61-0.85; P<0.001). Cardiac rehabilitation was associated with improved 1-year mortality, with homogeneous relative risk reductions in low- and intermediate-risk categories (HR 0.70, 95% CI 0.51-0.94) compared with high-risk patients (HR 0.72, 95% CI 0.59-0.88). In absolute terms, however, mortality decrease associated with cardiac rehabilitation was positively correlated with risk level (Group 1, 0.9% vs. 2.4%; Group 2, 3.0% vs. 4.2%; Group 3, 10.5% vs. 17.3%). CONCLUSION: Cardiac rehabilitation prescription was inversely correlated with patient risk. A positive association between cardiac rehabilitation and 1-year survival after acute myocardial infarction was present whatever the risk level, but the greatest mortality reduction was observed in high-risk patients.

Microvascular obstruction assessed by 3-tesla magnetic resonance imaging in acute myocardial infarction is correlated with plasma troponin I levels.

BACKGROUND: Microvascular obstruction (MVO) at the acute phase of myocardial infarction (MI) is associated with poor prognosis. We aimed to evaluate the correlation between plasma cardiac troponin I (cTnI) at the acute phase of MI and extent of no-reflow, as assessed by 3-T cardiac magnetic resonance imaging (MRI). Secondly, we defined a cut-off value for cTnI predictive of no-reflow. METHODS: 51 consecutive patients with no previous history of cardiovascular disease, presenting ST elevation MI within <12 h. Infarct size and extent of no-reflow were evaluated by 3-T MRI at day 5. Extent of no-reflow at 15 minutes (MVO) was correlated with cTnI at admission, 6, 12, 24, 48 and 72 hours. At 6 months, MRI was performed to evaluate the impact of MVO on LV remodeling. RESULTS: MVO was diagnosed in 29 patients (57%). Extent of MVO was significantly correlated to peak troponin, cTnI (except admission values) and area under the curve. Using Receiver-operating characteristic (ROC) curve analysis, a cut-off cTnI value >89 ng/mL at 12 h seemed to best predict presence of early MVO (sensitivity 63%, specificity 88%). At 6 months, MVO was associated with left ventricular (LV) remodeling, resulting in higher LV volumes. CONCLUSION: There is a relationship between cTnI at the acute phase of AMI and extent of MVO as assessed by 3-T cardiac MRI. A cut-off cTnI value of 89 ng/mL at 12 h seems to best predict presence of MVO, which contributes to LV remodeling.

Invasive assessment of doubtful aortic stenosis by measuring simultaneous transaortic gradient with a pressure wire.

Two-dimensional transthoracic echocardiography (2D-TTE) is the reference technique for evaluating aortic stenosis (AS) but may be unreliable in some cases. We aimed to assess whether the use of a pressure wire to measure simultaneous transaortic gradient and aortic valve area (AVA) could be helpful in patients in whom initial noninvasive evaluations were considered doubtful for AS. Fifty-seven patients (mean age 76 years; 39 men) underwent cardiac catheterization with single arterial access for assessment of AVA with the Gorlin and Gorlin formula. Transaortic pressure was obtained by 2 invasive methods: (1) conventional pullback method (PM) from the left ventricle toward the aorta and (2) simultaneous method (SM) with transaortic pressure simultaneously recorded with a 0.014-inch pressure wire introduced into the left ventricle and with a diagnostic catheter placed in the ascending aorta. Reasons for inaccurate assessment by 2D-TTE were low flow states (88%) and/or atrial fibrillation (79%). Agreement for severe AS defined by AVA <0.6 cm²/m² between SM and 2D-TTE and between SM and PM was fair, with kappa coefficients of 0.38 (95% confidence interval [CI] 0.14-0.75) and 0.36 (95% CI 0.22-0.7) respectively; agreement was poor between 2D-TTE and PM (kappa: 0.23; 95% CI 0.002-0.36). SM led to a reclassification of the severity of AS in 9 patients (15.8%) compared with 2D-TTE and in 11 patients (19.3%) compared with PM. In conclusion, invasive evaluation of doubtful AS by measuring simultaneous transaortic gradient using a pressure wire may provide an attractive method that can lead to a change in therapeutic strategy in a substantial proportion of patients.

Effect of macroscopic-positive thrombus retrieval during primary percutaneous coronary intervention with thrombus aspiration on myocardial infarct size and microvascular obstruction.

Adjunctive thrombus aspiration (TA) during primary percutaneous coronary intervention improves myocardial perfusion and survival; however, the effect of effective thrombus retrieval remains unclear. We evaluated whether macroscopic-positive TA in patients with ST-segment elevation myocardial infarction would reduce the infarct size (IS) and microvascular obstruction (MVO), as assessed by contrast-enhanced magnetic resonance imaging. A total of 88 patients with ST-segment elevation myocardial infarction were prospectively recruited and assigned to the TA-positive group (n = 38) or TA-negative group (n = 50) according to whether macroscopic aspirate thrombus was visible to the naked eye. The primary end points were the extent of early and late MVO as assessed by contrast-enhanced magnetic resonance imaging performed during in-hospital stay and IS evaluated in the acute phase and at 6 months of follow-up. The incidence of early and late MVO and IS in the acute phase was lower in the TA-positive group than in the TA-negative group (early MVO 3.8 ± 1.1% vs 7.6 ± 2.1%, respectively, p = 0.003; late MVO 2.1 ± 0.9% vs 5.4 ± 2.9%, p = 0.006; and IS 14.9 ± 8.7% vs 28.2 ± 15.8%, p = 0.004). At the 6-month contrast-enhanced magnetic resonance imaging study, the final IS was significantly lower in the TA-positive group (12.0 ± 8.3% vs 22.3 ± 14.3%, respectively) than in the TA-negative group (p = 0.002). After multivariate adjustment, macroscopic-positive TA represented an independent predictor of final IS (odds ratio 0.34, 95% confidence interval 0.03 to 0.71, p = 0.01). In conclusion, effective macroscopic thrombus retrieval before stenting during percutaneous coronary intervention for ST-segment elevation myocardial infarction is associated with an improvement in myocardial reperfusion, as documented by a clear reduction in the MVO extent and IS.

Recording of quality indicators in the management of acute coronary syndromes: predictors of reperfusion times.

BACKGROUND: There is wide variation in recording of reperfusion times in the management of ST segment elevation acute coronary syndromes (ACS). We investigated factors that could predict time to reperfusion. METHODS: Single-centre, retrospective study of all consecutive patients admitted for primary PCI from June 2009 to October 2010. Door-to-artery (D2A) and Door-to-balloon (D2B) times were calculated from times noted by cathlab. nurses and compared with times from digital recordings of PCI procedures. Predictors of time to reperfusion were identified by logistic regression. RESULTS: 300 patients were included. Median (interquartile range) D2B time recorded by cathlab. nurses (D2B-CN) was 35.5 (24; 52) minutes, 32 (20; 51) min from PCI recordings (D2B-PCI). Average difference between D2B-CN and D2B-PCI was 6.2 min (P < 0.0001). Concordance of percent patients with a D2B time < 90 and < 45 min was mediocre, kappa coefficients 0.44 (95% CI: 0.10-0.79) and 0.68 (95% CI: 0.57-0.80) respectively. By multivariate analysis, older patients had longest D2A times (P = 0.04); patients with longest D2A and D2B times more frequently had elevated creatinine (P = 0.002 (D2A), P = 0.0003 (D2B). Organizational aspects did not influence reperfusion times. CONCLUSION: Data regarding reperfusion times are unreliable when recorded by nurses. Age and creatinine levels are significantly associated with reperfusion times, whereas organizational aspects are not.