Outcomes of valve-in-valve transcatheter aortic valve implantation with and without bioprosthetic valve fracture.

BACKGROUND: Bioprosthetic valve fracture (BVF) is a technique to reduce gradients in valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) procedures. The outcome of VIV-TAVI with BVF has not been compared with VIV-TAVI without BVF. AIMS: The aim of this study was to evaluate the outcome of VIV-TAVI with BVF compared to VIV-TAVI without BVF. METHODS: In total, 81 cases of BVF VIV-TAVI (BVF group) from 14 centres were compared to 79 cases of VIV-TAVI without BVF (control group). RESULTS: VARC-2-defined device success was 93% in the BVF group and 68.4% in the control group (p<0.001). The mean transvalvular gradient decreased from 37±13 mmHg to 10.8±5.9 mmHg (p<0.001) in the BVF group and from 35±16 mmHg to 15.8±6.8 mmHg (p<0.001) in the control group with a significantly higher final gradient in the control group (p<0.001). The transvalvular gradients did not change significantly over time. In-hospital major adverse events occurred in 3.7% in the BVF group and 7.6% in the control group (p=0.325). A linear mixed model identified BVF, self-expanding transcatheter heart valves (THVs) and other surgical aortic valve (SAV) types other than Mitroflow as predictors of lower transvalvular gradients. CONCLUSIONS: Compared to VIV-TAVI alone, VIV-TAVI with BVF resulted in a significantly lower transvalvular gradient acutely and at follow-up. Independent predictors of lower gradients were the use of self-expanding THVs and the treatment of SAVs other than Mitroflow, irrespective of BVF performance. BVF significantly reduced the gradient independently from transcatheter or surgical valve type.

Bioprosthetic valve fracture: Predictors of outcome and follow-up. Results from a multicenter study.

OBJECTIVES: To evaluate outcome and its predictors of bioprosthetic valve fracture (BVF) in patients undergoing valve-in-valve transcatheter aortic valve replacement (VIV-TAVR). BACKGROUND: BVF is feasible and reduces transvalvular gradients in VIV-TAVR-procedures, but follow-up-data and information on factors influencing the outcome are missing. METHODS: The 81 cases of BVF-VIV-TAVR were collected from 14 international centers. RESULTS: Predominantly transcatheter heart valve (THV) was implanted first, followed by BVF. VARC-2 defined device success was 93%, most failures were attributed to residual high gradients. Mean gradients decreased from 37 ± 13 mmHg to 10.8 ± 5.9 mmHg (p < 0.001). BVF reduced the gradient by 16 mmHg. During follow-up (FU, 281 ± 164 days) mean gradient remained stable (10.8 ± 5.9 mmHg at discharge, 12.4 ± 6.3 mmHg at FU, p = ns). In-hospital major adverse events occurred in 3.7%. Event-free survival at 276 ± 237.6 days was 95.4%. The linear mixed model identified balloon-expandable valves (BEV), Mitroflow surgical valve, stenotic surgical bioprostheses and balloon only 1 mm larger than the true internal diameter of the surgical valve as predictors for higher gradients. CONCLUSIONS: BVF is safe and can significantly reduce gradients, which remain stable at FU. BEV, Mitroflow surgical valve, stenotic bioprostheses and balloon larger than the true internal diameter of the surgical valve of only 1 mm are predictors for higher final gradients.

Does valve in valve TAVR carry a higher risk for thromboembolic events compared to native valve TAVR?

OBJECTIVE: To evaluate the risk for brain lesions in valve in valve (VIV)-transcatheter aortic valve replacement (TAVR) compared to native valve procedures (NV-TAVR). BACKGROUND: TAVR is associated with the risk of stroke and a high incidence of brain lesions in diffusion-weighted magnetic resonance imaging (DW-MRI). The risk in VIV procedures is unknown. METHODS: Patients were included, if they received a Sapien-3 or an Evolut-R valve for an NV-TAVR or VIV-TAVR and a DW-MRI within 3-5 days after the procedure. RESULTS: Two hundred nine patients had NV-TAVR and 41 patients had VIV-TAVR. The VIV group was significantly younger (mean 82.3 vs. 74.7 years old, p < .001) but had higher mean EuroSCORE II (4.8 vs. 7.8, p < .001). Predilatation was significantly more common with native valve (39% vs. 2%, p < .01), postdilatation rate was lower in VIV but without statistical significance (17% vs. 7%, p = .110). Combined in-hospital safety outcome was comparable [13(6.6%) vs. 5(12.2%), p = .205]. Any stroke was documented in four (0.5%) patients after native valve and in one (2.4%) after VIV-TAVR. New DW-MRI brain lesions were significantly more often found in patients with native valves [153(73.2%) vs. 21(51.2%), p = .005], mean number of new lesions was also higher with native valve (2.8 ± 3.2 vs. 1.0 ± 1.4, p < .001). Forward stepwise of logistic regression found age and post dilatation significant predictors of new MRI lesions. CONCLUSIONS: Compared to native valves, VIV procedures were associated with lower incidence and number of brain lesions according to DW-MRI; these were explained by lower patients' age and lower rate of postdilatation.

Pulsed electric field and mild heating for milk processing: a review on recent advances.

Pulsed electric field (PEF) treatment consists of exposing food to electrical fields between electrodes within a treatment chamber, which can improve the preservation of fresh-like products such as milk. Although several studies support the use of PEF technology to process milk at low temperature, these studies reported microbial reductions of around 3 log10 cycles and also indicated a limited impact of PEF on some endogenous and microbial enzymes. This scenario indicates that increasing the impact of PEF on both enzymes and microorganisms remains a major challenge for this technology in milk processing. More recently, combining PEF with mild heating (below pasteurization condition) has been explored as an alternative processing technology to enhance the safety and to preserve the quality of fresh milk and milk products. Mild heating with PEF enhanced the safety of milk and derived products (3 log10 -6 log10 cycles reduction on microbial load and drastic impact on the activity enzymes related to quality decay). Moreover, with this approach, there was minimal impact on enzymes of technological and safety relevance, proteins, milk fat globules, and nutrients (particularly for vitamins) and improvements in the shelf-life of milk and selected derived products were obtained. Finally, further experiments should consider the use of milk processed by PEF with mild heating on cheese-making. The combined approach of PEF with mild heating to process milk and derived products is very promising. The characteristics of current PEF systems (which is being used at an industrial level in several countries) and their use in the liquid food industry, particularly for milk and some milk products, could advance towards this strategy. © 2019 Society of Chemical Industry.

Performance of the Evolut-R 34 mm versus Sapien-3 29 mm in Transcatheter aortic valve replacement patients with larger annuli: Early outcome results of Evolut-R 34 mm as compared with Sapien-3 29 mm in patients with Annuli ≥26 mm.

BACKGROUND: Evolut-R 34 mm (received CE mark in January 2017) and Sapien-3 29 mm are the only options for transcatheter aortic valve replacement (TAVR) in patients with annulus ≥26 mm. We compared the short-term outcomes of these valves in these patients. METHODS: Data was collected prospectively from consecutive patients with severe aortic stenosis and annulus diameter larger than 26 mm treated by femoral approach TAVR. RESULTS: Between February 1, 2014 to August 19, 2017 Sapien-3 29 mm was implanted in 55 and Evolut-R 34 mm in 37 consecutive patients. Device success rate was 98.2% and 97.3% (P = 1.0) and the composite peri-procedural complication rate was 7.3% and 2.7% (P = .645) in Sapin-3 29 mm and Evolut-R 34 mm, respectively. Composite endpoint of early safety in-hospital did not differ significantly [5(9.2%) vs 3(8.1%), P = 1.00], respectively. Prosthetic valve Gradients were significantly lower with Evolut-R 34 mm [maximal (18.0 ± 5.8 vs 11.2 ± 4.8 mmHg, P < .001) and mean (10.0 ± 3.3 vs 6.3 ± 2.7 mmHg, P < .001)]. Pacemaker implantation rate was high in both groups, and numerically but not statistically significant higher with Evolut-R [10/50 (20.0%) vs 8/28 (28.6%), P = .389]. CONCLUSIONS: As compared to Sapien-3 29 mm the Evolut-R 34 mm is a real alternative for TAVR in patients with a large annulus with a comparable peri-procedural complication rate, better hemodynamic results but a trend for higher pacemaker rate.

A Photoredox-Induced Stereoselective Dearomative Radical (4+2)-Cyclization/1,4-Addition Cascade for the Synthesis of Highly Functionalized Hexahydro-1H-carbazoles.

A stereoselective synthesis of functionalized hexahydrocarbazoles was developed based on an unprecedented photoredox-induced dearomative radical (4+2)-cyclization/1,4-addition cascade between 3-(2-iodoethyl)indoles and acceptor-substituted alkenes. The title reaction simultaneously generates three C-C bonds and one C-H bond, along with three contiguous stereogenic centers. The hexahydro-1H-carbazole products are highly valuable intermediates for the synthesis of novel antibiotics, as well as unnatural ring homologues of polycyclic indoline alkaloids.

Tricuspid regurgitation is a predictor of mortality after percutaneous mitral valve edge-to-edge repair.

AIMS: The aim of this study was to determine the impact of tricuspid regurgitation (TR) on mortality after edge-to-edge percutaneous mitral valve repair (PMVR), and also to analyse whether there is a difference in outcome between patients with improvement of TR after PMVR compared to patients without. METHODS AND RESULTS: Out of 197 consecutive patients who underwent PMVR, 139 patients with available follow-up (mean 428±386 days) were included in the study. Concomitant moderate/severe TR was present in 58.3% of patients. Kaplan-Meier analysis showed significantly reduced overall survival for patients with moderate/severe TR, compared to patients with none/mild TR (p=0.003). Cox multivariate regression analysis revealed severe TR at baseline as the strongest independent predictor of mortality (HR 4.367, p=0.003). An improvement of the baseline moderate/severe TR was observed in 45.5% of patients at 30-day follow-up. Patients with no improvement of TR after PMVR had a higher midterm mortality compared to patients in whom TR improved (40.5% versus 11.4%, p=0.005). CONCLUSIONS: More than half of patients undergoing PMVR have concomitant moderate/severe TR, which is associated with a worse outcome. Among predictors of mortality after edge-to-edge PMVR, severe TR at baseline is the most important. Patients with no improvement of TR at 30 days after PMVR have a significantly higher mortality at follow-up.

Increased Risk of Cerebral Embolization After Implantation of a Balloon-Expandable Aortic Valve Without Prior Balloon Valvuloplasty.

OBJECTIVES: The purpose of this study was to analyze the effect of transcatheter aortic valve replacement (TAVR) without versus with prior balloon aortic valvuloplasty (BAV) on the risk of cerebral embolization in patients who receive a balloon-expandable valve. BACKGROUND: Avoiding BAV prior to TAVR may simplify the procedure, but the risk of cerebral embolization is currently unknown. METHODS: A total of 87 consecutive high surgical-risk patients with no contraindications for diffusion-weighted magnetic resonance imaging (DW-MRI) were enrolled. Thirty-two patients received a balloon-expandable aortic valve with and 55 patients without BAV. The incidence, number, and volume of new ischemic lesions in DW-MRI performed 2 to 7 days after TAVI were evaluated. RESULTS: Mean age (83.8 ± 5.2 years vs. 82.9 ± 6.8 years) and sex (43.8% vs. 52.7% male) of the patients with versus without BAV, respectively, as well as other demographic and hemodynamic data were not significantly different between both groups. The procedural success rate was 93.5% with and 98.2% without BAV, and procedure duration and contrast volume were significantly lower without BAV. The incidence of new cerebral ischemic lesions in the total cohort was 66.7%. Compared with patients with BAV, those without BAV had a significantly higher total volume of cerebral ischemic lesions (235.4 ± 331.4 mm(3) vs. 89.5 ± 128.2 mm(3); p = 0.01). CONCLUSIONS: The implantation of a balloon-expandable aortic valve without versus with prior BAV, although performed with a shorter procedure time and lower contrast volume, is associated with a significantly higher volume of cerebral ischemic lesions.