Short-Term Clinical Outcomes of Transcatheter Aortic Valve Replacement in a Developing Country.

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) is an effective alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis in all surgical risk groups. Reports of clinical outcomes post-TAVR in developing countries are scarce. We aimed to address the clinical outcomes and safety profile of TAVR in a developing country. METHODS: We conducted a single-center, retrospective study on patients undergoing TAVR at the American University of Beirut Medical Center (AUBMC) from January 2016 to April 2023. We included a total of 399 patients. Our primary endpoint was to assess the rate of TAVR in-hospital and 30-day mortality, neurologic events, and new permanent pacemaker implantation (PPI) in patients, stratified by the Society of Thoracic Surgeons (STS) risk of mortality score. RESULTS: Survival rates were 98.7% (394) at discharge vs. 97.5% (389) at 30 days post-procedure. The technical success rate was 95% (379) at the end of the procedure. Device success and early safety rates were 93.5% (373) and 83% (331), respectively at 30 days post-procedure. The all-cause mortality rate increased from 1.3% (5) at discharge to 2.5% (10) at 30-day intervals. The rate of ischemic stroke was 1.3% (five) at discharge and increased to 2% (eight) at 30 days post-procedure. PPI was needed in 5.8% (23) of patients at discharge with an increase to 7% (28) at one-month interval. Overall, the rates of TAVR outcomes among the three risk groups were comparable including neurologic events, valve-related complications, bleeding problems, vascular and access-related complications, and myocardial infarction. CONCLUSION: This study at AUBMC highlights the successful implementation of the TAVR program in a developing country, showcasing its efficacy and safety within 30 days post-operation, despite challenges such as financial constraints and limited access to specialized training. Larger cohorts and longer follow-up periods are needed to accurately represent clinical outcomes in developing countries.

Photo-switchable Collectors for the Flotation of Lithium Aluminate for the Recycling of the Critical Raw Material Lithium.

Flotation of the mineral lithium aluminate by application of the natural product punicine from Punica granatum and some derivatives as collectors is examined. Punicines, 1-(2',5'-dihydroxyphenyl)-pyridinium compounds, are switchable molecules whose properties can be changed reversibly. They exist as cations, neutral mesomeric betaines, anions, and dianions depending on the pH. In light, they form radicals. Five punicine derivatives were prepared which possess ß-methyl, ß-chlorine, γ-tert.-butyl, and γ-acetyl groups attached to the pyridinium ring, and a pyrogallol derivative. On the other hand, LiAlO2 reacts with water to give species such as LiAl2(OH)7 on its surface. Flotations were performed applying the punicines in daylight (3000 lux), in darkness (<40 lux) and under UV-irradiation (4500 lux, 390-400 nm). The pH of the suspension, the collector's concentration, the conditioning time as well as the flotation time were varied. The recovery rates strongly depend on these parameters. For example, the recovery rate of lithium aluminate was increased by 116 % on changing the lighting condition from daylight to darkness, when the pyrogallol derivative of punicine was applied. UV, FTIR, TGA and zeta potential measurements as well as DFT calculations were performed in order to gain insight into the chemistry of punicines on the surface of LiAlO2 and LiAl2(OH)7 in water which influence the flotation's results.

Lithium aluminate flotation by pH- and light-switchable collectors based on the natural product punicine.

Derivatives of the natural product punicine [1-(2',5'-dihydroxyphenyl)pyridinium chloride] were developed as switchable collectors for the flotation of lithium-containing engineered artifical minerals (EnAMs). These EnAMs are e.g. formed by pyrometallurgical processing of end-of-life lithium-ion batteries. Depending on the pH value and the lighting conditions, punicines exist in water as cations, two different electrostatically neutral mesomeric betaines, anionic tripoles, radical cations or radical anions. The radical species form by photochemically induced disproportionation reactions. We prepared punicine derivatives introducing alkyl chains in the pyridinium moiety (4-methyl, 4-ethyl, 4-octyl and 4-undecanyl) to install hydrophobic groups and examined the recovery rates of the flotation of lithium aluminate (LiAlO2). We varied the lighting conditions (darkness, daylight, LED irradiation at λ = 390-400 nm) and the pH value, the collector's and frother's concentration, and the flotation time. With our collectors, recovery rates of lithium aluminate up to 90% were accomplished when the flotation was conducted in Hallimond tubes exposed to daylight at pH 11 in water.

Meta-Analysis of Randomized Trials: Efficacy and Safety of Colchicine for Secondary Prevention of Cardiovascular Disease.

Background: Colchicine has shown potential cardioprotective effects owing to its broad anti-inflammatory properties. We performed a meta-analysis to assess its safety and efficacy in secondary prevention in patients with established coronary artery disease (CAD). Methods: We searched Ovid Healthstar, MEDLINE, and Embase (inception to May 2022) for randomized controlled trials (RCTs) evaluating the cardiovascular effects of colchicine compared with placebo or usual care in patients with CAD. Study-level data on efficacy and safety outcomes were pooled using the Peto method. The primary outcome was the composite of cardiovascular (CV) death, myocardial infarction (MI), or stroke. Results: A total of 8 RCTs were included with a follow-up duration of ≥1 month, comprising a total of 12,151 patients. Compared with placebo or usual care, colchicine was associated with a significant risk reduction in the primary outcome (odds ratio (OR) 0.70, 95% CI 0.60 to 0.83, P < 0.0001; I2 = 52%). Risks of MI (OR 0.75, 95% CI 0.62 to 0.91, P = 0.003; I2 = 33%), stroke (OR 0.47, 95% CI 0.30 to 0.74, P = 0.001; I2 = 0%), and unplanned coronary revascularization (OR 0.67, 95% CI 0.55 to 0.82, P = 0.0001; I2 = 58%) were all reduced in the colchicine group. Rates of CV and all-cause mortality did not differ between the two groups, but there was an increase in noncardiac deaths with colchicine (OR 1.54, 95% CI 1.10 to 2.15, P = 0.01; I2 = 51%). The occurrence of all other adverse events was similar between the two groups, including GI reactions (OR 1.06, 95% CI 0.94 to 1.20, P = 0.35; I2 = 42%) and infections (OR 1.04, 95% CI 0.84 to 1.28, P = 0.74; I2 = 53%). Conclusions: Colchicine therapy may reduce the risk of future cardiovascular events in patients with established CAD; however, there remains a concern about non-CV mortality. Further trials are underway that will shed light on non-CV mortality and colchicine NCT03048825, and NCT02898610.

Percutaneous Coronary Intervention with Procedural Unfractionated Heparin without Activated Clotting Time Guidance: A Unique Opportunity to Assess Thrombotic and Bleeding Events.

Background: Rates of major bleeding and intraprocedural thrombotic events (IPTE) in the setting of percutaneous coronary intervention (PCI) using weight-adjusted unfractionated heparin (UFH) without activated clotting time (ACT) monitoring are not known. Methods: We reviewed 2,748 consecutive patients who underwent coronary angiography at our tertiary care university hospital between January 2017 and December 2020. All patients who underwent PCI with weight-adjusted UFH without ACT guidance were considered for further analysis. Major bleeding complications occurring within 48 hours of PCI were collected from patients' medical records. IPTE were collected independently by two interventional cardiologists after review of coronary angiograms. Results: There were 718 patients included in the analysis (65.4 ± 12.2 years old; 81.3% male). In total, 45 patients (7.8%) experienced a major bleed or IPTE. The most common IPTE were slow/no reflow (1.5%) and coronary artery dissection with decreased flow (1.1%). Other IPTE occurred in <1% of cases. Major bleeding occurred in 11 patients (1.5%), of whom 8 required blood transfusion and 3 required vascular intervention. Bleeding complications were more common with femoral compared with radial access (6.6% vs. 0.2%, P < 0.001). Conclusion: Weight-adjusted UFH use during PCI without ACT monitoring was related to low rates of major bleeding or IPTE.

The Role of CT-Guided Optimal Fluoroscopic Viewing Angle to Guide Right Endomyocardial Biopsy.

We report the case of a 64-year-old man with a history of chemotherapy-induced cardiomyopathy requiring heart transplant in 2022 who underwent successful endomyocardial biopsy using patient-specific computed tomographic fluoroscopic projections. (Level of Difficulty: Beginner.).

The Role of CT-Guided Optimal Fluoroscopic Viewing Angle for Coronary Engagement After TAVR.

We report the case of an 89-year-old woman with prior transcatheter aortic valve replacement who underwent successful left coronary artery engagement and left circumflex percutaneous coronary intervention using patient-specific computed tomography fluoroscopic projections. (Level of Difficulty: Advanced.).

Outcomes in Patients Undergoing Surgical Aortic Valve Replacement With vs Without a Preoperative Heart Team Assessment.

Background: This study sought to compare characteristics and outcomes of patients who underwent surgical aortic valve replacement (SAVR) after being referred to a heart team (HT), to those of patients referred directly for SAVR. Methods: An analysis of patients who underwent SAVR from 2015 to 2020 was conducted. Patients were categorized into 3 groups, as follows: (i) H-HT: patients referred to the HT from 2015 to 2017 (historical cohort); (ii) C-HT: patients referred to the HT from 2018 to 2020 (contemporary cohort); and (iii) No-HT: patients referred directly to cardiac surgery from 2018 to 2020. Two subanalyses were performed: H-HT vs C-HT patients, and C-HT vs No-HT patients. The primary outcome was a composite of in-hospital mortality, prolonged intubation, reoperation, sternal wound infection, and stroke. Results: This study consisted of 288 patients, distributed as follows: H-HT (n = 45); C-HT (n = 51); and No-HT (n = 192). The mean ages of H-HT, C-HT, and No-HT patients was 76.3 ± 6.9 years, 73.3 ± 7.6 years, and 69.6 ± 9.7 years, respectively (P = 0.0001). H-HT, C-HT, and No-HT patients had average Society of Thoracic Surgeons scores of 4.8 ± 2.2, 3.2 ± 1.6, and 4.2 ± 2 (P = 0.002), respectively. The composite outcome rate was more than 5 times higher among H-HT patients compared to that among the C-HT patients (20.0 vs 3.9%, P = 0.02), and was numerically higher in No-HT compared to C-HT patients (13.0 vs 3.9%, P = 0.07). Conclusions: Referral to an HT appears to be primarily driven by higher chronological age rather than overall risk profile. Patients assessed by the HT prior to undergoing SAVR have a low incidence of complications, comparable to that among patients referred directly to cardiac surgery.

Contexte: Cette étude visait à comparer les caractéristiques et le devenir de patients ayant subi une chirurgie de remplacement valvulaire aortique après avoir été orientés vers une équipe de cardiologie (EC) à ceux de patients orientés directement en chirurgie cardiaque pour une chirurgie de remplacement valvulaire aortique. Méthodologie: Une analyse portant sur les patients ayant subi une chirurgie de remplacement valvulaire aortique de 2015 à 2020 a été effectuée. Les patients ont été divisés en trois groupes, à savoir : i) CH-POEC : patients orientés vers une EC de 2015 à 2017 (cohorte historique); ii) CC-POEC : patients orientés vers une EC de 2018 à 2020 (cohorte contemporaine); iii) PODC : patients orientés directement en chirurgie cardiaque de 2018 à 2020. Deux sous-analyses ont été effectuées : CH-POEC vs CC-POEC, et CC-POEC vs PODC. Le paramètre d'évaluation principal était composite. Il comprenait la mortalité hospitalière, l'intubation prolongée, la réopération, l'infection de la plaie sternale et l'accident vasculaire cérébral. Résultats: L'étude regroupait 288 patients, répartis comme suit : CH-POEC, n = 45; CC-POEC, n = 51; PODC, n = 192. L'âge moyen dans les groupes CH-POEC, CC-POEC et PODC était respectivement de 76,3 ± 6,9 ans, 73,3 ± 7,6 ans et 69,6 ± 9,7 ans (P = 0,0001). Les groupes CH-POEC, CC-POEC et PODC présentaient des indices STS (Society of Thoracic Surgeons) moyens de 4,8 ± 2,2, 3,2 ± 1,6 et 4,2 ± 2 (P = 0,002), respectivement. Le taux composite d'événements au sein du groupe CH-POEC était plus de cinq fois supérieur à celui noté dans le groupe CC-POEC (20,0 vs 3,9 %, P = 0,02). Il était aussi plus élevé au sein du groupe PODC comparativement au groupe CC-POEC (13,0 vs 3,9 %, P = 0,07). Conclusions: Le principal motif d'orientation vers une EC semble être un âge chronologique avancé plutôt que le profil de risque global. Chez les patients qui sont évalués par une EC avant de subir une chirurgie de remplacement valvulaire aortique, l'incidence de complications est faible et comparable à celle observée chez les patients orientés directement en chirurgie cardiaque.

Aortic Annulus S-Curve: Implications for Transcatheter Aortic Valve Replacement and Related Procedures, Part 1.

Most transcatheter aortic valve replacement-related procedures (eg, transcatheter aortic valve replacement implantation depth, commissural alignment, coronary access, bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction, paravalvular leak closure) require an optimal fluoroscopic viewing angle located somewhere along the aortic annulus S-curve. Chamber views, coronary cusp and coronary anatomy, can be understood along the aortic annulus S-curve. A better understanding of the optimal fluoroscopic viewing angles along the S-curve may translate into increased operator confidence and improved safety and efficacy while reducing procedural time, radiation dose, contrast volume, and complication rates.

Post trans-catheter aortic valve replacement shock: Back to the basics.

Transcatheter aortic valve replacement (TAVR) is indicated for the treatment of patients with severe aortic stenosis (AS) at low, intermediate, and high risk. Immediate complications post-TAVR that lead to hemodynamic compromise include: retroperitoneal bleeding, aortic dissection or rupture, pericardial tamponade, coronary ostial obstruction, acute severe central or paravalvular regurgitation, heart block, and suicide left ventricle. The presence of significant paravalvular leak (PVL) after TAVR is now an uncommon complication with newer generation devices. We present a case of an 82-year-old frail female patient who presented to our clinic with dyspnea upon minimal exertion and orthopnea. She was found to have severe AS that was treated with TAVR. The procedure was complicated by hemodynamic compromise due to severe PVL and left ventricular outflow tract (LVOT) obstruction which was underestimated by transthoracic echocardiography. The PVL was eventually treated with a vascular plug device and the LVOT obstruction was treated with alcohol septal ablation. This case highlights the vital role of early and aggressive work up in unstable patients post-TAVR and the importance of transesophageal echocardiography in patients with unexplained hypotension post-TAVR to unmask the severe PVL and dynamic LVOT obstruction. .

First Report of Supra-Annular Atrially Placed Bioprosthetic Mitral Valve Leak Closure Through Percutaneous Approach.

An 81-year-old man underwent mitral valve replacement in 2015 for severe calcific mitral stenosis with multiple subsequent hospitalizations for pulmonary edema. TEE in 2019 revealed severe paravalvular regurgitation. This is the first reported case of suprannular atrially placed mitral paravalvular leak closure.

Immediate and long-term results of percutaneous mitral commissurotomy: up to 15 years.

PURPOSE: To evaluate immediate and long-term clinical results of percutaneous mitral commissurotomy (PMC) in patients with severe mitral stenosis. METHODS: In a retrospective study, data were included from 317 patients over 18 years of age (mean age 45) who had been treated for mitral stenosis between January 1993 and March 2015 with PMC using the Inoue balloon technique. Immediate results: Valvular function improved as evidenced by an increase in mitral valve area from 1.01 ± 0.24 cm2 to 2 ± 0.31 cm2 (P < 0.001) and a decrease in mean mitral gradient from 13.64 ± 6.03 mm Hg to 5.40 ± 2.49 mm Hg. Long-term follow-up: At 5-15 years (mean 10.2 years, Inter-quartile range 8.25), 105 (33.1%) of the 317 patients were available for follow-up, 95 living patients and 10 deceased. Of the deceased, average time from PMC to death was 8 years. Results were strongly significant showing that age at the time of PMC and surface area before the procedure were the best predictors of survival at 15 years follow-up, showing significance values of P = 0.022 and P = 0.001, respectively. CONCLUSIONS: PMC using the Inoue balloon technique improves morbidity and long-term mortality rates in patients with severe mitral stenosis. Lower Wilkins score and NYHA class at baseline were not found to be significant predictors of mortality in older patients (age > 45). Overall, 65 (61.9%) had survived at 5-15 years follow-up without further cardiac intervention.

Out-of-hospital cardiopulmonary resuscitation: a position statement of the Lebanese Society of Cardiology and the Lebanese Society of Emergency Medicine.

Out of hospital cardiac arrest (OHCA) is a leading cause of death worldwide. Early cardiopulmonary resuscitation (CPR) and early defibrillation are key to improving outcomes of patients with OHCA including return of spontaneous circulation (ROSC) and survival to hospital discharge with good neurologic outcomes. Lebanon like other developing countries, suffers from absence of organized prehospital cardiac arrest care bundle and from absence of a legal framework for community involvement in cardiac arrest care. Scientific societies, involved non-governmental organizations (NGOs) and local governmental stakeholders organized a national meeting to launch a strategy aiming at improving OHCA outcomes in Lebanon. This article represents a position statement of the Lebanese Society of Cardiology and the Lebanese Society of Emergency Medicine summarizing the strategy to improve out-of-hospital CPR. Participating stakeholders developed and submitted a law proposal of a "Good Samaritan Law" to the Lebanese parliament. Several of activities were also launched aiming at establishing public access defibrillation programs and at training bystanders in different areas in Lebanon to perform bystander CPR and use automated external defibrillators (AEDs). Additional recommendations were proposed to local emergency medical system (EMS) agencies to improve prehospital care and introduce medical direction to prehospital activities.

Acute aortoiliac occlusive disease during percutaneous transluminal angioplasty in the setting of ST-elevation myocardial infarction: a case report.

BACKGROUND: Aortoiliac occlusive disease, which is also referred to as Leriche syndrome, is a chronic atherosclerotic occlusive disease that occurs at the level of the aortic bifurcation. It is often thought to present with a triad of clinical symptoms: (1) intermittent lower extremity vascular claudication, (2) impotence, and (3) weak/absent femoral pulses. CASE PRESENTATION: We report a case of a 47-year-old Caucasian woman who presented with an acute inferior ST-elevation myocardial infarction. During percutaneous transluminal angioplasty, our patient suddenly developed severe bilateral lower extremity pain, absent femoral pulses, and cool extremities. Distal aortogram revealed 95% stenosis with an apple core-like lesion in the mid-abdominal aorta. Stent placement resulted in improved blood flow to the distal aortic segment and resolution of symptoms. CONCLUSIONS: The presence of significant peripheral vascular disease, significant cardiac risk factors, and/or difficulty accessing the femoral artery should caution a transfemoral approach during percutaneous transluminal angiography. This approach may precipitate aortoiliac occlusion and/or thromboembolism to the lower extremities. We encourage interventional cardiologists to (1) take extra caution when manipulating the wire and catheter and (2) strongly consider using a transradial approach in such patients.