Prevalence and prognostic impact of apical sparing contractility pattern in patients with aortic stenosis referred for transcatheter aortic valve implantation.

INTRODUCTION: Prolonged afterload increase in aortic stenosis (AS) may alter left ventricular (LV) contractility, irrespective of LV ejection fraction (LVEF). The prevalence and morbimortality associated with the apical sparing strain pattern (ASP), a typical finding of cardiac amyloidosis (CA), are not fully understood in patients with AS. We assessed the prevalence of the ASP in patients with severe AS and its clinical impact after transcatheter aortic valve implantation (TAVI). METHODS: Eighty-nine consecutive patients with severe AS and LV hypertrophy referred for TAVI were included. Baseline clinical and echocardiographic data were assessed, including the ASP in bull's eye plots (ASPB), relative apical longitudinal strain (RALS) and EF to global longitudinal strain (EF/GLS) ratio. We analysed all-cause mortality; a composite of all-cause mortality, stroke, and heart failure hospitalizations; and the rate of pacemaker implantation, after TAVI. RESULTS: Mean age was 82 ± 6 years and mean LVEF was 57 ± 10%. ASPB and RALS >1 were present in 43.8% and 24.7% of patients, respectively. Over a median follow-up of 13 months (IQR 6-32), ASPB was associated with higher rates of all-cause mortality (log-rank P=0.001) and was an independent predictor of all-cause mortality in multivariate analysis. Combination of the ASPB and GLS or EF/GLS ratio improved the risk stratification. Patients with RALS >1 were more likely to have new BBB and an indication for pacemaker implantation (P=0.048). CONCLUSION: The ASP, as assessed by the ASPB and RALS, was frequent in patients with AS regardless of the diagnosis of CA. The ASPB may refine risk stratification in patients referred for TAVI.

Long-Term Follow Up After Successful Percutaneous Balloon Mitral Valvuloplasty.

BACKGROUND: Percutaneous balloon mitral valvuloplasty (PMV) is the cornerstone of rheumatic mitral stenosis treatment in suitable patients. Previous studies have reported low rates of technical failure and few major complications, with good long-term results after successful PMV. The study aim was to assess the very long-term outcome in patients after PMV performed at a single tertiary center. METHODS: Between 1991 and 2010, a total of 213 consecutive patients underwent PMV at the authors' center. The criteria used to define successful procedure were post-procedural mitral valve area ≥1.5 cm2 and mitral regurgitation less than grade III, without in-hospital major cardiac or cerebrovascular events. The primary endpoint evaluated during the follow up period was the occurrence of cardiovascular death and need for mitral reintervention (percutaneous or surgical). Kaplan-Meier curves were generated to determine event rates, and predictors of major cardiac events in patients with successful PMV were determined using Cox regression analysis. RESULTS: A total of 190 patients (89%) underwent a successful PMV; 88% of these are currently being followed up at the authors' center. During a mean follow up of 11.2 ± 7.3 years, at least one major adverse cardiac event occurred in 25.1% of patients (6.6% all-cause death, 6.6% repeated PMV, 21% required mitral valve surgery). Cumulative event-free survival at 20 years was 54.7 ± 6.3%. On univariate analysis, the echocardiographic score [hazard ratio (HR) = 1.25 (1.00-1.70), p <0.05], left atrial diameter [HR = 1.06 (1.01-1.11), p <0.05] and mean mitral valve gradient soon after the procedure [HR = 1.25 (1.02-1.55), p <0.05] were predictors of events. On multivariate analysis, the echocardiographic mitral valve score before PMV was the only independent predictor of primary outcome [HR=1.75 (1.16-2.64), p<0.01]. CONCLUSIONS: Up to 20 years after successful PMV, a sizeable proportion of patients remained event-free, which confirmed the late efficacy of PMV. Among the present patient cohort, echocardiographic score before PMV was the only independent predictor of long term events.

Rotational Atherectomy Combined With Bioresorbable Vascular Scaffold Implantation: A Feasible Approach for Recurrent In-stent Restenosis When Other Therapies Failed.

The optimal treatment for recurrent in-stent restenosis (ISR) is uncertain. Everolimus-eluting bioresorbable vascular scaffold (BVS) use has been reported in a few cases as an interesting alternative, as it avoids long-term metal exposure to coronary circulation. Nevertheless, the underlying neointima and the multiple layers of previously implanted stents with underexpanded struts may contribute to recurrent ISR following BVS placement. We describe a feasible combined treatment for recurrent ISR in 2 patients using neointimal debulking and ablation of underexpanded stents by rotational atherectomy followed by BVS implantation. This conceptually attractive approach has not yet been reported.

Prosthetic mitral valve thrombosis in pregnancy: from thrombolysis to anticoagulation.

INTRODUCTION: Pregnant women with mechanical prosthetic heart valves are at increased risk for valve thrombosis. Management decisions for this life-threatening complication are complex. Open-heart surgery has a very high risk of maternal mortality and fetal loss. Bleeding and embolic risks associated with thrombolytic agents, the limited efficacy of thrombolysis in certain subgroups, and a lack of experience in the setting of pregnancy raise important concerns. CASE REPORT: We report a case of mitral prosthetic valve thrombosis in early pregnancy, which was successfully treated with streptokinase. Ten years later, the same patient had an uneventful pregnancy, throughout which acenocoumarol was maintained. CONCLUSION: With this case we review the prevention (with oral anticoagulant therapy) and treatment of prosthetic valve thrombosis during pregnancy, which is important for both obstetrician and cardiologist.

The Ibero-American transcatheter aortic valve implantation registry with the CoreValve prosthesis. Early and long-term results.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is the recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery. The aim of this study was to describe early experience and long-term follow-up with the CoreValve self-expanding aortic prosthesis at 42 Ibero-American hospitals. METHODS: Multiple centre observational study including 1220 consecutive patients with symptomatic severe aortic stenosis who are not suitable candidates for surgery and underwent transcatheter aortic valve implantation with the self-expanding Medtronic CoreValve System between December 2007 and May 2012. RESULTS: The registry included 1220 consecutive patients with a mean age of 80.8 ± 6.3 years and a mean logistic euroSCORE of 17.8% ± 13%. The procedural success rate was 96.1%. Hospital mortality was 7.3% and combined end-point was 21.3%. Aortic regurgitation after TAVI was present in 24.5% (Sellers grade ≥ 2). The estimated 1-year and 2-year survival rates were 82.1% and 73.4% respectively. The following issues were significant independent risk factors for hospital mortality: acute kidney failure (odds ratio 3.55); stroke (odds ratio 5.72); major bleeding (odds ratio 2.64) and euroSCORE (odds ratio 1.02). Long-term predictors of mortality were diabetes mellitus (hazard ratio 1.59, 95% confidence interval 1.09-2.31), severe chronic obstructive pulmonary disease (hazard ratio 1.85, 95% confidence interval 1.85-2.88), and functional classes NYHA III-IV (hazard ratio 1.31, 95% confidence interval 1.01-1.70). CONCLUSIONS: Transcatheter aortic valve implantation constitutes a safe and viable therapeutic option for high operative risk patients with severe aortic stenosis. Long-term prognosis is conditioned by associate comorbidities.

Position statement on transcatheter aortic valve implantation in Portugal.

OBJECTIVE: To evaluate the clinical indications and guidelines for transcatheter aortic valve implantation (TAVI) and to propose adaptations for its use in Portugal. METHODS AND RESULTS: The working group analyzed the epidemiology of aortic stenosis and current clinical recommendations in the light of current evidence, taking into consideration their own experience in Portugal. The evidence shows that TAVI significantly reduces mortality in patients with severe aortic stenosis considered unsuitable for surgery. This technique has a comparable safety profile, efficacy and quality of life improvement to conventional surgery in patients with high surgical risk, when carefully selected by multidisciplinary teams. TAVI procedures should be performed within multidisciplinary programs in centers with on-site cardiac surgery by experienced teams treating no fewer than 50 cases per year in order to maintain proficiency. The technique is little used in Portugal, with seven implantations/year per million population, a seventh of the European average and the lowest rate in Europe. From a societal standpoint, it is important to evaluate clinical outcomes and analyze the incremental cost involved in order to define the situations in which the technique is appropriate and should be used. CONCLUSION: TAVI is the only treatment for severe aortic stenosis in patients unsuitable for surgery, and can also be applied in selected cases with high surgical risk. Patients who are considered for this treatment should be evaluated in centers of excellence performing the technique and with a formal program of multidisciplinary team work. The first cases should be supervised until the team has established its routine. The program should perform the recommended minimum number of procedures per year in order to maintain proficiency and must keep a prospective clinical registry for monitoring purposes.

Optical coherence tomography assessment of calcified plaque modification after rotational atherectomy.

Rotational atherectomy (RA) facilitates stent delivery in highly calcified coronary plaques (CCP). However, lesion ablation by RA in angulated segments may be affected by guidewire bias, leading to a non-uniform plaque modification. Intravascular optical coherence tomography (iOCT) is the highest resolution (∼10 µm axial) intravascular imaging modality available for clinical use; furthermore, near infrared light easily penetrates calcium, with significantly fewer artifacts, including no "blooming effect" as seen by intravascular ultrasound. Therefore, it may pose as a unique tool for serial calcium quantification, as related in this article with pre- and post-RA assessment, allowing accurate characterization of plaque modification, as well as quality of stent deployment. The effects of guidewire bias in the debulking process have not been well documented by iOCT. We present a case of lesion preparation by RA affected by guidewire bias in which iOCT revealed unique insights into CCP modification.

Mitral valve myxomas: an unusual entity.

Primary tumours of the heart are uncommon entities, cardiac myxomas being the most frequent. However, mitral valve myxomas are exceptionally rare. In the last 12 years, there have been 25 myxomas diagnosed at our institution, with only two of them originating from the mitral valve. Both patients were female, the first, 25, and the second, 72 years old. The younger patient was very symptomatic with a large mass, 4 cm long, which involved both leaflets causing significant obstruction to the left ventricular inflow. The second one had a smaller mass located at the atrial side of the posterior leaflet that only produced some flow divergence. Neither of them had constitutional nor embolic symptoms. Both patients were submitted to emergent surgical resection that in the first case involved the mitral valve and replacement with mechanical prosthesis. The macroscopic appearance of these tumours suggested a malignant aetiology which may represent somewhat different features of the myxomas when originating from the cardiac valves. Both patients are well reflecting the good prognosis of this illness after resection, although the younger patient was re-operated because of prosthetic valve obstruction and suspicion of recurrence that was not confirmed. Because of the illustrative images and different presentations, we found it interesting to report and discuss them together.