Five-Year Survival and Complications of Thoracic Endovascular Aortic Repair (TEVAR): A Single Tertiary Center Registry for All-Comers Patients.

INTRODUCTION: Studies on the mid and long-term outcomes of thoracic endovascular aortic repair (TEVAR) are scarce. This study aimed to investigate the long-term outcomes of TEVAR for all-comers patients with various types of thoracic aortic pathologies, predominantly thoracic aortic dissections and thoracic aortic aneurysms. METHODS: Between January 2005 and December 2015, 123 consecutive patients with thoracic aortic pathologies underwent TEVAR. The patients were divided into groups based on aortic pathologies (dissections or aneurysms) and the type of procedure (hybrid TEVAR or non-hybrid TEVAR). Mortality, complications, and reintervention rates were compared between these four groups. The Kaplan-Meier curve and the Cox regression analysis were employed to estimate survivals and factors associated with 5-year mortality. RESULTS: One hundred twenty-three consecutive patients with various aortic pathologies undergoing TEVAR were evaluated. Hypertension (79.7 %) and smoking (39 %) were the most common comorbidities in the study population. The patients were followed up for a mean duration of 58.1 ± 7.1 months to evaluate the postprocedural surveillance. Most complications occurred in the dissection and hybrid groups; however, these differences were nonsignificant. The overall 5-year surveillance and reintervention rates were 65 % and 12.1 %, respectively. A significant difference existed in 5-year survival between the patients with aneurysmal and aortic dissection pathologies based on the log-rank test (P = 0.01). On the other hand, no significant differences were observed in 5-year survival between the patients who underwent hybrid and non-hybrid TEVAR. The Cox regression analysis confirmed that chronic kidney disease, previous coronary artery bypass grafting, age >65 years, platelet counts <150∗ 103/µL, aneurysmal aortic pathology, and ejection fraction ≤ 50 % were predictors of 5-year mortality. CONCLUSIONS: The long-term outcomes of TEVAR for various aortic pathologies disclosed that this procedure was well-tolerated in a group of patients with high comorbid conditions. The five-year survival rate of TEVAR for thoracic aortic dissections was more favorable than that for thoracic aortic aneurysms, but there were no significant differences between hybrid and non-hybrid procedures regarding the mortality rate.

Transcatheter tricuspid valve-in-valve implantation with bioprosthetic balloon expandable valve.

OBJECTIVES: This study was conducted to evaluate the outcome of the transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves with transcatheter aortic valves. METHODS: This retrospective study enrolled all consecutive patients who were considered high risk for reoperations by the heart team and who underwent transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves in Tehran Heart Center, Tehran, Iran. All the procedures were performed via the transfemoral venous route under echocardiography and fluoroscopy guidance with Edwards SAPIEN transcatheter heart valves (Edwards Lifesciences, Irvine, CA). RESULTS: Ten patients underwent successful transcatheter valve-in-valve implantation in the tricuspid position without any major complications or need for emergency surgical interventions. The mean age was 54.1 ± 17.1 years, and 8 patients were female. The median follow-up was 19.5 months (16-32.25 mon). The mean period between the last tricuspid valve replacement and transcatheter valve-in-valve implantation was 4.9 ± 2.2 years. The bioprosthetic valves were Hancock in three patients, Mosaic in the other three patients, and Biocor, Pericarbon, Perimount, and Epic in the other patients. After the procedure, the clinical and functional status improved significantly in all the patients. The mean transvalvular gradient decreased from 6.75 ± 2.66 mm Hg to 2.85 ± 0.89 (P < 0.001), and the postoperative tricuspid regurgitation severity decreased significantly in almost all the patients. The hospitalization period after the procedure was 4.4 ± 1.7 days. CONCLUSIONS: In high-risk patients, transcatheter valve-in-valve implantation seems to be a safe and minimally invasive alternative to reoperations for degenerated tricuspid bioprosthetic valves.

Prognostic implications of calculated Apo-lipoprotein B in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: Outcome is tied to lower cut-points.

BACKGROUND: Debates still surround using lipoproteins including Apo-B in risk assessment, management, and prognosis of patients with coronary artery disease. During an acute ST-segment elevation myocardial infarction, Apo-B might help to achieve incremental prognostic information. OBJECTIVE: We sought to determine the potential prognostic utility of calculated Apo-B in a cohort of patients with STEMI undergoing primary PCI. METHODS: A retrospective cohort study was conducted enrolling 2,259 patients with a diagnosis of acute STEMI who underwent primary PCI. Apo-B was obtained using a valid equation based on initial lipid measurements. High Apo-B was defined as a level of 65 or higher. Primary endpoint of the study was major adverse cardiovascular events (MACE). RESULTS: Mean age of the participants was 59.54 years and 77.9% of them were male. After a Median follow up of 15 (6.2) months, high Apo-B was associated with MACE and the OR (95% CI) was 3.02 (1.07-8.47), p = .036. Odds ratios for prediction of MACE pertaining to LVEF, and smoking were 0.97 (p = .044), and 1.07 (p = .033), respectively. However, High Apo-B was not able to predict suboptimal TIMI flow. Accordingly, the Odds ratio was 0.56 (0.17-1.87), p = 0.349. The power of High LDL-C and Non-HDLC for prediction of MACE were assessed in distinct models. Attained odds ratios were [2.40 (0.90-6.36), p = .077] and [1.80 (0.75-4.35), p = 0.191], respectively. CONCLUSION: Calculated Apo-B appears to be a simple tool applicable for prediction of cardiovascular events in patients with STEMI superior to both Non-HDLC and LDL-C.

One-Month Clinical Outcomes of ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention at a High-volume Cardiac Tertiary Center: Routine Hours Versus Off-hours.

Primary percutaneous coronary intervention (PCI) is the treatment of choice for patients with ST-elevation myocardial infarction (STEMI). We aimed to compare 1-month major adverse cardiac events (MACE) of patients undergoing primary PCI between 2 routine-hour and off-hour working shifts. In this cross-sectional study, 1791 STEMI patients were retrospectively evaluated who underwent primary PCI. The patients were classified into 2 groups of routine and off-hour according to the PCI start time and date [495 patients (27.7%) in routine-hour group; 1296 patients (72.3%) in off-hour group]. Cardiovascular risk factor, angiographic, procedural data, door-to-device time, and 1-month follow-up data of patients were compared between 2 groups. There was a statistical difference in door-to-device time between routine-hour and off-hour group [55 minutes (40-100 minutes) in off-hour group vs. 49 minutes (35-73 minutes) in routine-hour group; P ≤ 0.001]. However, most of the patients in both groups had door-to-device time ≤60 minutes. The frequency of 1-month MACE was 8.5% in off-hour group and 6.9% in routine-hour group (P = 0.260). After adjustment for possible confounders, the procedure result, in-hospital death, and 1-month MACE were not significantly different between both study groups. We found that STEMI patients treated with primary angioplasty during off-hour shifts had similar 1-month clinical outcomes to routine-hour shifts. Considering the high number of patients requiring primary PCI during off-hours, the importance of early revascularization in acute myocardial infarction, and the comparable clinical outcomes and procedural success, full-time provision of primary PCI services seems to be beneficial.

Transcatheter heart valve in valve implantation with Edwards SAPIEN bioprosthetic valve for different degenerated bioprosthetic valve positions (First Iranian ViV report with mid-term follow up).

Introduction: After early successful experience with transcatheter aortic valve replacement (TAVR), concept of transcatheter implantation of a new valve within a failing bioprosthetic valve emerged. Valve-in-valve (ViV) implantation seems to be a simpler option for high risk surgical patients. Methods: We performed five ViV procedures in different valve positions. We included patients with failing bioprosthetic valves with high surgical risk due to concomitant comorbidities. We performed 2 transapical ViV procedures for failing mitral bioprosthetic valves, 1 transfemoral procedure for failing pulmonary valve and 2 transfemoral ViV implantation for failing tricuspid bioprosthetic valves. Results: The procedures were successfully completed in all 5 cases with initial excellent fluoroscopic and echocardiographic verification. There was no valve embolization or paravalvular leakage in any of the cases. Transcatheter valve function was appropriate with echocardiography. Post procedural clinical adverse events like pleural effusion and transient ischemic attack were managed successfully. In midterm follow up all cases remained in appropriate functional class except from the transcatheter pulmonary valve which became moderately stenotic and regurgitant. Conclusion: As the first Iranian all-comers case series with midterm follow up for ViV implantation, we had no mortality. Interestingly none of our patients had neurologic sequelae after the procedure. Midterm follow up for our patients was acceptable with good functional class and appropriate echocardiographic findings. Due to high surgical risk of the redo procedure after failing of a bioprosthetic valve especially in elderly patients with comorbidities, ViV implantation would be a good alternative to surgery for this high risk group.

Midterm to long-term safety and efficacy of self-expandable nitinol stent implantation for coarctation of aorta in adults.

PURPOSE: Endovascular treatment of coarctation of aorta (CoA) by self-expandable Nitinol stents is one of the recognized treatment methods and may be an alternative to surgery or balloon-expandable stent implantation for CoA but there is little information about midterm to long term results of self-expandable stents. METHODS: Sixty-two patients with CoA (40 men), with a mean age of 30.7 ± 11 years, (range 17-63 years) underwent stent implantation with Optimed self-expandable Nitinol stents between 2005 and 2014. Successful outcome was defined as peak systolic pressure gradient ≤20 mmHg after stent implantation. The patients were followed-up clinically and by echocardiography and in patients, in whom there was suspicion of recoarctation, CT angiography or recatheterization was performed. RESULTS: 65 stents were successfully implanted in all 62 patients. Peak systolic pressure gradient decreased from mean 62.4 ± 18 mmHg (range 35-100 mmHg) to mean 2.8 ± 5 mmHg (range 0-15 mmHg; P < 0.001). Stent displacement occurred in 3 patients during the procedure. These were managed successfully by an overlapping second stent. None of the patients had major complications such as aortic dissection, rupture, or vascular access problems. In follow up, only three patients had recoarctation, and two of these were managed successfully by balloon redilation or further stenting 16 and 18 months after the first procedure and one patient refused reintervention. There were two deaths, unrelated to the procedure, 12 and 78 months after the initial intervention. Follow-up of a mean of 45.5 ± 17 months (range 12-105 months) demonstrated no evidence of aneurysm formation or stent fracture. CONCLUSIONS: Self-expandable nitinol stents for the treatment of native and recurrent CoA is safe and has good efficacy with acceptable midterm to long-term outcome.

Endovascular Aortic Aneurysm and Dissection Repair (EVAR) in Iran: Descriptive Midterm Follow-up Results.

BACKGROUND: Endovascular repair of aorta in comparison to open surgery has a low early operative mortality rate, but its long-term results are uncertain. OBJECTIVES: The current study describes for the first time our initial four-year experience of elective endovascular aortic repair (EVAR) at Tehran heart center, the first and a major referral heart center in Iran, as a pioneer of EVAR in Iran. PATIENTS AND METHODS: A total of 51 patients (46 men) who had the diagnosis of either an abdominal aortic aneurysm (AAA) (n = 36), thoracic aortic aneurysm (TAA) (n = 7), or thoracic aortic dissection (TAD) (n = 8) who had undergone EVAR by Medtronic stent grafts by our team between December 2006 and June 2009 were reviewed. RESULTS: The rate of in-hospital aneurysm-related deaths in the group with AAA stood at 2.8% (one case), while there was no in-hospital mortality in the other groups. All patients were followed up for 13-18 months. The cumulative death rate in follow-up was nine cases from the total 51 cases (18%), out of which six cases were in the AAA group (four patients due to non-cardiac causes and two patients due to aneurysm-related causes), one case in the TAA group (following a severe hemoptysis), and two cases in the TAD group (following an expansion of dissection from re-entrance). The major event-free survival rate was 80.7% for endovascular repair of AAA, 85.7% for endovascular repair of TAA, and 65.6% for endovascular repair of TAD. CONCLUSION: The endovascular stent-graft repair of the abdominal and thoracic aortic aneurysm and aortic dissection had high technical success rates in tandem with low-rate early mortality and morbidity, short hospital stay, and acceptable mid-term free symptom survival among Iranian patients.

A Risk-Scoring Model to Predict One-year Major Adverse Cardiac Events after Percutaneous Coronary Intervention.

BACKGROUND: The aim of the present study was to develop a scoring system for predicting 1-year major adverse cardiac events (MACE), including mortality, target vessel or target lesion revascularization, coronary artery bypass graft surgery, and non-fatal myocardial infarction after percutaneous coronary intervention (PCI). METHODS: The data were extracted from a single center PCI registry. The score was created based on the clinical, procedural, and laboratory characteristics of 8206 patients who underwent PCI between April 2004 and October 2009. Consecutive patients undergoing PCI between November 2009 and February 2011 (n= 2875) were included as a validation data set. RESULTS: Diabetes mellitus, increase in the creatinine level, decrease in the left ventricular ejection fraction, presentation with the acute coronary syndrome, number of diseased vessels, primary PCI, PCI on the left anterior descending artery and saphenous vein graft, and stent type and diameter were identified as the predictors of the outcome and used to develop the score (R² = 0.795). The models had adequate goodness of fit (Hosmer-Lemeshow statistic; p value = 0.601) and acceptable ability of discrimination (c-statistics = 0.63). The score categorized the individual patients as low-, moderate-, and high-risk for the occurrence of MACE. The validation of the model indicated a good agreement between the observed and expected risks. CONCLUSION: An individual risk-scoring system based on both clinical and procedural variables can be used conveniently to predict 1-year MACE after PCI. Risk classification based on this score can assist physicians in decision-making and postprocedural health care.

Percutaneous treatment of left main coronary stenosis following bentall surgery.

A 65-year-old male underwent percutaneous coronary stenting of the left main trunk seven months after the Bentall procedure as a probable consequence of surgical glue.

Staged endovascular treatment of left common carotid artery large aneurysm with Gore-Hemobahn stent-graft after right common carotid artery stenosis angioplasty.

We describe a patient with the coexistence of a stenosis and aneurysm of the carotid arteries and a past history of surgical aneurysmectomy. The patient had a 60% stenosis in the right common carotid artery associated with a fusiform aneurysm in the left one. A month after treating the right carotid stenosis with self-expanding stent, a Gore Hemobahn stent-graft was placed through the left carotid aneurysm. Endovascular treatment of carotid artery aneurysm by Hemobahn stent-graft seems to be a safe and an effective alternative to surgery in high surgical risk conditions.

A novel scoring system for identifying high-risk patients undergoing carotid stenting.

BACKGROUND/OBJECTIVE: In patients with severe concurrent coronary and carotid artery disease, two different treatment strategies may be used: simultaneous endarterectomy and coronary bypass surgery, and carotid stenting with delayed coronary bypass surgery after a few weeks. To evaluate the safety and efficacy of carotid stenting with delayed coronary bypass surgery after a few weeks in patients referred to Tehran Heart Center, Tehran, Iran and to determine the independent predictors that may be used to identify the appropriate treatment plan for such patients. METHODS: This prospective study was performed from December 2003 through October 2004. Symptomatic patients with >60% stenosis and asymptomatic patients with >80% stenosis were included in this study. The risks and benefits of carotid stenting were explained. Patients were excluded from the study if any of the following was applicable: age > or =85 years, history of a major stroke within the last week, pregnancy, intracranial tumor or arteriovenous malformation, severely disabled as a result of stroke or dementia, and intracranial stenosis that exceeded the severity of the extracranial stenosis. Thirty consecutive patients who underwent carotid stenting were enrolled in this study. RESULTS: The mean +/- SD age of patients was 66.3 +/- 8 years. The procedural success rate was 96.7%. During a mean +/- SD follow-up period of 5.6 +/- 3.2 months, 4 (17%) deaths occurred; none of which were attributed to a neurologic causes. Moreover, 1 (3%) patient developed a minor nonfatal stroke with transient cognitive disorder. Most of patients (80%) with major complications acquired a score of > or =26. CONCLUSION: To reduce the rate of carotid stenting complications in high-risk patients with heart disease, to optimize the patient selections, and to determine the best treatment strategy, based on the clinical and lesion characteristics of patients, we proposed a new scoring system.