Balloon-expanding transcatheter aortic valve implantation for degenerated Mitroflow bioprostheses: clinical and echocardiographic long-term outcomes.

OBJECTIVES: This study aims to analyse the risks associated with valve-in-valve procedures for treating structural valve deterioration in Mitroflow bioprostheses, as well as to determine the impact of the original Mitroflow size on the patients' long-term outcomes. METHODS: Between January 2012 and September 2019, 21 patients (61.9% males; mean age 82.4 ± 5.4 years) were treated for Mitroflow deterioration with valve-in-valve procedures (12 transapical and 9 transfemoral). RESULTS: Mean EuroSCORE I and EuroSCORE II were 28.2% ± 13.6% and 10.5% ± 6.1%, respectively. Six patients presented an indexed aortic root diameter <14 mm/m2 and 7 patients a diameter of sinus of Valsalva <30 mm. Implanted transcatheter valve sizes were 20 mm in 6 cases, 23 mm in 14 cases and 26 mm in 1 patient. A Valve Academic Research Consortium-2 complication occurred in 23.8% of cases, including 3 coronary occlusions. In-hospital mortality was 9.5%. The 20 mm transcatheter valves presented significantly higher postoperative peak and mean aortic gradients than other sizes (54.1 ± 11.3 mmHg vs 29.9 ± 9.6 mmHg, P = 0.003; and 29.3 ± 7.7 mmHg vs 17.4 ± 5.9 mmHg, P = 0.015, respectively). There were 12 cases of patient-prosthesis mismatch (57.1%) and 3 cases (14.3%) of severe patient-prosthesis mismatch. Cumulative survival was 85.7% ± 7.6% at 1 year, 74.3% ± 10% at 2 years and 37.1% ± 14.1% at 5 years. CONCLUSIONS: Valve-in-valve procedures with balloon-expandable transcatheter valves associate a high risk of coronary occlusion in patients with indexed aortic root diameter <14 mm/m2 and low coronary ostia <12 mm. Valve-in valve procedures with 20 mm balloon-expandable transcatheter valves in ≤21 mm Mitroflow bioprosthesis leave significant residual transvalvular gradients that might obscure patients' long-term outcomes.

Efficacy and safety of transcatheter valve-in-valve replacement for Mitroflow bioprosthetic valve dysfunction.

OBJECTIVES: Bioprostheses with pericardial leaflets mounted externally on the stent pose a high risk for valve-in-valve (ViV) procedures. This study analyzed the efficacy and safety of ViV procedures for treating structural valve deterioration (SVD) in Mitroflow bioprostheses. METHODS: Between January 2012 and August 2017, 11 patients (mean age 80.3 ± 5.6 years) were treated for SVD of Mitroflow bioprostheses with transcatheter ViV procedures (six transapical [TA] and five transfemoral [TF]) using balloon expandable bioprostheses. RESULTS: All patients but one were in NYHA class III-IV. Mean STS PROM, euroSCORE I, and euroSCORE II were 8 ± 6.5%, 27.8 ± 11.5%, and 12 ± 5.9%, respectively. Two patients had a "porcelain aorta." The size of implanted valves were 23 mm in 10 cases and 26 mm in one case. One patient suffered a coronary occlusion during a TF approach. The mean volume of contrast used in TF implants was 163 ± 69.8 mL. No contrast media were used in TA procedures. There was one in-hospital death (10%). At 1 year of follow-up, peak and mean aortic gradients were 25.5 ± 5.8 mmHg and 15.5 ± 5.7 mmHg, respectively. One patient had mild paravalvular regurgitation. Cumulative survival was 90.9% at 1 year, 70.7% at 2 years, and 53% at 3 years. CONCLUSIONS: ViV procedures with balloon-expandable aortic valves provide good hemodynamic and clinical mid-term results for treating patients with a degenerated Mitroflow aortic bioprosthesis. Special care must be taken in small aortic roots, when the stented valve is in the supra-annular position to avoid coronary ostial obstruction.

Puncture Versus Surgical Cutdown Complications of Transfemoral Aortic Valve Implantation (from the Spanish TAVI Registry).

Vascular complications in transcatheter aortic valve implantation using transfemoral approach are related to higher mortality. Complete percutaneous approach is currently the preferred technique for vascular access. However, some centers still perform surgical cutdown. Our purpose was to determine complications related to vascular access technique in the population of the Spanish TAVI National Registry. From January 2010 to July 2015, 3,046 patients were included in this Registry. Of them, 2,465 underwent transfemoral approach and were treated with either surgical cutdown and closure (cutdown group, n = 632) or percutaneous approach (puncture group, n = 1,833). Valve Academic Research Consortium-2 definitions were used to assess vascular and bleeding complications. Propensity matching resulted in 615 matched pairs. Overall, 30-day vascular complications were significantly higher in the puncture group (109 [18%] vs 42 [6.9%]; relative risk [RR] 2.60; 95% confidence interval [CI] 1.85 to 3.64, p <0.001) due mostly by minor vascular events (89 [15%] vs 25 [4.1%], RR 3.56, 95% CI 2.32 to 5.47, p <0.001). Bleeding rates were lower in the puncture group (18 [3%] vs 40 [6.6%], RR 0.45, 95% CI 0.26 to 0.78, p = 0.003) mainly driven by major bleeding (9 [1.5%] vs 21 [3.4%], RR 0.43, 95% CI 0.20 to 0.93, p = 0.03). At a mean follow-up of 323 days, complication rates remained significantly different between groups (minor vascular complications 90 [15%] vs 31 [5.1%], hazard ratio 2.99, 95% CI 1.99 to 4.50, p <0.001 and major bleeding 10 [1.6%] vs 21 [3.4%], hazard ratio 0.47, 95% CI 0.22 to 1.0, p = 0.04, puncture versus cutdown group, respectively). In conclusion, percutaneous approach yielded higher rates of minor vascular complications but lower rates of major bleeding compared with the surgical cutdown, both at 30-day and at mid-term follow-up in our population.

Percutaneous closure of paravalvular leaks after transcatheter aortic valve implantation with Edwards SAPIEN prosthesis: a report of two cases.

Significant periprosthetic aortic regurgitation after transcatheter aortic valve implantation with Edwards SAPIEN prosthesis has become a major concern of this technique given its association with impaired survival. We report the successful closure of such defects using vascular occlusion devices with significant improvement in clinical status of patients.

Effect of stent thrombosis on the risk-benefit balance of drug-eluting stents and bare metal stents.

INTRODUCTION AND OBJECTIVES: To determine the difference in the risk of stent thrombosis between drug-eluting stents (DES) and bare-metal stents (BMS) and to assess the clinical implications. METHODS: A retrospective analysis of two cohorts of patients treated at our center with either > or =1 paclitaxeleluting stents (PES) (n=430) or > or =1 BMSs (n=1230) during 2003-2004 was carried out using propensity score methods to compare the adjusted risks of stent thrombosis, instent restenosis, cardiovascular death, acute myocardial infarction (AMI), and target-lesion revascularization with the two stent types. RESULTS: After a median follow-up of 46 months, there was a higher risk of stent thrombosis in PESs (hazard ratio [HR]=3; 95% confidence interval [CI], 1.2-7.1] though the risk of in-stent restenosis was lower (HR=0.3; 95% CI, 0.2-0.7]. There was no difference in the risk of cardiovascular death, AMI or target-lesion revascularization. With PESs, the risks of target-lesion revascularization (HR=0.33; 95% CI, 0.2-0.7) and in-stent restenosis (HR=0.32; 95% CI, 0.2-0.7) were reduced during the first year of follow-up. After this time, the risks of target-lesion revascularization (HR=1.8; 95% CI, 1-3.2) and very late stent thrombosis (HR=12.8; 95% CI, 3-55.1) both increased. CONCLUSIONS: Our findings indicate that the balance of risks and benefits of PESs compared with BMSs is different in the early and late periods after stent implantation. The greatly increased risk of very late stent thrombosis in PESs could cancel out the clinical benefits associated with the reduction in in-stent restenosis observed in PESs relative to BMSs.

Natural history of a giant coronary aneurysm with spontaneous dissection.

Primary spontaneous coronary artery dissection may appear in young women during the peripartum period or as a result of atherosclerosis. We present a patient with familial hypercholesterolemia who developed a giant aneurysm of the right coronary artery in the setting of atherosclerotic spontaneous coronary dissection over an 8 year period. This report illustrates the association between spontaneous coronary artery dissection and subsequent coronary aneurysm formation.

Statin therapy and contrast-induced nephropathy after primary angioplasty.

A recent study suggested that statin therapy may prevent contrast-induced nephropathy (CIN) following primary angioplasty. Our aim was to assess the effect of statins in this setting in a larger population. We evaluated 589 consecutive patients with acute myocardial infarction who underwent primary angioplasty at our institution. Contrast-induced nephropathy was defined as an increase in serum creatinine by > or =0.5 mg/dL within 72 h following the procedure. Overall, 69 patients (11.9%) developed CIN. The incidence of CIN in the group on statins was 15.9%, as compared with 10.8% in the group not taking statins (p=0.2). Thus, we did not observe a protective effect of statin therapy on CIN development after primary angioplasty.

[Transradial approach to coronary angiography and angioplasty: initial experience and learning curve]. / Coronariografía y angioplastia coronaria por vía radial: experiencia incial curva de aprendizaje.

INTRODUCTION: The transradial approach has emerged as an attractive alternative to the femoral approach for coronary angiography and interventions. We describe our experience with the transradial approach and analyze the influence of the learning curve. PATIENTS AND METHODS: The transradial approach was attempted in patients with a good radial pulse and normal Allen test. When feasible and clinically indicated, we attempted ad hoc intervention. We divided the study population into two groups: Group A (the first 200 cases) and B (all other patients). We compared the radial group with a matched femoral control group. RESULTS: We attempted the transradial approach in 526 patients (77.6% male; age 63.5 +/- 11.51), and obtained a success rate of 93.7%. We found differences between group A and B in the success rate (91.0 vs 95.4%, p = 0,04), duration of procedure [23 (16-29) vs. 19 (15-24) minutes; p < 0.001], and fluoroscopy time [6.4 (4.2-10) vs. 5.0 (3.0-7.7) minutes; p < 0,001]. At 24 h of follow-up, we found small hematomas in 9.4%, bleeding in 4.9%, and radial artery obstruction in 2.8%, with no cases of arteriovenous fistula, pseudoaneurysm, or need for vascular surgery. We attempted intervention in 169 patients with 258 lesions, achieving angiographic success in 96.1%. We found no differences in the characteristics of the lesions and patients, or in the angiographic success rate of the radial and femoral PTCA groups. CONCLUSIONS: The transradial approach is a safe and effective alternative to femoral catheterization. There is a significant learning curve associated with the successful performance of transradial procedures.