Valve-in-valve transcatheter aortic valve implantation: The issues behind crossing a bioprosthesis.

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing.

Autologous blood reinfusion during iatrogenic acute hemorrhagic cardiac tamponade: Safety and feasibility in a cohort of 30 patients.

BACKGROUND: Iatrogenic hemorrhagic pericardial tamponade (IHPT) represents a life-threating condition requiring emergency pericardiocentesis. In this clinical context, reinfusion of pericardial blood can stabilize the patient and sustain hemodynamic conditions. AIMS AND METHODS: We reviewed all cases of IHPT occurred at our hospital over a 10 years span. In all patient autologous blood reinfusion through a femoral vein was performed. RESULTS: In our clinical experience of 30 consecutive patients with hemorrhagic cardiac tamponade, this technique was successful to limit blood transfusions, to prevent further clinical worsening and bridge patients with intractable bleeding, to cardiac surgery. No major adverse reactions were directly related to blood autotransfusion. CONCLUSION: In the complex clinical scenario of acute tamponade occurring during catheter-based cardiac procedures, autotransfusion of pericardial blood through a femoral vein is safe and effective. It can be a useful trick up the sleeve of the interventional cardiologist.

Trans-radial closure of coronary artery fistulae using Amplatzer vascular plug IV: A case series.

BACKGROUND: Trans-catheter closure of coronary artery fistulae (CAF) has become a successful alternative to cardiac surgery with excellent results and acceptable low rate of complications. Different techniques and devices are available to treat the extreme anatomical variability of CAF. AIM: We retrospectively describe our case series of five patients trans-radially treated using an Amplatzer vascular plug IV (AVP-IV) with telescoping catheter technique. RESULTS: Trans-radial closure of CAF using the "Child in Mother" technique with dedicated catheters to deliver the vascular plugs AVP-IV was successfully performed in all patients, in one case for a complex CAF, an hybrid step approach using coils and plugs was needed. CONCLUSIONS: Trans-radial closure of CAF using AVP-IV and a telescoping catheter appeared to be safe and feasible in our case series. A persistent closure of CAF was achieved in all patients at 2 year coronary angiography follow-up.

Bilateral Slender Transradial Aortic Balloon Valvuloplasty.

Percutaneous aortic balloon valvuloplasty as a bridge-to-decision strategy was performed in an 89-year-old woman with multiple comorbidities and cachexia. The patient did well; after 2 weeks, she was discharged home and referred for possible TAVR.

Transulnar recanalization of a chronic radial artery occlusion.

Trans-ulnar access is a viable alternative approach by experienced operators when the radial and femoral arteries cannot be accessed or used to preserve the contralateral radial artery as possible vascular graft for coronary bypass surgery, hemodynamic monitoring, or shunt creation for hemodialysis. We report a challenging case of ipsilateral trans-ulnar recanalization of a chronic radial artery occlusion, which allowed us to perform a complex trans-ulnar PCI.

Radiation Therapy-Induced Cardiovascular Disease Treated by a Percutaneous Approach.

We report the case of a 51-year-old woman, treated with radiotherapy at the age of two years, for a pulmonary sarcoma. Subsequently she developed severe aortic stenosis and bilateral ostial coronary artery disease, symptomatic for dyspnea (NYHA III functional class). Due to the prohibitive surgical risk, she underwent successful stenting in the right coronary artery and left main ostia with drug eluting stents and, afterwards, transcatheter aortic valve replacement with transfemoral implantation of a 23 mm Edwards SAPIEN XT valve. The percutaneous treatment was successful without complications and the patient is in NYHA II functional class at 2 years' follow-up, fully carrying out normal daily activities.

Impact of different stent alloys on human vascular response to everolimus-eluting stent: an optical coherence tomography study: the OCTEVEREST.

BACKGROUND: New generation drug-eluting stents (DES) incorporate thinner struts and novel alloys to improve clinical performance. Nevertheless, the impact of novel stent materials and designs on human vascular response to DES remains elusive. We sought to evaluate the in-vivo coronary artery response to platinum-chromium (PtCr) versus cobalt-chromium (CoCr) stents featuring the same durable polymer and antiproliferative drug by optical coherence tomography (OCT). METHODS AND RESULTS: A total of 42 patients with de novo lesions in native coronary vessels was treated with PtCr-everolimus eluting stent (EES; n = 21) or CoCr-EES (n = 21). Angiography, intravascular ultrasound, and OCT were performed at the index procedure and 6-month follow-up. PtCr-EES and CoCr-EES had similar concentric expansion (stent eccentricity index; median 0.91 vs. 0.90, respectively, P = 0.47) and very low rate of strut malapposition (median 1.15 vs. 1.80%, P = 0.92) at post implantation. Proportion of struts embedded in tissue was lower in PtCr-EES compared to CoCr-EES (median 2.67 vs. 15.23%, P < 0.001). The primary prespecified end point, the percentage of uncovered struts per patient at 6 months follow-up, was 8.46% [interquartile range (IQR) = 3.05-17.26] in PtCr-EES and 5.88% (IQR = 1.35-13.27) in CoCr-EES (P = 0.36), whereas malapposed struts were observed in 0.00% (IQR = 0.00-0.25) versus 0.48% (IQR = 0.00-1.44), respectively, (P = 0.10). Strut-level neointimal thickness did not differ between the two platforms (median 0.09 vs. 0.08 mm, P = 0.49). CONCLUSIONS: Acute and mid-term responses to EES using PtCr or CoCr platforms were similar, with concentric stent expansion, low malapposition, similar strut coverage and limited amount of neointima. Conversely, at postprocedure, PtCr-EES had fewer embedded struts compared with CoCr-EES.

Safety and feasibility of selective angiography of left internal mammary artery grafts via right transradial approach.

BACKGROUND AND PURPOSE: Right transradial approach (TRA) for cardiovascular procedures is becoming common practice, but angiography and PCI of left mammary artery by-pass graft (LIMA) via the right radial artery is still technically challenging. Aim of the study was to evaluate the possibility to put a stable catheter in left mammary from right radial approach. METHODS: From June 2002 to March 2009, 246 consecutive patients (88% male; age 67.7 +/- 7.8 years) with previous CABG underwent LIMA graft angiography via right TRA by a single experienced operator. RESULTS: An adequate radial access was obtained in all patients. Selective angiography of LIMA was successfully performed in 218 patients (89.1%). In the remaining 28 (10.9%) the LIMA approach from right radial failed because of severe tortuosity of brachiocephalic trunk or severe calcified and tortuous left subclavian artery. 13 patients underwent PCI and stentingon mid-distal native LAD trough LIMA using 6FIM4 guiding catheter. No periprocedural cerebro-vascular complications, no vascular injury at the LIMA takeoff as a result of selective canulation, no injury of the left subclavian artery were observed CONCLUSIONS: In patients with previous CABG, the presence of LIMA grafts is not a limitation to successfully perform diagnostic and interventional procedures via the right radial approach with experienced operators.

Through the drug-eluting stent labyrinth.

For interventional cardiologists restenosis has represented the main limit for the successful long-term treatment of coronary artery disease. The past 2 years witnessed the extraordinary results of drug-eluting stents (DES), putting this technique at the center stage. The safety and efficacy of sirolimus and paclitaxel-eluting stents have been proved in large prospective, multicenter, randomized trials (RAVEL, SIRIUS, TAXUS II). It is possible that the introduction of DES will lead to substantial changes in the therapeutic and/or the economic strategies of the treatment of ischemic coronary artery disease (increase in the complexity of patients treated, reduction in surgical indications, growing costs). Realizing the potential value of this technology will require the successful management of more complex coronary situations (for lesions and patients characteristics). Many extreme situations are still unexplored, although for some of them studies are currently in progress or already being planned.