Practical guide to prevention of contrast-induced acute kidney injury after percutaneous coronary intervention.

Contrast-induced acute kidney injury (CI-AKI) represents a common but serious complication of percutaneous coronary interventions (PCI)-and in general of all those examinations requiring iodinated contrast injection-which affects not only renal function but also long-term prognosis. While several prophylactic approaches were designed in order to prevent CI-AKI, most failed to demonstrate clear benefits in randomized trials, and their implementation is therefore discouraged in clinical practice. The most notorious examples include pre-procedural bicarbonate or N-acetylcysteine, and preprocedural withdrawal of ACE inhibitors/Angiotensin receptor blockers. Those strategies that were instead demonstrated effective include the appropriate use of preprocedural hydration, reduction in contrast volume utilization, adoption of techniques for zero- or ultra-low-contrast procedures, and pharmacological treatments with statins. In this brief review, we summarize the main preventive strategies into brief and pragmatic recommendations designed to improve everyday clinical practice.

Computed tomography analysis of coronary ostia location following valve-in-valve transcatheter aortic valve replacement with the ACURATE neo valve: Implications for coronary access.

BACKGROUND: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is an emerging alternative to re-do surgery. However, the challenge of coronary access (CA) following ViV-TAVR is a potential limitation as TAVR expands to younger lower-risk populations. OBJECTIVES: Using post-implantation computed tomography (CT) scans to evaluate the geometrical relationship between coronary ostia and valve frame in patients undergoing ViV-TAVR with the ACURATE neo valve. METHODS: Post-implant CT scans of 18 out of 20 consecutive patients treated with the ACURATE neo valve were analyzed. Coronary ostia location in relation to the highest plane (HP) (highest point of the ACURATE neo or surgical valve) was determined. Ostia located below the highest plan were further subclassified according to the gap available between the transcatheter heart valve frame and ostium (transcatheter-to-coronary [TTC] distance). The impact implantation depth has on these geometrical relationships was evaluated. RESULTS: A total of 21 out of 36 coronary ostia (58%) were located below the level of the HP with the left coronary artery (36%) more likely to be affected than the right (22%). Further sub-classification of these ostia revealed a large (>6 mm), moderate (4-6 mm), and small (<4 mm) TTC distance in 57% (12/21), 38% (8/21), and in 6% (1/18) of cases, respectively. At an implantation depth <4 mm compared to >4 mm, all ostia were located below the HP with no difference in post-procedural mean gradients (14.5 mmHg ± 4.7 vs. 12.6 mmHg ± 5.8; p = .5, 95%CI 3.8-7.5). CONCLUSIONS: CA following ACURATE neo implantation for ViV-TAVR could potentially be challenging in a significant proportion of patients and specific consideration should be given to the implantation depth.

Evidence of tricuspid valve remodeling in patients with severe mitral regurgitation independently of degree of functional tricuspid regurgitation: a two- and three-dimensional echocardiographic study.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate whether, in patients with severe mitral regurgitation (MR), tricuspid valve remodeling was independent of the degree of functional tricuspid regurgitation (FTR) present. Whether any differences in the analysis remodeling, as assessed by two-dimensional (2D) and three-dimensional (3D) echocardiography, can be demonstrated was also addressed. METHODS: A total of 188 patients (mean age 63.5 +/- 16.0 years) with severe organic or functional MR with or without associated FTR, and 30 normal controls (mean age 59.2 +/- 15 years) were enrolled in the study. Subsequently, both 2D and 3D transthoracic anatomic and functional parameters of the tricuspid valve were analyzed. RESULTS: Patients and controls differed in all 2D and 3D parameters of tricuspid valve remodeling, except for the 2D end-diastolic annular diameter and circularity indices. The patients were then allocated to either group A (trivial/mild FTR) or group B (moderate/severe FTR). Significant differences were identified between groups A and B compared to controls in all tricuspid valve remodeling indices, except for the diastolic 2D annular diameter and circularity indices. Groups A and B had similar 2D and 3D parameters of tricuspid valve remodeling. The right ventricular end-diastolic diameter (RVEDD) (beta = 0.24, 95% CI: 0.11 to 0.22, p = 0.02) and fractional area change (beta = -0.48, 95% CI: -0.24 to 0.09, p = 0.0001, R2 = 0.22) were independent predictors of the tenting area, whereas the RVEDD was the only independent predictor of the diastolic 3D tricuspid annular area (beta = 0.53, 95% CI: 1.2 to 2.7, p = 0.0001, R2 = 0.28). CONCLUSION: In patients with severe MR, tricuspid valve remodeling was also demonstrated in those with trivial/mild FTR, but was better characterized by 3D echocardiography. Tricuspid valve remodeling and right ventricular dilation were the main determinants of tricuspid valve regurgitation.

Percutaneous edge-to-edge repair as a bailout option to treat Iatrogenic leaflet perforation.

An 80-year-old man was referred to our center for heart failure and severe degenerative mitral regurgitation (MR). Transesophageal echocardiography revealed severe MR due to anterior leaflet prolapse, mainly in its central portion (A2) in the context of fibroelastic deficiency.

A Case of Catheter-Based Tricuspid Valve Repair Reversing the Previous Success of Transcatheter Mitral Valve Repair: A New Scenario Requires New Answers.

Concomitant severe mitral-tricuspid regurgitation is observed in up to 30% of patients with reduced left ventricular ejection fraction. In symptomatic subjects at high surgical risk, transcatheter treatment is a viable option in the presence of suitable anatomy. We present a case of mitral regurgitation worsening after TriClip (Abbott, Abbott Park, IL) implantation in a patient with a previous successful MitraClip (Abbott) intervention. The correction of tricuspid regurgitation by catheter repair improves overall hemodynamics, but it can sometimes paradoxically worsen mitral regurgitation, as herein displayed. Clinical care is needed to detect tricuspid regurgitation repair-induced worsening of mitral regurgitation and ensure optimal management.

Lung ultrasound in bronchiolitis: comparison with chest X-ray.

The diagnosis of bronchiolitis is based mainly on the patient's medical history and physical examination. However, in severe cases, a further evaluation including chest X-ray (CXR) may be necessary. At present, lung ultrasound (LUS) is not included in the diagnostic work-up of bronchiolitis. This study aimed to compare the diagnostic accuracy of LUS and CXR in children with bronchiolitis, and to evaluate the correlation between clinical and ultrasound findings. Only patients with a diagnosis of bronchiolitis, who had undergone a CXR, were enrolled in the study. Fifty-two infants underwent LUS and CXR. LUS was also performed in 52 infants without clinical signs of bronchiolitis. LUS was positive for the diagnosis of bronchiolitis in 47/52 patients, whereas CXR was positive in 38/52. All patients with normal LUS examination had a normal CXR, whereas nine patients with normal CXR had abnormal LUS. In these patients, the clinical course was consistent with bronchiolitis. We found that LUS is a simple and reliable tool for the diagnosis and follow-up of bronchiolitis. It is more reliable than CXR, can be easily repeated at the patient's bedside, and carries no risk of irradiation. In some patients with bronchiolitis, LUS is able to identify lung abnormalities not revealed by CXR. Furthermore, there is a good correlation between clinical and ultrasound findings. Given the short time needed to get a US report, this technique could become the routine imaging modality for patients with bronchiolitis.

Systematic Fluoroscopic-Echocardiographic Fusion Imaging Protocol for Transcatheter Edge-to-Edge Mitral Valve Repair Intraprocedural Monitoring.

BACKGROUND: Whether fluoroscopic-echocardiographic fusion imaging (FI) might offer added value for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair is yet unknown, and few data exist regarding the safety and feasibility of this novel technology. METHODS: The aim of this single-center study was to test and validate a FI protocol for intraprocedural monitoring of transcatheter edge-to-edge mitral valve repair and assess its clinical usefulness. Eighty patients underwent MitraClip implantation using FI guidance (FI+) for either degenerative (35%) or functional (65%) mitral regurgitation and were compared with the last 80 patients before FI introduction, treated using conventional echocardiography and fluoroscopic monitoring (FI-). RESULTS: The number of patients treated for functional and degenerative mitral regurgitation was similar between the FI+ and FI- groups, as well as the number of devices implanted (1.51 ± 0.5 vs 1.58 ± 0.6, P = .46). The prevalence of complex mitral anatomy for percutaneous repair was high (32.5%, up to 39.2% in the hybrid arm). Fluoroscopy time was significantly lower in FI+ patients (37.3 ± 14.6 vs 48.3 ± 28.3 min, P = .003), but not kerma area product (91.5 ± 74.1 vs 108.8 ± 105.0 Gy · cm2, P = .23) or procedural time (92.2 ± 36.1 vs 103.1 ± 42.7 min, P = .086). After adjusting for confounding factors (MitraClip XT device and complex anatomy), FI reduced fluoroscopy time (coefficient = -10.4 min; 95% CI, -18.03 to -2.82; P = .007) and improved procedural success at the end of the procedure (odds ratio, 2.87; 95% CI, 1.00 to 8.24; P = .049) and discharge (odds ratio, 2.24; 95% CI, 1.04 to 4.80; P = .039). Rates of periprocedural complications were similar in both groups (8.9% vs 13.0%, P = .40). CONCLUSIONS: The authors describe the systematic use of an FI protocol for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair, demonstrating a reduction in fluoroscopy time and an improvement in procedural success in a population with a high prevalence of challenging mitral anatomy for percutaneous repair.

Patient selection, procedural planning and interventional guidance for transcatheter aortic valve intervention.

Transcatheter aortic valve replacement (TAVR) is an established treatment for severe aortic stenosis across a broad spectrum of patient risk profiles. Preprocedural planning using multislice computed tomography (MSCT) is a fundamental component to ensure acute and long-term procedural success. MSCT can establish the procedural feasibility, the type vascular of approach as well as the device which is more likely to give a good result. Moreover, MSCT is a key tool to estimate the risk of potentially life-threatening complications. In this review, the role of MSCT for preprocedural TAVR planning will be discussed providing a panoramic overview of the key elements that should be considered when performing TAVR. Additionally, the adjunctive role of fluoroscopy and echocardiography to plan and guide a TAVR procedure will also be discussed.

Acute Tricuspid Valve Remodelling After MitraClip Deployment: Rationale for a Dual-Staged Procedure.

A 70-year-old woman was admitted to our hospital for severe tricuspid regurgitation caused by cardioverter-defibrillator lead impingement; treatment with MitraClip system (Abbott Vascular, Santa Clara, CA) was attempted. After realizing the impossibility of grasping in the regurgitant area because of extensive leaflets gap, we implanted a clip in another commissure, even in the absence of regurgitation originating from that area. In this way, we achieved a significant acute valve remodelling, which allowed the subsequent successful deployment of a second clip in the regurgitant area. This proposed dual-staged approach can be considered systematically for the treatment of anatomies generally regarded as unfavourable or unsuitable.

Looking for Optimal Implantation Height in Bicuspid Aortic Valve Patients Undergoing Transcatheter Aortic Valve Implantation: A Case Series.

TAVR in bicuspid aortic valve (BAV) represents a challenging scenario. Valve sizing and positioning are the most important determinants of procedural success. In BAV the maximal prosthesis-anatomy interference occurs at the supra-annular level. Supra-annular prosthesis implantation may improve valve sealing and hemodynamic result. In this case series, we propose a new site for prosthesis implantation, guided CT scan supra-annular sizing for BAV undergoing TAVR.

Percutaneous Treatment of a Four-Leaf Clover Valve Using the MitraClip Technology.

Percutaneous treatment of tricuspid valve regurgitation using MitraClip can be performed safely achieving improvement in reduction of regurgitation. Tricuspid valve shows different anatomic variations, in particular regarding the number of leaflets, which could represent a challenge for transcatheter valve intervention. We present a case of massive tricuspid regurgitation in a 4-leaf clover valve. We implanted a first MitraClip into the anteroseptal commissure and then a second one between the 2 posterior leaflets, with a successful reduction of residual regurgitation. In conclusion, this approach can be safely performed in a 4-leaflet right ventricular valve.

Valve-in-Valve Transcatheter Aortic Valve Implantation With Acurate neo for a Degenerated bio-Bentall.

A 79-year-old man with heart failure was referred to our attention for a degenerated bio-Bentall Mitroflow 27. The Heart Team decided for a valve-in-valve (ViV) transcatheter aortic valve implantation with an Acurate neo M associated to coronary protection due to high risk of coronary obstruction (CO). Besides the supra-anular design, this case shows additional potential advantages of the Acurate neo in ViV procedures: the upper crown, which is meant to favor supra-anular anchoring, also let to cap the bioprosthesis leaflets and minimize the risk of CO; there is not any interference between the valve cage and the stents protruding into the aorta, avoiding potential stent crushing and assuming an easier future coronary engagement.

Future Perspectives in Percutaneous Treatment of Tricuspid Regurgitation.

Tricuspid regurgitation (TR) has a not negligible prevalence and its severity is correlated with poorer outcomes. However, surgical options are rarely offered to these patients because of their high surgical risk. Given that medical therapy plays a limited role in the management of these patients, there is an increasing clinical need for transcatheter treatment options. Although, transcatheter tricuspid valve interventions (TTVIs) are still at an early stage, emerging data suggests their clinical effectiveness and safety, with preliminary results highlighting the potential benefits of transcatheter treatments over medical therapy. In this review, we highlight the challenges and future directions of current and emerging technologies dedicated to the treatment of TR along with an analysis of the next steps required in future clinical trials and studies dedicated to the treatment of the forgotten valve.

Loss of Leaflet Insertion After Percutaneous Mitral Valve Repair Requiring Left Ventricular Assist Device Implantation: Usefulness of 3D Multiplanar Reconstruction.

Three-dimensional multiplanar reconstruction was used to diagnose recurrence of mitral regurgitation after MitraClip implantation in a 71-year-old man. Subsequent mitral valve surgery in such a case is high risk, and repeat MitraClip intervention could be feasible but is technically challenging. This imaging series demonstrates that LVAD implantation may be a solution to address MitraClip failure.

[New therapeutic options for the treatment of tricuspid regurgitation]. / Nuove possibilità terapeutiche nel trattamento dell'insufficienza tricuspidale.

Tricuspid regurgitation is a common finding in patients with left-sided heart disease with prognostic implications. In addition, isolated tricuspid valve surgery is associated with high mortality and is infrequently performed. Hence, a largely unmet clinical need exists and less invasive therapeutic options are emerging: multiple percutaneous therapies have been developed, including tricuspid valve repair or replacement. This review aims to provide an overview with diagnostic and clinical perspectives, potential challenges and future directions.

Tricuspid valve imaging.

The right ventricle and tricuspid valve (TV) have long been neglected by cardiologists. Functional tricuspid regurgitation (TR) is nowadays the most common cause of severe TR and is emerging as a prognostic factor in many heart diseases. A multimodality imaging approach is fundamental for defining the pathophysiology of TR, using both two-dimensional and three-dimensional echocardiography, as well as CT scan. In particular, 3D echocardiography can characterize TV apparatus and tricuspid annulus; CT offers complementary information about annular structure, and its relationship with the right coronary artery. The following review will describe TV anatomy, define transthoracic and transesophageal echocardiographic views for evaluating TV morphology, function and TR grading with some clues on interventional perspectives.

[Saphenous vein graft aneurysm: percutaneous exclusion using detachable coils]. / Aneurisma del graft venoso: esclusione percutanea mediante l'uso di spirali.

We report the case of a 78-year-old man admitted to the emergency department for typical angina onset with evidence of a large aneurysm of the coronary artery venous bypass graft, successfully closed using a percutaneous approach.

Effects of functional tricuspid regurgitation on renal function and long-term prognosis in patients with heart failure.

AIMS: Renal dysfunction is common in heart failure. Recent evidence suggests a pivotal role for systemic venous congestion and functional tricuspid regurgitation (FTR) in the pathophysiology of renal dysfunction. We investigated the role of FTR as a determinant of renal dysfunction and a predictor of long-term prognosis in chronic systolic heart failure patients. METHODS AND RESULTS: Four hundred and thirteen consecutive patients (mean age 74.2 ± 11 years) with chronic heart failure and left ventricular ejection fraction below 50% were enrolled. The FTR severity was quantified by transthoracic echocardiography. Renal function was evaluated with the estimated glomerular filtration rate measured by the simplified Modification of Diet in Renal Disease formula. The association between moderate/severe FTR and renal dysfunction, and its impact on heart failure episodes and overall mortality were also assessed. The median follow-up was 36 months (range 1-144 months). Through multivariate analysis, the interaction between moderate/severe FTR with tricuspid annular plane systolic excursion less than 16 mm was found to be an independent determinant of renal dysfunction [odds ratio 1.2, 95% confidence interval (CI) 1.1-1.5, P = 0.04]. Moderate/severe FTR (hazard ratio 1.3, 95% CI 1.2-2.7, P = 0.02) and tricuspid annular plane systolic excursion below 16 mm (hazard ratio 1.2, 95% CI 1.0-3.7, P = 0.01) were significantly related to the heart failure episodes. Moreover, the Kaplan-Meier analysis showed a worse outcome in patients with moderate/severe FTR (log-rank test 8.6, P = 0.003). CONCLUSIONS: The combination of significant FTR and right ventricular dysfunction, but not FTR and right ventricular dysfunction alone, is independently associated with renal dysfunction. The presence of significant FTR is related to an excess event rate of heart failure and has significant impact on outcome.