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BACKGROUND: Patients with severe aortic stenosis (AS) frequently present with concomitant obstructive coronary artery disease (CAD). In those, current guidelines recommend combined coronary artery bypass grafting (CABG) and surgical aortic valve replacement (SAVR) as the preferred treatment option, although this surgical approach is associated with a high rate of clinical events. Combined transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) with or without FFR have evolved as a valid alternative for cardiac surgery in patients with AS and multivessel or advanced CAD. To date, no dedicated trial has prospectively evaluated the outcomes of a percutaneous versus surgical treatment for patients with both severe AS and CAD. AIMS: To investigate whether fractional-flow reserve (FFR)-guided PCI and TAVI is noninferior to combined CABG and SAVR for the treatment of severe AS and multivessel or advanced CAD. METHODS: The Transcatheter Valve and Vessels (TCW) trial (clinicaltrial.gov: NCT03424941) is a prospective, randomized, controlled, open label, international trial. Patients ≥ 70 years with severe AS and multivessel (≥ 2 vessels) or advanced CAD, deemed feasible by the heart team for both; a full percutaneous or surgical treatment, will be randomised in a 1:1 fashion to either FFR-guided PCI followed by TAVI (intervention arm) vs. CABG and SAVR (control arm). The primary endpoint is a patient-oriented composite of all-cause mortality, myocardial infarction, disabling stroke, unscheduled clinically-driven target vessel revascularization, valve reintervention, and life threatening or disabling bleeding at 1 year. The TCW trial is powered for noninferiority, and if met, superiority will be tested. Assuming a primary endpoint rate of 30% in the CABG-SAVR arm, with a significance level α of 5%, a noninferiority limit delta of 15% and a loss to follow-up of 2%, a total of 328 patients are needed to obtain a power of 90%. The primary endpoint analysis is performed on an intention-to-treat basis. SUMMARY: The TCW Trial is the first prospective randomized trial that will study if a less invasive percutaneous treatment for severe AS and concomitant advanced CAD (i.e., FFR-guided PCI-TAVI) is noninferior to the guidelines recommended approach (CABG-SAVR).
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Estenose da Valva Aórtica , Doença da Artéria Coronariana , Reserva Fracionada de Fluxo Miocárdico , Intervenção Coronária Percutânea , Substituição da Valva Aórtica Transcateter , Humanos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Valva Aórtica/cirurgia , Intervenção Coronária Percutânea/efeitos adversos , Estudos Prospectivos , Ponte de Artéria Coronária , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: During transcatheter aortic valve implantation (TAVI), secondary access is required for angiographic guidance and temporary pacing. The most commonly used secondary access sites are the femoral artery (angiographic guidance) and the femoral vein (temporary pacing). An upper extremity approach using the radial artery and an upper arm vein instead of the lower extremity approach using the femoral artery and femoral vein may reduce clinically relevant secondary access site-related bleeding complications, but robust evidence is lacking. TRIAL DESIGN: The TAVI XS trial is a multicentre, randomised, open-label clinical trial with blinded evaluation of endpoints. A total of 238 patients undergoing transfemoral TAVI will be included. The primary endpoint is the incidence of clinically relevant bleeding (i.e. Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding) of the randomised secondary access site (either diagnostic or pacemaker access, or both) within 30 days after TAVI. Secondary endpoints include time to mobilisation after TAVI, duration of hospitalisation, any BARC type 2, 3 or 5 bleeding, and early safety at 30 days according to Valve Academic Research Consortium3 criteria. CONCLUSION: The TAVI XS trial is the first randomised trial comparing an upper extremity approach to a lower extremity approach with regard to clinically relevant secondary access site-related bleeding complications. The results of this trial will provide important insights into the safety and efficacy of an upper extremity approach in patients undergoing transfemoral TAVI.
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BACKGROUND AND AIM OF THE STUDY: The coronavirus disease 2019 (COVID-19) pandemic has put an enormous strain on healthcare systems and intensive care unit (ICU) capacity, leading to suspension of most elective procedures, including transcatheter aortic valve replacement (TAVR). However, deferment of TAVR is associated with significant wait-time mortality in patients with severe aortic valve stenosis. Conversely, there is currently no data available regarding the safety and feasibility of a continued TAVR program during this unprecedented crisis. The aim of this study is to evaluate the safety and feasibility of patients undergoing TAVR during the COVID-19 pandemic in our center, with specific emphasis on COVID-19 related outcomes. METHODS: All patients who underwent TAVR in our center between February 27, 2020, and June 30, 2020, were evaluated. Clinical outcomes were described in terms of Valve Academic Research Consortium 2 definitions. Patient follow-up was done by chart review and telephone survey. RESULTS: A total of 71 patients have undergone TAVR during the study period. Median age was 80 years, 63% were men, and 25% were inpatients. Procedural success was 99%. After TAVR, 30% involved admission to the ICU, and 94% were ultimately discharged to the cardiac care unit on the same day. Two patients (3%) had confirmed COVID-19 a few days after TAVR, and both died of COVID-19 pneumonia within 2 weeks after hospital discharge. CONCLUSIONS: A continued TAVR program during the COVID-19 pandemic is feasible despite limited hospital resources. However, COVID-19 related mortality after TAVR is of concern.
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Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , COVID-19/epidemiologia , Pandemias , SARS-CoV-2 , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/epidemiologia , Comorbidade , Feminino , Humanos , Masculino , Países Baixos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Extracorporeal circulation is accompanied by changes in red blood cell morphology and structural integrity that affect cell function and survival, and thereby may contribute to the various side effects of heart-lung machine-assisted surgery. Our main objectives were to determine the effect of circulation of red blood cells in a stand-alone extracorporeal circuit on several parameters that are known to be affected by, as well as contribute to red blood cell aging. As a source of RBCs, we employed blood bank storage units of different ages. In order to assess the relevance of our in vitro observations for the characterization of extracorporal circulation technology, we compared these changes in those of patients undergoing extracorporeal circulation-assisted cardiac surgery. Our results show that circulation in a heart-lung machine is accompanied by changes in red blood cell volume, an increase in osmotic fragility, changes in deformability and aggregation behavior, and alterations in the exposure of phosphatidylserine and in microvesicle generation. RBCs from 1-week-old concentrates showed the highest similarities with the in vivo situation. These changes in key characteristics of the red blood cell aging process likely increase the susceptibility of red blood cells to the various mechanical, osmotic, and immunological stress conditions encountered during and after surgery in the patient's circulation, and thereby contribute to the side effects of surgery. Thus, aging-related parameters in red blood cell structure and function provide a foundation for the validation and improvement of extracorporeal circulation technology.
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Eritrócitos/fisiologia , Máquina Coração-Pulmão/efeitos adversos , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Agregação Eritrocítica/fisiologia , Deformação Eritrocítica/fisiologia , Volume de Eritrócitos , Eritrócitos/patologia , Feminino , Hemólise , Humanos , MasculinoRESUMO
OBJECTIVES: The aim of the study was to investigate trends over time in the occurrence of left bundle branch block (LBBB) and permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) with the Medtronic CoreValve System (MCS) and Edwards SAPIEN Valve (ESV). BACKGROUND: TAVI-induced conduction abnormalities (TAVI-CAs) such as LBBB and the need for PPI are frequent postoperative complication. New techniques, procedural refinements, and increased awareness are focused on the reduction of these abnormalities. METHODS: Electrocardiograms of 549 patients without preprocedural LBBB and/or pacemaker were assessed to determine the frequency and nature of TAVI-CAs. To study the effect of experience, patients were subdivided per center into tertiles based on the number of procedures. Univariate and multivariate logistic regression was used to study predictors of TAVI-induced LBBB (TAVI-LBBB) and PPI. RESULTS: TAVI-LBBB occurred in 185 patients (33.7%) and significantly decreased over time, from 42.6% to 27.3% (P=0.006). This effect was only significant after implantation of the MCS (59.6% vs. 46.5% vs. 31.1%, P=0.001, ESV: 22.6% vs. 13.1% vs. 24.8%, P=0.11). Between tertiles there was no difference in the frequency of PPI after TAVI (n=73, 13.1% vs. 14.8% vs. 12%, P=0.74). Multivariate analysis revealed that, independent from valve type, depth of implantation was the only significant predictor of TAVI-LBBB (OR [95% C.I.]: 1.16 [1.10-1.24], P<0.001). In case of PPI pre-existing RBBB (OR [95% C.I.]: 7.22 [3.28-15.88], P<0.001) was the only significant predictor. CONCLUSIONS: Over time the frequency of LBBB after TAVI decreased significantly, especially in patients undergoing TAVI with the MCS. Experience and the subsequent reduction in depth of implantation seem responsible for this reduction. Contrary to TAVI-LBBB, the incidence of PPI remained unchanged over time and was not affected by experience. Although experience has led to a decrease in new CAs after TAVI, elucidation of pathophysiologic mechanisms underlying these CAs and subsequent changes in patient stratification, valve design and the procedure are needed to further reduce this complication.
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Bloqueio de Ramo/epidemiologia , Marca-Passo Artificial , Complicações Pós-Operatórias , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/cirurgia , Bloqueio de Ramo/etiologia , Bloqueio de Ramo/terapia , Eletrocardiografia , Feminino , Seguimentos , Próteses Valvulares Cardíacas/efeitos adversos , Humanos , Incidência , Masculino , Países Baixos/epidemiologia , Quebeque/epidemiologia , Estudos RetrospectivosRESUMO
OBJECTIVES: To determine the optimal imaging time point for transcatheter aortic valve implantation (TAVI) therapy planning by comprehensive evaluation of the aortic root. METHODS: Multidetector-row CT (MDCT) examination with retrospective ECG gating was retrospectively performed in 64 consecutive patients referred for pre-TAVI assessment. Eighteen different parameters of the aortic root were evaluated at 11 different time points in the cardiac cycle. Time points at which maximal (or minimal) sizes were determined, and dimension differences to other time points were evaluated. Theoretical prosthesis sizing based on different measurements was compared. RESULTS: Largest dimensions were found between 10 and 20% of the cardiac cycle for annular short diameter (10%); mean diameter (10%); effective diameter and circumference-derived diameter (20%); distance from the annulus to right coronary artery ostium (10%); aortic root at the left coronary artery level (20%); aortic root at the widest portion of coronary sinuses (20%); and right leaflet length (20%). Prosthesis size selection differed depending on the chosen measurements in 25-75% of cases. CONCLUSION: Significant changes in anatomical structures of the aortic root during the cardiac cycle are crucial for TAVI planning. Imaging in systole is mandatory to obtain maximal dimensions. KEY POINTS: ⢠Most aortic root structures undergo significant dimensional changes throughout the cardiac cycle. ⢠The largest dimensions of aortic parameters should be determined to optimize TAVI. ⢠Circumference-derived diameter showed maximum dimension at 20% of the cardiac cycle.
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Aorta Torácica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/patologia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/patologia , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/patologia , Estenose da Valva Aórtica/cirurgia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores/métodos , Tamanho do Órgão , Desenho de Prótese , Estudos Retrospectivos , SístoleRESUMO
Myasthenia gravis (MG) with antibodies against the acetylcholine receptor (AChR-MG) is considered as a prototypic autoimmune disease. The thymus is important in the pathophysiology of the disease since thymus hyperplasia is a characteristic of early-onset AChR-MG and patients often improve after thymectomy. We hypothesized that thymic B cell and antibody repertoires of AChR-MG patients differ intrinsically from those of control individuals. Using immortalization with Epstein-Barr Virus and Toll-like receptor 9 activation, we isolated and characterized monoclonal B cell lines from 5 MG patients and 8 controls. Only 2 of 570 immortalized B cell clones from MG patients produced antibodies against the AChR (both clones were from the same patient), suggesting that AChR-specific B cells are not enriched in the thymus. Surprisingly, many B cell lines from both AChR-MG and control thymus samples displayed reactivity against striated muscle proteins. Striational antibodies were produced by 15% of B cell clones from AChR-MG versus 6% in control thymus. The IgVH gene sequence analysis showed remarkable similarities, concerning VH family gene distribution, mutation frequency and CDR3 composition, between B cells of AChR-MG patients and controls. MG patients showed clear evidence of clonal B cell expansion in contrast to controls. In this latter aspect, MG resembles multiple sclerosis and clinically isolated syndrome, but differs from systemic lupus erythematosus. Our results support an antigen driven immune response in the MG thymus, but the paucity of AChR-specific B cells, in combination with the observed polyclonal expansions suggest a more diverse immune response than expected.
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Autoanticorpos/imunologia , Linfócitos B/imunologia , Herpesvirus Humano 4/fisiologia , Miastenia Gravis/imunologia , Timo/patologia , Adulto , Autoanticorpos/sangue , Linhagem Celular Transformada , Transformação Celular Viral , Células Clonais , Feminino , Humanos , Hiperplasia , Músculo Estriado/imunologia , Mutação/genética , Receptores Colinérgicos/imunologia , Anticorpos de Domínio Único/genética , Receptor Toll-Like 9/metabolismo , Adulto JovemRESUMO
BACKGROUND: The accuracy of a three-dimensional robotic-assisted videothoracoscopic approach may favor a radical resection of thymomas. The aim of this study was to demonstrate the feasibility of the robotic approach by reporting 8 years experience in a single referral center of surgical treatment of thymomas. METHODS: We retrospectively analyzed all consecutive patients who underwent a thymectomy from April 2004 to April 2012. We analyzed the procedure time, morbidity, mortality, conversions, hospitalization, freedom from recurrence, time to progression, and overall survival. RESULTS: From 2004 until 2012, a total of 138 robotic procedures for mediastinal tumors were performed in our center, of which 37 patients with a mean age of 57.3 years underwent a thymectomy for a thymoma. Histological analysis revealed four type A thymomas (10.8 %), seven type AB thymomas (18.9 %), seven type B1 thymomas (18.9 %), fourteen type B2 thymomas (37.8 %), four type B3 thymomas (10.8 %), and one thymus carcinoma (2.7 %). The MasaokaKoga stages were as follows: stage I in twenty patients (54 %), stage IIA in five patients (13.5 %), stage IIB in eight patients (21.6 %), stage III in three patients (8.1 %), and stage IVa in one patient (2.7 %). The mean overall procedure time was 149 min (range 88353). No surgical mortality was reported, and there were no peri-operative complications. No conversions were needed for surgical complications. In three cases, a conversion to sternotomy was preferred by the surgeon because tumor invasion in greater vessels was suspected. Two patients (5.4 %) suffered from a myasthenic crisis postoperatively and required prolonged mechanical ventilation. One patient (2.7 %) underwent a procedure for a thoracic herniation 6 months following thymectomy. The median hospitalization was 3 days. The follow-up analysis showed an overall survival of 100 % and tumor recurrence in one patient (2.7 %). CONCLUSIONS: Robotic thymectomies are safe in patients with early-stage thymomas. Robotic surgery may also be feasible for some selected advanced thymomas.
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Imageamento Tridimensional , Robótica/métodos , Timectomia/métodos , Timoma/cirurgia , Neoplasias do Timo/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Países Baixos/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Timoma/diagnóstico , Timoma/epidemiologia , Neoplasias do Timo/diagnóstico , Neoplasias do Timo/epidemiologia , Fatores de Tempo , Tomografia Computadorizada por Raios XRESUMO
Mitral annular abscesses are rare and can be caused by infective endocarditis. We present the case of a patient with an infected mitral prosthesis, with multiple suspected periprosthetic abscesses. However, perioperative inspection showed a supra-annular implanted prosthesis.
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Transcatheter aortic valve replacement (TAVR) is the standard of care in aortic stenosis with results comparable to surgical aortic valve replacement. However, paravalvular regurgitation (PVR) is more common after TAVR. With the alteration of devices and implantation techniques, the incidence of moderate or more PVR has declined. Mild PVR is still common in around 30% of TAVR patients in low-risk trials. Progression of AS causes myocardial hypertrophy and varying degrees of diastolic dysfunction which may cause heart failure even in combination with small volumes of PVR. Any degree of PVR is associated with an increased risk of overall and cardiovascular mortality. Predictors of PVR are annular eccentricity, severe calcification of the aortic valve, bicuspid aortic valves, and type of prosthesis where balloon-expandable devices are associated with less PVR. PVR is diagnosed using echocardiography, aortic angiogram with or without videodensitometry, haemodynamic parameters, or cardiac magnetic resonance. PVR can be treated using post-dilation, interventional treatment using a vascular plug, or implantation of a second device. Successful post-dilation depends on balloon size which should at least be equal to or >95% of the mean annulus diameter. Implantation of a second device to reduce PVR is successful in â¼90% of cases, either through lengthening of the sealing skirt in case of inadequate position or through further expansion of the index device. Implantation of a vascular plug can successfully reduce PVR and reduce mortality.
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Background The femoral vein is commonly used as a pacemaker access site during transcatheter aortic valve replacement (TAVR). Using an upper arm vein as an alternative access site potentially causes fewer bleeding complications and shorter time to mobilization. We aimed to assess the safety and efficacy of an upper arm vein as a temporary pacemaker access site during TAVR. Methods We evaluated all patients undergoing TAVR in our center between January 2020 and January 2023. Upper arm, femoral, and jugular vein pacemaker access was used in 255 (45.8%), 191 (34.3%), and 111 (19.9%) patients, respectively. Clinical outcomes were analyzed according to pacemaker access in the overall population and in a propensity-matched population involving 165 upper arm and 165 femoral vein patients. Primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 pacemaker access site-related bleeding. Results In the overall population, primary endpoint was lowest for upper arm, followed by femoral and jugular vein access (2.4% vs. 5.8% vs. 10.8%, p = 0.003). Time to mobilization was significantly longer (p < 0.001) in the jugular cohort compared with the other cohorts. In the propensity-matched cohort, primary endpoint showed a trend toward lower occurrence in the upper arm compared with the femoral cohort (2.4% vs. 6.1%, p = 0.10). Time to mobilization was significantly shorter (480 vs. 1140 min, p < 0.001) in the upper arm cohort, with a comparable skin-to-skin time (83 vs. 85 min, p = 0.75). Cross-over from upper arm pacemaker access was required in 17 patients (6.3% of attempted cases via an upper arm vein). Conclusions Using an upper arm vein as a temporary pacemaker access site is safe and feasible. Its use might be associated with fewer bleeding complications and shorter time to mobilization compared with the femoral vein.
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BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a novel therapy for treatment of severe aortic stenosis. Although 30% to 50% of patients develop new left bundle-branch block (LBBB), its effect on clinical outcome is unclear. METHODS AND RESULTS: Data were collected in a multicenter registry encompassing TAVI patients from 2005 until 2010. The all-cause mortality rate at follow-up was compared between patients who did and did not develop new LBBB. Of 679 patients analyzed, 387 (57.0%) underwent TAVI with the Medtronic CoreValve System and 292 (43.0%) with the Edwards SAPIEN valve. A total of 233 patients (34.3%) developed new LBBB. Median follow-up was 449.5 (interquartile range, 174-834) days in patients with and 450 (interquartile range, 253-725) days in patients without LBBB (P=0.90). All-cause mortality was 37.8% (n=88) in patients with LBBB and 24.0% (n=107) in patients without LBBB (P=0.002). By multivariate regression analysis, independent predictors of all-cause mortality were TAVI-induced LBBB (hazard ratio [HR], 1.54; confidence interval [CI], 1.12-2.10), chronic obstructive lung disease (HR, 1.56; CI, 1.15-2.10), female sex (HR, 1.39; CI, 1.04-1.85), left ventricular ejection fraction ≤50% (HR, 1.38; CI, 1.02-1.86), and baseline creatinine (HR, 1.32; CI, 1.19-1.43). LBBB was more frequent after implantation of the Medtronic CoreValve System than after Edwards SAPIEN implantation (51.1% and 12.0%, respectively; P<0.001), but device type did not influence the mortality risk of TAVI-induced LBBB. CONCLUSIONS: All-cause mortality after TAVI is higher in patients who develop LBBB than in patients who do not. TAVI-induced LBBB is an independent predictor of mortality.
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Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Bloqueio de Ramo/mortalidade , Bloqueio de Ramo/cirurgia , Cateterismo Cardíaco/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Ensaios Clínicos como Assunto/tendências , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Sistema de Registros , Fatores de Risco , Resultado do TratamentoRESUMO
AIMS: Paravalvular regurgitation (PVR) is a common complication after transcatheter aortic valve replacement (TAVR) that poses an increased risk of rehospitalization for heart failure and mortality. The aim of this study was to assess the accuracy of haemodynamic indices to predict relevant PVR. METHODS AND RESULTS: In this prospective single-centre clinical trial, four haemodynamic indices of PVR measured during TAVR were assessed for their correlation with gold standard cardiac magnetic resonance (CMR)-derived regurgitant fraction (CMR-RF) at 1 month follow-up: diastolic delta (DD), heart rate-adjusted diastolic delta (HR-DD), aortic regurgitation index (ARI), and aortic regurgitation index ratio (ARI ratio). These haemodynamic indices were analysed for their ability to predict relevant PVR (defined as CMR-RF > 20%) using receiver operating characteristic (ROC) curves with corresponding area under the ROC curves (AUCs). A total of 77 patients were included and had CMR performed 41 ± 14 days after TAVR. Mean CMR-RF was 12.4 ± 9.3%. Fifteen (19.5%) patients had CMR-RF > 20%. DD had the best correlation with CMR-RF and the highest AUC to predict relevant PVR (0.82; 95% CI, 0.72-0.92), followed by HR-DD (AUC 0.78; 95% CI, 0.67-0.89), ARI (AUC 0.78; 95% CI, 0.66-0.89), and ARI ratio (AUC 0.65; 95% CI, 0.49-0.81). The optimal cut-off value for DD was 32 mmHg, with sensitivity of 69% and specificity of 77% in predicting relevant PVR. CONCLUSION: DD measured during TAVR best predicts relevant PVR. Correction for heart rate (HR-DD) or systolic blood pressure (ARI, ARI ratio) did not improve this predictive value.
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Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Humanos , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Próteses Valvulares Cardíacas/efeitos adversos , Espectroscopia de Ressonância Magnética/efeitos adversos , Estudos Prospectivos , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do TratamentoRESUMO
OBJECTIVE: We investigated the impact of papillary muscle dyssynchrony (DYS-PAP) in predicting recurrent mitral regurgitation (MR) in patients with ischemic cardiomyopathy (ICM) undergoing undersized mitral ring annuloplasty (UMRA). METHODS: One hundred forty-four ICM patients (left ventricular ejection fraction <35%) in sinus rhythm undergoing UMRA between January 2001 and December 2010 at three Institutions (University Hospital, Maastricht, The Netherlands; Careggi Hospital, Florence, Italy; Civic Hospital, Brescia, Italy) were recruited. The primary endpoint was the recurrence of MR at the latest echocardiographic study defined as insufficiency ≥2+ in patients with no/trivial MR at discharge. The assessment of DYS-PAP was performed by applying two-dimensional (2D) speckle-tracking imaging. RESULTS: In patients with MR recurrence, DYS-PAP significantly worsened (84.1 ± 8.8 msec vs.65.4 ± 8.8 msec at baseline, P < 0.001) whereas in patients with no MR recurrence, DYS-PAP did not vary (22.3 ± 5.3 msec vs. 25.9 ± 7.2 msec at baseline, P = 0.8). Recurrent MR was positively correlated with preoperative DYS-PAP (P < 0.001), baseline anterior mitral leaflet tethering angle α (P < 0.001) and tethering symmetry index α/ß before surgery (P < 0.001). There was no significant correlation between MR recurrence and other echocardiographic parameters. Logistic regression analysis revealed that baseline values of DYS-PAP (OR: 5.4 [95% CI: 3.1-7.7], P < 0.001), α (OR: 5.0 [2.6-6.7], P < 0.001), and α/ß (OR: 3.9 [2.5-5.7], p < 0.001) were predictors of recurrent MR. A DYS-PAP value ≥ 58 msec predicted recurrence of MR with 100% sensitivity and 83% specificity (area under the curve [AUC]: 0.92 [0.7-1], P < 0.001). CONCLUSIONS: A DYS-PAP cutoff value of 58 msec is useful to identify patients in whom UMRA is likely to fail. That way decision making in ischemic functional MR might be facilitated.
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Ecocardiografia Doppler de Pulso/métodos , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Mitral/fisiopatologia , Contração Miocárdica/fisiologia , Isquemia Miocárdica/fisiopatologia , Músculos Papilares/fisiopatologia , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/cirurgia , Isquemia Miocárdica/complicações , Isquemia Miocárdica/diagnóstico por imagem , Músculos Papilares/diagnóstico por imagem , Valor Preditivo dos Testes , Recidiva , Estudos Retrospectivos , SístoleRESUMO
Minimally invasive mitral valve surgery is evolving rapidly since the early 1990's and is now increasingly adopted as the standard approach for mitral valve surgery. It has a long and challenging learning curve and there are many considerations regarding technique, planning and patient selection when starting a minimally invasive program. In the current review, we provide an overview of all considerations and the decision-making process during the learning curve.
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OBJECTIVES: To examine the occupational radiation dose during transcatheter aortic valve implantation (TAVI) in both transfemoral and transapical approach. BACKGROUND: Interventional fluoroscopic guided cardiac procedures lead inevitably to radiation exposure of workers, which over time may be associated with an increased incidence of cancer and cataract. METHODS: Using thermoluminescence dosimeters, the radiation dose of the cardiothoracic surgeon, cardiologist, and two assistants was measured on the apron at chest height and on both feet. In addition, dose measurements were performed on the hands of the two operators and on the eyes of the cardiothoracic surgeon. This study involved 11 transapical and 11 transfemoral TAVIs. The effective dose was estimated from the dose measured on the apron. RESULTS: In the transapical TAVI the cardiothoracic surgeon received a significantly higher equivalent hand dose (average ± SD), 1.9 ± 0.6 mSv, equivalent foot dose, 0.57 ± 0.31 mSv, equivalent eye dose, 0.11 ± 0.06 mSv, and effective dose, 0.03 ± 0.02 mSv, than any staff member in the transfemoral TAVI, with highest average doses of 0.03 ± 0.02 mSv, 0.22 ± 0.19 mSv, 0.03 ± 0.01 mSv, and 0.003 ± 0.005 mSv, respectively. CONCLUSIONS: This study provides hitherto unavailable data on the radiation exposure of staff during transfemoral and transapical TAVIs. Relatively high doses were observed in the transapical approach. The dose of the right hand of the cardiothoracic surgeon will reach the annual limit within about 250 procedures per year, implying that hand dose measurements should become standard and that the number of procedures performed by the cardiothoracic surgeon involving X-rays may have to be limited.
Assuntos
Valva Aórtica/diagnóstico por imagem , Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca/métodos , Exposição Ocupacional , Doses de Radiação , Radiografia Intervencionista , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/efeitos adversos , Cinerradiografia , Feminino , Artéria Femoral/diagnóstico por imagem , Fluoroscopia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Países Baixos , Traumatismos Ocupacionais/etiologia , Traumatismos Ocupacionais/prevenção & controle , Lesões por Radiação/etiologia , Lesões por Radiação/prevenção & controle , Proteção Radiológica , Radiografia Intervencionista/efeitos adversos , Medição de Risco , Fatores de Risco , Dosimetria TermoluminescenteRESUMO
OBJECTIVES: The valve-in-valve (VIV) technique is an emerging therapeutic option for patients with failure of previously implanted xenografts. We describe a balloon-expandable transthoracic transapical mitral VIV implantation in an emergency setting in a 69-year-old woman with dysfunction of the mitral bioprosthesis. METHODS: Left ventricular apical access was applied. After balloon valvuloplasty, a 26-mm Edwards-Sapien transcatheter valve (Edwards Lifesciences LLC, Irvine, CA, USA) was deployed within the mitral xenograft, using rapid ventricular pacing. RESULTS: The transcatheter valve functioned properly postoperatively and three-dimensional echocardiography carried out 1 month later showed a well-functioning VIV prosthesis and no mitral stenosis (mitral valve area 3 cm(2) , mean gradient 3 mmHg). CONCLUSIONS: In this patient, VIV implantation was found to be a safe alternative to an emergent valve replacement. It might represent a suitable option to conventional procedures even among lower risk patients.
Assuntos
Cateterismo/métodos , Ecocardiografia , Implante de Prótese de Valva Cardíaca/métodos , Ventrículos do Coração , Estenose da Valva Mitral/terapia , Valva Mitral/patologia , Idoso , Cateterismo/instrumentação , Tratamento de Emergência/instrumentação , Tratamento de Emergência/métodos , Feminino , Artéria Femoral , Sobrevivência de Enxerto , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Valva Mitral/diagnóstico por imagem , Estenose da Valva Mitral/patologiaRESUMO
Grading paravalvular leak (PVL) at the time of transcatheter aortic valve implantation (TAVI) deployment is challenging. Per-procedural invasive hemodynamic measurements could serve to optimize PVL grading and predict outcome after TAVI. The aim of this study was to compare hemodynamic measures of paravalvular leak and their prognostic relevance in self-expanding TAVI devices. Between December 2008 and December 2017 consecutive patients treated for severe symptomatic aortic valve stenosis with self-expanding devices were prospectively studied. Peri-procedural hemodynamic measurements, echocardiographic data as well as clinical follow-up according to VARC-2 criteria were prospectively collected. Diastolic delta (DD), heart rate adjusted DD, aortic regurgitation index (ARI) and ARI ratio were calculated and assessed for their association with 1-year mortality. A total of 651 patients were studied. Moderate or severe paravalvular leakage was found in 4.8% of patients. ARI ratio < 0.6 (hazard ratio 1.96 [1.23-3.12], P = 0.005) was the best independent predictor of 1-year mortality. This study confirms the value of hemodynamic measures, specifically ARI ratio, for prognostication, potentially supporting procedural decision-making with regard to PVL.
Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Próteses Valvulares Cardíacas/efeitos adversos , Humanos , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
AIMS: Vascular complications are among the most commonly observed complications after TAVI. Iliofemoral vascular outcome has been described extensively. Little is known about vascular complications in transaxillary TAVI. The aim of the current study was to describe the incidence and predictors of axillary artery complications incorporating computed tomography angiography (CTA) measurements. METHODS AND RESULTS: CT analysis was performed in two hundred patients treated with transaxillary TAVI in our centre between January 2014 and December 2017. Vascular complications occurred in 37 (18.5%) patients. Patient characteristics predicting this outcome were female gender (aOR 3.88 [1.48-10.14], p=0.006) and age (aOR 1.08 [1.01-1.16], p=0.034). The CTA measurement predicting vascular complications was a sheath to artery area ratio (SAAR) equal to or larger than 1.63 (OR 3.95 [1.29-12.12], p=0.016). CONCLUSIONS: The present study describes the incidence of axillary artery complications and identifies patient characteristics associated with this outcome. CTA analysis was shown to be an important screening tool in the assessment of patient (access) eligibility. Axillary artery dimensional screening should be based on vascular luminal area assessment rather than diameter measurement alone.
Assuntos
Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Artéria Axilar , Feminino , Artéria Femoral , Humanos , Incidência , Resultado do TratamentoRESUMO
Bone cement leakage is a common complication after percutaneous kyphoplasty. In rare cases, leakage into the venous system occurs, which can be life-threatening, especially when it embolizes the heart. Here, we present a case of cement embolization of the right ventricle with tricuspid valve involvement. A 69-year-old woman with an asymptomatic severe tricuspid valve regurgitation was referred to our department. She had a history of balloon kyphoplasty because of osteoporotic collapsed vertebrae in 2010. Echocardiography showed a foreign body attached to the right ventricle, prolapsing into the right atrium and causing a severe tricuspid valve regurgitation. The foreign body was surgically removed, and the tricuspid valve was replaced with a biological valve. The foreign body was analysed by scanning electron microscopy and element analysis. Zirconium was identified within the foreign body, which is an additive in bone cement used in orthopaedic surgery. Intracardiac cement embolism following percutaneous kyphoplasty is a rare but life-threatening complication. Here, we present a case of tricuspid valve destruction caused by the long-term presence of an intracardiac foreign body, specifically a cement embolus.