Superior vena cava tear during transvenous lead extraction: Medical management in hemodynamically stable patients.

INTRODUCTION: Superior vena cava (SVC) tear is the most lethal complication during transvenous lead extraction (TLE) with a mortality rate as high as 50%. Treatment involves aggressive attempts to maintain cardiac output and immediate sternotomy to localize and repair the vascular tear. Occlusion balloons have been developed to provisionally occlude the lacerated SVC and to provide hemodynamic stability allowing time for surgery. In case of mediastinal hematoma without hemodynamic instability, the strategy remains unclear. METHODS AND RESULTS: We describe two cases of SVC tear during TLE. The first case was a 60-year-old man who presented with a right ventricular single-chamber defibrillator lead fracture and innominate vein stenosis. The RV lead was removed using a laser sheath causing a mediastinal hematoma with no active bleeding during surgical exploration few hours later. The second case was a 28-year-old man that presented with a right atrial (RA) lead fracture and RV lead insulation failure in a dual-chamber defibrillator (ICD). CONCLUSION: Both the RA and RV leads were removed with mechanical sheaths, and a mediastinal hematoma was medically managed.

Life cycle assessment of the French municipal solid waste incineration sector.

This study aims at assessing the environmental performances of the French MSW incineration sector in a life cycle perspective, considering nine midpoint impact categories. It is the first application of the WILCI tool, dedicated to the LCA of MSW incineration in the French situation (Beylot et al., 2017). The model is primarily based on operational data relative to 90 plants, representing 73% of the total mass of MSW annually incinerated in France. Regarding seven impact categories out of the nine under study, incineration of MSW in France provides a benefit (that is, a "negative" impact). The uncertainty analysis confirms the relatively large degree of confidence of this conclusion regarding acidification and particulate matter, but in the meantime highlights the remaining uncertainty regarding most other impact categories. Energy recovery is responsible for the main share of the total environmental impacts and benefits of MSW incineration in France. Moreover, this study confirms the importance of technology differentiation in the LCA of MSW incineration. The predominance, in the French incineration sector, of energy recovery as CHP, and of SCR for NOx abatement, results in the global environmental benefits calculated per tonne of average MSW incinerated. Finally, this study addresses the contribution of each waste fraction to the total impacts and benefits of MSW incineration. It identifies several fractions whose contributions to impacts and benefits are not in line with their share in the composition of MSW incinerated.

Soil and land use research in Europe: Lessons learned from INSPIRATION bottom-up strategic research agenda setting.

We introduce the INSPIRATION bottom-up approach for the development of a strategic research agenda for spatial planning, land use and soil-sediment-water-system management in Europe. Research and innovation needs were identified by more than 500 European funders, endusers, scientists, policy makers, public administrators and consultants. We report both on the concept and on the implementation of the bottom-up approach, provide a critique of the process and draw key lessons for the development of research agendas in the future. Based on identified strengths and weaknesses we identified as key opportunities and threats 1) a high ranking and attentiveness for the research topics on the political agenda, in press and media or in public awareness, 2) availability of funding for research, 3) the resources available for creating the agenda itself, 4) the role of the sponsor of the agenda development, and 5) the continuity of stakeholder engagement as bases for identification of windows of opportunity, creating ownership for the agenda and facilitating its implementation. Our derived key recommendations are 1) a clear definition of the area for which the agenda is to be developed and for the targeted user, 2) a conceptual model to structure the agenda, 3) making clear the expected roles, tasks, input formats regarding the involvement and communication with the stakeholders and project partners, 4) a sufficient number of iterations and checks of the agenda with stakeholders to insure completeness, relevance and creation of co-ownership for the agenda, and 5) from the beginning prepare the infrastructure for the network to implement the agenda.

A consumption approach to wastes from economic activities.

In a context of waste management policies aimed at promoting waste prevention and recycling and, conversely, reducing waste landfilling, this study investigates how waste is generated and treated in a consumption perspective. A Waste Input-Output Analysis is implemented that considers 14 waste fractions and four waste management techniques. Input-Output Tables extended to wastes are initially compiled for the year 2008 considering France and five of its main import suppliers, and further completed with data on waste treatment. Wastes from economic activities are accordingly reallocated to the product categories of household consumption that induce their production. In particular, considering five waste categories (dry recyclable wastes, mixed wastes, mineral wastes, organic wastes, and total wastes) as an aggregation of the 14 waste fractions studied, the ten product categories with the highest contribution account for 64-86% of the total generation of wastes. Waste intensity and volume of expenses are analyzed as the drivers for the amounts of wastes induced by each product category. Similarly, the products responsible for the largest amounts of waste landfilling and incineration without energy recovery, i.e. the management techniques at the bottom of the "waste management hierarchy", are identified. Moreover, this study highlights the relative importance of waste produced abroad as compared to that produced in France, regarding the total amount of waste induced by French household consumption. The sensitivity of results to the modeling of import production is subsequently discussed. Finally, the potential perspectives for this type of consumption approach are considered with respect to its utility and current limitations in a context of waste policy planning, and more particularly regarding the way waste policy targets are set.

Life Cycle Assessment of mechanical biological pre-treatment of Municipal Solid Waste: a case study.

The environmental performance of mechanical biological pre-treatment (MBT) of Municipal Solid Waste is quantified using Life Cycle Assessment (LCA), considering one of the 57 French plants currently in operation as a case study. The inventory is mostly based on plant-specific data, extrapolated from on-site measurements regarding mechanical and biological operations (including anaerobic digestion and composting of digestate). The combined treatment of 46,929 tonnes of residual Municipal Solid Waste and 12,158 tonnes of source-sorted biowaste (as treated in 2010 at the plant) generates 24,550 tonnes CO2-eq as an impact on climate change, 69,943kg SO2-eq on terrestrial acidification and 19,929kg NMVOC-eq on photochemical oxidant formation, in a life-cycle perspective. On the contrary MBT induces environmental benefits in terms of fossil resource depletion, human toxicity (carcinogenic) and ecotoxicity. The results firstly highlight the relatively large contribution of some pollutants, such as CH4, emitted at the plant and yet sometimes neglected in the LCA of waste MBT. Moreover this study identifies 4 plant-specific operation conditions which drive the environmental impact potentials induced by MBT: the conditions of degradation of the fermentable fraction, the collection of gaseous flows emitted from biological operations, the abatement of collected pollutants and NOx emissions from biogas combustion. Finally the results underline the relatively large influence of the operations downstream the plant (in particular residuals incineration) on the environmental performance of waste MBT.

Chronic obstructive pulmonary disease in patients undergoing transcatheter aortic valve implantation: insights on clinical outcomes, prognostic markers, and functional status changes.

OBJECTIVES: This study sought to determine the effects of chronic obstructive pulmonary disease (COPD) on clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) and to determine the factors associated with worse outcomes in COPD patients. BACKGROUND: No data exist on the factors determining poorer outcomes in COPD patients undergoing TAVI. METHODS: A total of 319 consecutive patients (29.5% with COPD) who underwent TAVI were studied. Functional status was evaluated by New York Heart Association (NYHA) functional class, Duke Activity Status Index, and the 6-min walk test (6MWT) at baseline and at 6 to 12 months. The TAVI treatment was considered futile if the patient either died or did not improve in NYHA functional class at 6-month follow-up. RESULTS: Survival rates at 1 year were 70.6% in COPD patients and 84.5% in patients without COPD (p = 0.008). COPD was an independent predictor of cumulative mortality after TAVI (hazard ratio: 1.84; 95% confidence interval: 1.08 to 3.13; p = 0.026). Improvement in functional status was observed after TAVI (p < 0.001 for NYHA functional class, Duke Activity Status Index, and 6MWT), but COPD patients exhibited less (p = 0.036) improvement in NYHA functional class. Among COPD patients, a shorter 6MWT distance predicted cumulative mortality (p = 0.013), whereas poorer baseline spirometry results (FEV1 [forced expiratory volume in the first second of expiration]) determined a higher rate of periprocedural pulmonary complications (p = 0.040). The TAVI treatment was futile in 40 COPD patients (42.5%) and a baseline 6MWT distance <170 m best determined the lack of benefit after TAVI (p = 0.002). CONCLUSIONS: COPD was associated with a higher rate of mortality at mid-term follow-up. Among COPD patients, a higher degree of airway obstruction and a lower exercise capacity determined a higher risk of pulmonary complications and mortality, respectively. TAVI was futile in more than one-third of the COPD patients, and a shorter distance walked at the 6MWT predicted the lack of benefit after TAVI. These results may help to improve the clinical decision-making process in this challenging group of patients.

Environmental impacts of residual municipal solid waste incineration: a comparison of 110 French incinerators using a life cycle approach.

Incineration is the main option for residual Municipal Solid Waste treatment in France. This study compares the environmental performances of 110 French incinerators (i.e., 85% of the total number of plants currently in activity in France) in a Life Cycle Assessment perspective, considering 5 non-toxic impact categories: climate change, photochemical oxidant formation, particulate matter formation, terrestrial acidification and marine eutrophication. Mean, median and lower/upper impact potentials are determined considering the incineration of 1 tonne of French residual Municipal Solid Waste. The results highlight the relatively large variability of the impact potentials as a function of the plant technical performances. In particular, the climate change impact potential of the incineration of 1 tonne of waste ranges from a benefit of -58 kg CO2-eq to a relatively large burden of 408 kg CO2-eq, with 294 kg CO2-eq as the average impact. Two main plant-specific parameters drive the impact potentials regarding the 5 non-toxic impact categories under study: the energy recovery and delivery rate and the NOx process-specific emissions. The variability of the impact potentials as a function of incinerator characteristics therefore calls for the use of site-specific data when required by the LCA goal and scope definition phase, in particular when the study focuses on a specific incinerator or on a local waste management plan, and when these data are available.

Life Cycle Assessment of landfill biogas management: sensitivity to diffuse and combustion air emissions.

GOAL AND SCOPE: The life cycle inventory of landfill emissions is a key point in Life Cycle Assessment (LCA) of waste management options and is highly subject to discussion. Result sensitivity to data inventory is accounted for through the implementation of scenarios that help examine how waste landfilling should be modeled in LCA. METHOD: Four landfill biogas management options are environmentally evaluated in a Life Cycle Assessment perspective: (1) no biogas management (open dump), conventional landfill with (2) flaring, (3) combined heat and power (CHP) production in an internal combustion engine and (4) biogas upgrading for use as a fuel in buses. Average, maximum and minimum literature values are considered both for combustion emission factors in flares and engines and for trace pollutant concentrations in biogas. RESULTS: Biogas upgrading for use as a fuel in buses appears as the most relevant option with respect to most non-toxic impact categories and ecotoxicity, when considering average values for trace gas concentrations and combustion emission factors. Biogas combustion in an engine for CHP production shows the best performances in terms of climate change, but generates significantly higher photochemical oxidant formation and marine eutrophication impact potentials than flaring or biogas upgrading for use as a fuel in buses. INTERPRETATION AND DISCUSSION: However the calculated environmental impact potentials of landfill biogas management options depend largely on the trace gas concentrations implemented in the model. The use of average or extreme values reported in the literature significantly modifies the impact potential of a given scenario (up to two orders of magnitude for open dumps with respect to human toxicity). This should be taken into account when comparing landfilling with other waste management options. Also, the actual performances of a landfill top cover (in terms of oxidation rates) and combustion technology (in terms of emission factors) appear as key parameters affecting the ranking of biogas management options.

Transcatheter aortic valve implantation for the treatment of surgical valve dysfunction ("valve-in-valve"): assessing the risk of coronary obstruction.

Acute coronary obstruction is one of the most feared complications associated with transcatheter aortic valve-in-valve implantation. Strategies for assessing the risk of coronary occlusion during these procedures as well as preventive measures are discussed.

Effect of thoracic epidural analgesia on clinical outcomes following transapical transcatheter aortic valve implantation.

OBJECTIVE: To determine the impact of perioperative thoracic epidural analgesia (TEA) on acute and late outcomes following transapical transcatheter aortic valve implantation (TA-TAVI). PATIENTS AND INTERVENTION: A total of 135 consecutive patients who underwent TA-TAVI were included. All patients received catheter-based pain control, either via TEA (TEA group, n=74) or intercostal local analgesia with a catheter placed at the surgical incision site (non-TEA group, n=61), depending on the preference of the anaesthesiologist responsible for the case. MAIN OUTCOME MEASURES: Pain level during early postoperative period (verbal rating scale from 1 to 10), 30-day/in-hospital complications and mortality, and 1-year mortality. RESULTS: There were no differences in baseline or procedural characteristics between groups except for a lower left ventricular ejection fraction in the TEA group. The maximal pain score related to thoracotomy in the postoperative period was higher in the non-TEA group as compared with the TEA group (4 (IQR: 3-5)) vs 2 (IQR: 1-3), p<0.001). Non-TEA was associated with a higher rate of pulmonary complications (p<0.05 for nosocomial pneumonia, reintubation and tracheostomy). The 30-day/in-hospital mortality rate was higher in the non-TEA group (22.9% vs 2.7% in the TEA group, p<0.001). At 1-year follow-up, overall mortality remained higher in the non-TEA group (31.1%) compared with the TEA group (10.8%), p=0.005. Similar periprocedural and late results were obtained in a propensity score-matched analysis that included 100 matched patients. In the multivariable analysis, STS score (p=0.027) and absence of TEA (p=0.039) were independent predictors of increased cumulative late mortality. CONCLUSIONS: TEA provided superior analgesia following TA-TAVI, and was associated with a dramatic reduction in periprocedural respiratory complications, and both, short- and long-term mortality. These results highlight the importance of obtaining optimal analgesia following TA-TAVI to improve the results associated with this procedure.

Predictive factors, efficacy, and safety of balloon post-dilation after transcatheter aortic valve implantation with a balloon-expandable valve.

OBJECTIVES: This study sought to evaluate the predictive factors, effects, and safety of balloon post-dilation (BPD) for the treatment of significant paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). BACKGROUND: Very few data exist on BPD after TAVI with a balloon-expandable valve. METHODS: A total of 211 patients who underwent TAVI with a balloon-expandable valve were included. BPD was performed after TAVI if paravalvular AR ≥ 2 was identified by transesophageal echocardiography. Clinical events and echocardiographic data were prospectively recorded, and median follow-up was 12 (6 to 24) months. RESULTS: BPD was performed in 59 patients (28%), leading to a reduction in at least 1 degree of AR in 71% of patients, with residual AR <2 in 54% of the patients. The predictors of the need for BPD were the degree of valve calcification and transfemoral approach, with valve calcification volume >2,200 and >3,800 mm(3) best determining the need for and a poor response to BPD, respectively. Patients who underwent BPD had a higher incidence of cerebrovascular events at 30 days (11.9% vs. 2.0%, p = 0.006), with most (83%) events within the 24 h after the procedure occurring in patients who had BPD. No significant changes in valve area or AR degree were observed at follow-up in BPD and no-BPD groups. CONCLUSIONS: BPD was needed in about one-fourth of the patients undergoing TAVI with a balloon-expandable valve and was successful in about one-half of them. A higher degree of valve calcification and transfemoral approach predicted the need for BPD. BPD was not associated with any deleterious effect on valve function at mid-term follow-up, but a higher rate of cerebrovascular events was observed in patients who had BPD.

Prominent septal hypertrophy: a contra-indication for transapical aortic valve implantation?

We report a case of transapical aortic valve implantation in a patient with severe left ventricular hypertrophy. The valve was deployed but failed to attain stable seating because of a hypertrophied septal ridge encroaching on the landing zone. Moderate perivalvar insufficiency was also noted. A second valve was deployed in an attempt to achieve stable seating and correct the perivalvar leak. This was unsuccessful and the two-valve complex embolized into the ascending aorta. The valves were moved and seated in the proximal descending thoracic aorta. The technical issues of transapical aortic valve implantation in patients with severe left ventricular hypertrophy are reviewed.

Incidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aortic valve implantation.

OBJECTIVES: This study sought to evaluate the incidence, predictive factors, and prognostic value of new-onset atrial fibrillation (NOAF) following transcatheter aortic valve implantation (TAVI). BACKGROUND: Very few data exist on the occurrence of NOAF following TAVI. METHODS: A total of 138 consecutive patients with no prior history of atrial fibrillation (AF) underwent TAVI with a balloon-expandable valve. Patients were on continuous electrocardiogram monitoring until hospital discharge, and NOAF was defined as any episode of AF lasting >30 s. All clinical, echocardiographic, procedural, and follow-up data were prospectively collected. RESULTS: NOAF occurred in 44 patients (31.9%) at a median time of 48 h (interquartile range: 0 to 72 h) following TAVI. The predictive factors of NOAF were left atrial (LA) size (odds ratio [OR]: 1.21 for each increase in 1 mm/m(2), 95% confidence interval [CI]: 1.09 to 1.34, p < 0.0001) and transapical approach (OR: 4.08, 95% CI: 1.35 to 12.31, p = 0.019). At 30-day follow-up, NOAF was associated with a higher rate of stroke/systemic embolism (13.6% vs. 3.2%, p = 0.021, p = 0.047 after adjustment for baseline differences between groups), with no differences in mortality rate between groups (NOAF: 9.1%, no-NOAF: 6.4%, p = 0.57). At a median follow-up of 12 months (interquartile range: 5 to 20 months), a total of 27 patients (19.6%) had died, with no differences between the NOAF (15.9%) and no-NOAF (21.3%) groups, p = 0.58. The cumulative rate of stroke and stroke/systemic embolism at follow-up were 13.6% and 15.9%, respectively, in the NOAF group versus 3.2% in the no-NOAF group (p = 0.039, adjusted p = 0.037 for stroke; p = 0.020, adjusted p = 0.023 for stroke/systemic embolism). CONCLUSIONS: NOAF occurred in about one-third of the patients with no prior history of AF undergoing TAVI and its incidence was increased in patients with larger LA size and those undergoing transapical TAVI. NOAF was associated with a higher rate of stroke/systemic embolism, but not a higher mortality, at 30 days and at 1-year follow-up.

Incidence, predictive factors, and prognostic value of myocardial injury following uncomplicated transcatheter aortic valve implantation.

OBJECTIVES: This study sought to: 1) determine the incidence, degree, and timing of the rise in serum cardiac markers of myocardial injury associated with uncomplicated transcatheter aortic valve implantation (TAVI); and 2) evaluate the predictive factors and prognostic value of myocardial injury associated with TAVI. BACKGROUND: Very few data exist on the occurrence and clinical relevance of myocardial injury during TAVI procedures. METHODS: A total of 101 patients who underwent successful TAVI (transfemoral [TF] approach, n = 38; transapical [TA] approach, n = 63) were included. Creatine kinase-MB (CK-MB) and cardiac troponin T (cTnT) levels were determined at baseline and at 6 to 12, 24, 48, and 72 h following TAVI. RESULTS: TAVI was associated with some degree of myocardial injury in 99% of the patients (TF: 97%, TA: 100%) as determined by a rise in cTnT (maximal value, 0.48 µg/l, interquartile range [IQR]: 0.24 to 0.82 µg/l) and in 77% of the patients (TF: 47%, TA: 95%) as determined by a rise in CK-MB (maximal value, 18.6 µg/l; IQR: 11.0 to 27.4 µg/l). TA approach and baseline renal dysfunction were associated with a higher increase in biomarkers of myocardial injury (p < 0.01 for both). A larger myocardial injury was associated with a smaller improvement of left ventricular ejection fraction (LVEF) (p < 0.01). The degree of rise in cTnT was an independent predictor of cardiac mortality at 9 ± 10 months of follow-up (hazard ratio: 1.14 per each increase of 0.1 µg/l, 95% confidence interval: 1.02 to 1.28, p = 0.028). CONCLUSIONS: TAVI was systematically associated with some degree of myocardial injury, with TA approach and baseline renal dysfunction determining a higher increase in biomarkers of myocardial injury. A greater degree of myocardial injury was associated with less improvement in LVEF and a higher cardiac mortality at follow-up.

Performance-based functional assessment of patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Very few data exist on the functional evaluation of patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The aims of this prospective study were (1) to evaluate the Duke Activity Status Index (DASI) as a measure of functional status pre-TAVI and post-TAVI, (2) to determine the clinical parameters associated with DASI changes after TAVI, and (3) to compare functional status as evaluated by DASI and the New York Heart Association (NYHA) class with exercise capacity as evaluated by the 6-minute walk test (6MWT) in such patients. METHODS: A total of 76 patients (80 ± 8 years old) who underwent successful TAVI were included. All patients completed the DASI self-questionnaire at baseline and at 6 months after TAVI, and 46 patients also performed a 6MWT. RESULTS: The mean DASI increased from 10.3 ± 5.4 to 16.3 ± 8.3 at 6 months after TAVI (P < .0001). However, the DASI did not change or even decreased to some extent in 30% of patients after TAVI. Renal dysfunction as evaluated by the estimated glomerular filtration rate was identified as the independent predictor of DASI impairment after TAVI (OR 1.7 for each decrease in estimated glomerular filtration rate of 10 mL/min/1.73 m(2), 95% CI 1.3-2.3, P = .005). The mean distance walked increased from 165.9 ± 77.6 to 211.8 ± 78.7 m (P = .0001) at follow-up. The DASI showed a good correlation with the distance walked at baseline (r = 0.55, P < .0001) and at follow-up (r = 0.66, P < .0001). The NYHA class improved to some degree in all but 5 patients; however, the NYHA class did not correlate with the results of DASI and the 6MWT. CONCLUSIONS: Transcatheter aortic valve implantation was associated with a significant increase in functional status at 6-month follow-up as evaluated by the DASI, although no improvement was observed in about one third of patients. The presence of baseline renal dysfunction better determined this lack of improvement in functional status. The DASI, but not the NYHA class, correlated with distance walked in the 6MWT. These results suggest that the DASI might become a useful tool for evaluating both candidates for and the impact of TAVI procedures.

Usefulness of TEE as the primary imaging technique to guide transcatheter transapical aortic valve implantation.

OBJECTIVES: The aim of this study was to: 1) determine the usefulness of transesophageal echocardiography (TEE) as the primary technique to guide transapical (TA) transcatheter aortic valve implantation (TAVI); and 2) to compare TEE with angiography as the primary imaging modality for TA-TAVI guidance. BACKGROUND: TEE has been routinely used as an adjunct to angiography during TA-TAVI procedures, but very few data exist on the use of TEE as the primary imaging technique guiding TA-TAVI. METHODS: One hundred consecutive high-risk patients (mean age 79 ± 9 years, mean logistic EuroSCORE: 25.8 ± 17.6%) who underwent TA-TAVI in our center were included. The Edwards valve was used in all cases, and all procedures were performed in an operating room without hybrid facilities. The TA-TAVI was primarily guided by angiography in the first 25 patients (A-TAVI group) and by TEE in the last 75 patients (TEE-TAVI group). Procedural, 30-day, and follow-up results were evaluated. RESULTS: No differences were observed between groups at baseline except for a higher (p = 0.001) prevalence of moderate or severe mitral regurgitation in the TEE-TAVI group. The procedure was successful in 97.3% and 100% of the patients in the TEE-TAVI and A-TAVI groups, respectively (p = 1.0), and a lower contrast volume was used in the TEE-TAVI group (12 [5 to 20] ml vs. 40 [20 to 50] ml, p < 0.0001). There were no differences between groups in the occurrence of valve malposition needing a second valve (TEE-TAVI: 5.3%; A-TAVI: 4%; p = 1.0) or valve embolization (TEE-TAVI: 1.3%; A-TAVI: 4%; p = 0.44). The results regarding post-procedural valve hemodynamic status and aortic regurgitation were similar between groups. The survival rates at 30-day and 1-year follow-up were 87% and 75% in the TEE-group and 88% and 84% in the A-TAVI group, respectively (log-rank = 0.49). CONCLUSIONS: TEE-TAVI was associated with similar acute and midterm results as A-TAVI and significantly reduced contrast media use during the procedures. These results suggest the feasibility and safety of performing TA-TAVI procedures in an operating room without hybrid facilities, but larger studies are needed to confirm these findings.

Cerebral embolism following transcatheter aortic valve implantation: comparison of transfemoral and transapical approaches.

OBJECTIVES: The objective of this study was to compare the incidence of cerebral embolism (CE) as evaluated by diffusion-weighted magnetic resonance imaging (DW-MRI) following transapical (TA) transcatheter aortic valve implantation (TAVI) versus transfemoral (TF) TAVI. BACKGROUND: The TA-TAVI approach avoids both the manipulation of large catheters in the aortic arch/ascending aorta and the retrograde crossing of the aortic valve, and this avoidance might lead to a lower rate of CE. METHODS: This was a prospective multicenter study including 60 patients who underwent cerebral DW-MRI the day before and within the 6 days following TAVI (TF approach: 29 patients; TA approach: 31 patients). Neurologic and cognitive function assessments were performed at DW-MRI time points. RESULTS: The TAVI procedure was performed with the Edwards valve and was successful in all cases but one (98%). A total of 41 patients (68%) had 251 new cerebral ischemic lesions at the DW-MRI performed 4 ± 1 days after the procedure, 19 patients in the TF group (66%) and 22 patients in the TA group (71%; p = 0.78). Most patients (76%) with new ischemic lesions had multiple lesions (median number of lesions per patient: 3, range 1 to 31). There were no differences in lesion number and size between the TF and TA groups. No baseline or procedural factors were found to be predictors of new ischemic lesions. The occurrence of CE was not associated with a measurable impairment in cognitive function, but 2 patients (3.3%) had a clinically apparent stroke within the 24 h following the procedure (1 patient in each group). CONCLUSIONS: TAVI is associated with a high rate of silent cerebral ischemic lesions as evaluated by DW-MRI, with no differences between the TF and TA approaches. These results provide important novel insight into the mechanisms of CE associated with TAVI and support the need for further research to both reduce the incidence of CE during these procedures and better determine their clinical relevance.

Transcatheter aortic valve implantation with "no touch" of the aortic arch for the treatment of severe aortic stenosis associated with complex aortic atherosclerosis.

We present the case of an 80-year-old woman diagnosed with severe aortic stenosis and complex aortic atherosclerotic plaques who underwent transapical TAVI guided by transesophageal echocardiography and fluoroscopy with no catheter/wire manipulation across the aortic arch to avoid any systemic embolism.

Electrocardiographic changes and clinical outcomes after transapical aortic valve implantation.

BACKGROUND: Transapical aortic valve implantation (TAVI) for the treatment of severe aortic stenosis requires the insertion of a large catheter through the left ventricular apex. However, the electrocardiographic (ECG) changes associated with the incision and repair of the left ventricular apex and the potential damage to the conduction system caused by implanting a balloon-expandable valve in aortic position are not known. The objective of our study was to determine the incidence, type, and timing of ECG changes associated with TAVI. METHODS: The standard 12-lead ECGs of 33 consecutive patients (mean age 81 +/- 9 years, 13 men) diagnosed with symptomatic severe aortic stenosis (valve area 0.62 +/- 0.16 cm(2)) who underwent TAVI with an Edwards-SAPIEN valve were analyzed at baseline (within 24 hours before the procedure), immediately (within 6 hours) after the procedure, at hospital discharge, and at 1-month follow-up. RESULTS: There were no procedural deaths, and 30-day mortality was 6%. The incidence of complete left ventricular branch block (LBBB) and left anterior hemiblock (LAHB) increased from 9% and 3% at baseline to 27% and 36% after the procedure, respectively (P < .03 for both). A lower (ventricular) position of the valve relative to the hinge point of the anterior mitral leaflet was associated with a higher incidence of new LBBB (35% vs 0%, P = .029); and a greater valve size-aortic annulus ratio, with the occurrence of new LAHB (1.20 +/- 0.07 vs 1.14 +/- 0.06, P = .021). At 1-month follow-up, the rate of LBBB and LAHB decreased to 13% and 10%, respectively (P = not significant compared with baseline). There were no cases of new atrioventricular block, and no patient needed pacemaker implantation. Transient (<48 hours) ST-elevation changes, mostly in the anterior and/or lateral leads, occurred in 6 patients (18%) immediately after the procedure; but only 1 of these patients presented new Q waves at 1-month follow-up. CONCLUSIONS: Transapical aortic valve implantation was associated with a significant but transient (<1 month) increase in LBBB and LAHB, with no patient requiring pacemaker implantation. These changes were partially related to both lower (more ventricular) valve positioning and greater valve oversizing. Transient (<48 hours) ST-segment elevation changes occurred in about one fifth of the patients after the procedure, but only a minority developed new Q waves in the ECG.