Five-Year Transcatheter Aortic Valve Replacement Outcomes in Chronic Hemodialysis vs. Non-Hemodialysis Patients Using Balloon-Expandable Devices.

BACKGROUND: Based on the results of a clinical trial in Japan, transcatheter aortic valve replacement (TAVR) for hemodialysis (HD) patients gained approval; however, mid-term TAVR outcomes and transcatheter aortic valve (TAV) durability in HD patients remain unexplored.Methods and Results: We analyzed background, procedural, in-hospital outcome, and follow-up data for 101 HD patients and 494 non-HD patients who underwent TAVR using balloon-expandable valves (SAPIEN XT or SAPIEN 3) retrieved from Osaka University Hospital TAVR database. Periprocedural mortality and TAVR-related complications were comparable between HD and non-HD patients. However, Kaplan-Meier analysis revealed that HD patients had significantly lower survival rates (log-rank test, P<0.001). In addition, HD patients had significantly higher rates of severe structural valve deterioration (SVD) than non-HD patients (Gray test, P=0.038). CONCLUSIONS: TAVR in HD patients had comparable periprocedural mortality but inferior mid-term survival and TAV durability than in non-HD patients. Indications for TAVR in younger HD patients should be carefully determined, considering the possibility of a TAV-in-TAV procedure when early SVD occurs.

The usefulness of chest drain and epicardial pacing wire culture for diagnosing mediastinitis after open-heart surgery.

PURPOSE: Culture of extracted drains or epicardial pacing wires is an easy and noninvasive method for detecting mediastinitis after open-heart surgery, although studies on its sensitivity and specificity are limited. We, therefore, investigated the usefulness of this approach for diagnosing mediastinitis. METHODS: We retrospectively studied the culture results of drains and epicardial pacing wires extracted from 3308 patients. Prediction models of mediastinitis with and without culture results added to clinical risk factors identified by a logistic regression analysis were compared. RESULTS: The incidence of mediastinitis requiring surgery was 1.89% (n = 64). Staphylococcus was the causative bacterium in 64.0% of cases. The sensitivity, specificity, and positive and negative predictive values of positive culture results were 50.8%, 91.8%, 10.7%, and 99.0%, respectively. Methicillin-resistant Staphylococcus aureus had the highest positive predictive value (61.5%). A multivariate analysis identified preoperative hemodialysis (OR 5.40 [2.54-11.5], p < 0.01), long operative duration (p < 0.01), postoperative hemodialysis (OR 2.25 [1.01-4.98], p < 0.05), and positive culture result (OR 10.2 [5.88-17.7], p < 0.01) as independent risk factors. The addition of culture results to pre- and postoperative hemodialysis and a lengthy operative time improved the prediction of mediastinitis. CONCLUSIONS: A culture survey using extracted drains and epicardial pacing wires may provide useful information for diagnosing mediastinitis.

Clinical Outcomes and Factors Associated With Aortic Shrinkage After Thoracic Endovascular Aortic Repair for Aneurysmal Chronic Aortic Dissection.

PURPOSE: The effectiveness of thoracic endovascular aortic repair (TEVAR) for chronic aortic dissection (AD) with aneurysmal degeneration remains controversial. We retrospectively investigated clinical outcomes and assessed predictors of aortic shrinkage after TEVAR for chronic aneurysmal AD. MATERIALS AND METHODS: Between January 2010 and December 2021, 70 patients with double-barrel-type chronic AD were enrolled. Major intimal tears in thoracic aorta were covered by stent graft. Early and late clinical outcomes, and diameter change of downstream aorta during follow-up period were reviewed. Subsequently, factors associated with aortic shrinkage were assessed by logistic regression analysis. RESULTS: Mean age was 63 (interquartile range [IQR]: 54-68) years, 54 (80%) men, median duration from AD onset was 4 (IQR: 1-10) years, and maximum aortic diameter was 53 (IQR: 49-58) mm. Supra-aortic debranching procedure was required in 57 (81%) patients. Early aorta-related death occurred in 2 (3%) patients. Both stroke and spinal cord ischemia occurred in 1 (2%) patient. Five-year freedom rates from aorta-related death and reintervention were 96% and 51%, respectively. Sixty-four patients underwent follow-up computed tomography (84%) 1 year after TEVAR, with 33 (52%) achieving aortic shrinkage. In multivariable analysis, duration from AD onset (per year) (odds ratio [OR]: 0.82, 0.70-0.97; p=0.017) and maximum aortic-diameter ratio between aortic arch and descending aorta (per 0.1) (morphologic index; OR: 1.34, 1.04-1.74; p=0.023) were independent aortic shrinkage predictors. CONCLUSIONS: Thoracic endovascular aortic repair for chronic AD with aneurysmal degeneration achieved satisfactory survival outcomes, but with a considerable reintervention rate. Duration from AD onset and preoperative aortic morphology could affect post-TEVAR aortic shrinkage. Earlier intervention could lead to better aortic shrinkage. CLINICAL IMPACT: Thoracic endovascular aortic repair for chronic aortic dissection with aneurysmal degeneration showed low incidence of early and late aorta-related death. By contrast, aortic shrinkage rate was low with high incidence of reintervention to the residual downstream aorta. According to the assessment of preoperative variables, chronicity and aortic morphology could predict postoperative aortic shrinkage.

Impact of the Patency of Inferior Mesenteric Artery on 7-Year Outcomes After Endovascular Aneurysm Repair.

PURPOSE: The impact of preoperative patent inferior mesenteric artery (IMA) on late outcomes following endovascular aneurysm repair (EVAR) remains unclear. This study aimed to investigate the specific influence of IMA patency on 7-year outcomes after EVAR. MATERIALS AND METHODS: In this retrospective cohort study, 556 EVARs performed for true abdominal aortic aneurysm cases between January 2006 and December 2019 at our institution were reviewed. Endovascular aneurysm repairs performed using a commercially available device with no type I or type III endoleak (EL) during follow-up and with follow-up ≥12 months were included. A total of 336 patients were enrolled in this study. The cohort was divided into the patent IMA group and the occluded IMA group according to preoperative IMA status. The late outcomes, including aneurysm sac enlargement, reintervention, and mortality rates, were compared between both groups using propensity-score-matched data. RESULTS: After propensity score matching, 86 patients were included in each group. The median follow-up period was 56 months (interquartile range: 32-94 months). The incidence of type II EL at discharge was 50% in the patent IMA group and 19% in the occluded IMA group (p<0.001). The type II EL from IMA and lumbar arteries was significantly higher in the patent IMA group than in the occluded IMA group (p<0.001 and p=0.002). The rate of freedom from aneurysm sac enlargement with type II EL was significantly higher in the occluded IMA group than in the patent IMA group (94% vs 69% at 7 years; p<0.001). The rate of freedom from reintervention was significantly higher in the occluded IMA group than in the patent IMA group (90% vs 74% at 7 years; p=0.007). Abdominal aortic aneurysm-related death and all-cause mortality did not significantly differ between groups (p=0.32 and p=0.34). CONCLUSIONS: Inferior mesenteric artery patency could affect late reintervention and aneurysm sac enlargement but did not have a significant impact on mortality. Preoperative assessment and embolization of IMA might be an important factor for improvement in late EVAR outcomes. CLINICAL IMPACT: The preoperative patency of the inferior mesenteric artery was significantly associated with a higher incidence of sac enlargement and reintervention with type II endoleak following endovascular aneurysm repair, even after adjustment for patient background. Preoperative assessment and embolization of inferior mesenteric artery might be an important factor for improvement in late EVAR outcomes.

Efficacy of a Protective Sheet for Reducing Ocular Radiation Exposure During Transcatheter Aortic Valve Implantation.

BACKGROUND: The use of hybrid operating rooms (HOR) for transcatheter aortic valve implantation (TAVI) has increased, so radiation exposure during procedures that use X-ray fluoroscopy is a fundamental problem not only for patients but also for surgeons and interventional cardiologists, increasing the risk of cataracts among operators. We investigated the efficacy of leaded glasses and protective sheets for ocular radiation protection.Methods and Results: Between January 2020 and February 2021 we enrolled 54 TAVI procedures using the transfemoral approach. The subjects were divided into a curtain protection group (Group C, n=20), glass protection group (Group G, n=17), and sheet protection group (Group S, n=17). The cumulative dose (CD) of the operators showed a decreasing trend in Group S compared with the other two groups. The CD normalized by dose area product (CD/DAP) of the operators was significantly reduced in Group S compared with Group C. However, Group G showed no significant difference compared with Group C. Regarding the distribution of CD/DAP, Group S had a significantly lower distribution than that in groups C and G. CONCLUSIONS: Protective sheets provide more stable radiation protection than conventional curtains or leaded glasses.

Preoperative hypomagnesemia as a possible predictive factor for postoperative increase of transvalvular pressure gradient in hemodialysis patients treated with transcatheter aortic valve implantation.

BACKGROUND: Patients undergoing maintenance hemodialysis (HD) with severe aortic stenosis are at a high risk for bioprosthetic valve dysfunction after transcatheter aortic valve implantation (TAVI). Currently, preoperative factors that predict the occurrence of valve dysfunction after TAVI on HD patients remain to be elucidated. The aim of this study is to analyze the association between preoperative clinical factors and valve stenosis after TAVI on HD patients. METHODS: Twenty-four of HD patients who underwent TAVI at our institution between April 2012 and January 2016 were analyzed. The mean aortic transvalvular pressure gradient (MPG) and effective orifice area index (EOAi) were assessed by serial echocardiography. Associations between preoperative clinical factors and time-series changes in MPG were examined using mixed-effects linear regression model for repeated measures. RESULTS: Three patients developed severe structural valve deterioration with calcific valve stenosis requiring reoperation. A multivariate linear mixed-effects model showed that lower serum magnesium (sMg) levels were associated with the increase of MPG after TAVI (beta-coefficient = 0.019, p = 0.03). No correlation was observed with serum calcium, phosphorus, or intact parathyroid hormone. Time-series changes of MPG and EOAi had significant difference between lower and higher sMg group. All 3 of the patients who underwent reoperation showed lower preoperative sMgs. CONCLUSION: Among bone-mineral metabolism markers, preoperative hypomagnesemia was associated with the increase of MPG after TAVI, suggesting that hypomagnesemia could predict post-TAVI valve dysfunction in HD patients. Further studies with larger sample sizes are warranted.

Nosocomial infections caused by vancomycin-resistant Enterococcus in a Japanese general hospital and molecular genetic analysis.

INTRODUCTION: Vancomycin-resistant Enterococcus (VRE) is a rare bacterium in Japan, but an outbreak due to nosocomial transmission in medical facilities has been reported in recent years. Here, we report the outbreak of vanA vancomycin-resistant Enterococcus faecium (VREfm) in multiple wards of Nara Prefectural General Medical Center in 2019 and results of the molecular epidemiology analysis. METHODS: An aggressive screening program was conducted after the first VREfm was detected in a patient in the A ward. During the outbreak, 6000 rectal swab samples were screened for VRE by culture. Isolates from 60 patients with VREfm detected were clustered using pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). RESULTS: PFGE revealed a cluster consisting of three major clusters and four multi-strains. The first major cluster consisted of 26 isolates, the second consisted of 10 isolates, the third consisted of 6 isolates, and the remaining 4 clusters consisted of 2 isolates. MLST identified an allele profile (ST80) in most clusters of clone types P01-P06 but an allele profile (ST992) in cluster P07. CONCLUSION: Based on the PFGE pattern, this case was considered to be a nosocomial infection due to multiple clones. Later, in addition to screening, sharing of hospital information, cohorting of patients and staff, and strengthening of environmental cleanup were carried out, and horizontal infection was suppressed.

A case of Bordetella trematum and Kerstersia gyiorum infections in a patient with congestive dermatitis.

Bordetella trematum and Kerstersia gyiorum are rare gram-negative bacilli that are not frequently detected in human infections. In this report, we describe a case of a 48-year-old man who presented to our hospital with an infected wound on his leg. Discharges from the cracks of the granulation were collected and evaluated in our microbiology laboratory. Gram staining of the specimen showed polymorphonuclear leukocytes and abundant gram-negative bacilli. Three types of colonies were isolated on blood agar and were identified as B. trematum and Alcaligenes faecalis using VITEK MS. Moreover, K. gyiorum and B. trematum were identified and confirmed via 16S ribosomal RNA (rRNA) gene sequencing. The patient successfully recovered following application of meropenem antibacterial therapy and surgical debridement. This is the first reported case of complex wound infection caused by both B. trematum and K. gyiorum. Identification of B. trematum has recently been made possible by routine bacterial identification using matrix-assisted laser desorption-ionization time-of-flight mass spectrometry (MALDI-TOF MS). However, K. gyiorum isolation is still rare, and species identification requires 16S rRNA sequencing. Thus, this case highlighted the importance of using multiple methods, such as MALDI-TOF MS and 16S rRNA gene sequencing, for identification of rarely isolated species from clinical specimens.

Factors associated with viral clearance periods from patients with COVID-19: A retrospective observational cohort study.

INTRODUCTION: Knowledge is limited on the virologic course of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, particularly the time taken for viral clearance and the optimal time to discontinue isolation. This study aims to identify the clinical and demographic factors influencing the time taken for viral clearance in patients with COVID-19 to determine the optimal isolation period. METHODS: This two-center retrospective observational cohort study was conducted between March 1 and June 31, 2020. Patients with COVID-19, which was confirmed by real-time reverse transcription polymerase chain reaction, were included. Data were extracted from medical records. The positive duration, which was defined as the period from the day of symptom onset to the negative conversion day, was assessed using a generalized linear model. RESULTS: We included 63 patients. The mean positive duration was 20 days. The positive duration was significantly shorter for patients younger than 30 years of age and those between 30 and 60 years of age than for patients older than 60 years of age. We observed a more scattered distribution of the positive duration in older patients than in younger patients. CONCLUSIONS: Younger patients who recovered from COVID-19 took less time to clear SARS-CoV-2 than older patients; thus, a classification of the isolation periods based on age could be considered. A uniform viral clearance period for older patients may be difficult to determine because of biases such as underlying medical conditions. Further surveillance measures are recommended to determine the viral clearance time and the optimal isolation period.

Transcatheter aortic valve replacement as a bridge to surgical aortic valve replacement in a younger patient with extremely high surgical risk.

A 50-year-old man with decompensated aortic stenosis displayed significantly reduced ejection fraction, an ascending aortic aneurysm (55 mm in diameter), and bilateral giant bullae, and was evaluated as having extremely high surgical risk. Therefore, as a bridge to definitive treatment, he simultaneously underwent transcatheter aortic valve replacement (TAVR) and upper left lung lobectomy. His heart function recovered 6 months later and he underwent surgical aortic valve replacement (SAVR) and graft replacement of the ascending aorta. TAVR may serve as a bridge procedure before SAVR for aortic stenosis in younger patients with high surgical risk.

Midterm Outcomes of Transcatheter Aortic Valve Replacement in Dialysis Patients With Aortic Valve Stenosis.

BACKGROUND: Little is known about late outcomes after transcatheter aortic valve replacement (TAVR) in dialysis patients.Methods and Results:We enrolled 25 dialysis patients (mean age 76.5 years; mean STS score 14.7%; men 60.0%) with aortic valve stenosis undergoing TAVR at our institute. Cardiovascular mortality and stroke were defined according to the VARC-2 criteria, and major adverse cardiac and cerebrovascular events (MACCE) were investigated. Twenty-three patients (92.0%) were discharged, and the median hospital stay after TAVR was 9 days (IQR, 7.5-11 days). Mortality at 30 days was not observed. The overall survival rate at 1 and 3 years were 80.0% and 55.7%, respectively (follow-up period, 879±493 days; range, 40-1,826 days). At 1 and 3 years, rates of freedom from cardiovascular mortality, disabling stroke, and MACCE were 100% and 83.0%, 91.2% and 84.7%, and 69.8% and 39.9%, respectively. Three patients required redo-TAVR for valve dysfunction at 23, 36, and 38 months after the first TAVR, respectively (The rate of freedom from severe structural valve deterioration at 1 and 3 years was 100% and 85.9%, respectively). CONCLUSIONS: Satisfactory in-hospital outcomes were achieved in dialysis patients after TAVR. Various problems, however, such as complications particular to dialysis patients and valve durability, remained at midterm follow-up. Further studies are recommended to solve these problems, and prudent preoperative assessments should be mandatory.

Overview of the 82nd Annual Scientific Meeting of the Japanese Circulation Society　- Futurability: Pioneering the Future of Circulatory Medicine.

The 82nd Annual Scientific Meeting of the Japanese Circulation Society was held in Osaka, Japan, on March 23-25, 2018, when the cherry blossoms were just opening everywhere around the venue. This was the 5th Annual Scientific Meeting of JCS in which a cardiovascular surgeon served as Congress Chairperson. The main theme of this meeting was "Futurability: Pioneering the Future of Circulatory Medicine". The word, futurability, is a neologism of future ability, because we now have to contemplate what constitutes the essence of cardiovascular medicine, how it should develop as medicine for future generations, and how its ability should be displayed. The meeting was favored by splendid weather and the number of participants was recorded as being higher than 18,700. There were heated and profound discussions about the "futurability" of cardiology, cardiovascular surgery, and heart team medical care as well, in every session. The meeting was successfully completed and we sincerely appreciate the great cooperation and support from all affiliates.

Five-Year Outcomes of the First Pivotal Clinical Trial of Balloon-Expandable Transcatheter Aortic Valve Replacement in Japan (PREVAIL JAPAN).

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has been an alternative less invasive therapy for high-surgical risk/inoperable patients with aortic valve stenosis (AS) in Japan. We report 5-year outcomes of the first pivotal clinical trial of TAVR in Japan (PREVAIL JAPAN).Methods and Results:A total of 64 patients with AS who were considered unsuitable candidates for surgery were enrolled at 3 centers in Japan (mean age: 84.3±6.1 years, female: 65.6%, STS score: 9.0±4.5%). Transfemoral approach (TF) and transapical approach (TA) was performed in 37 patients and 27 patients, respectively. At 5 years, freedom from all-cause death was 52.7% (TF: 51.3%, TA: 56.3%). Risk of all stroke at 5-year was 15.8% (TF: 8.9%, TA: 25.5%) and risk of major adverse cardiac and cerebrovascular events at 5 years was 58.0% (TF: 51.3%, TA: 69.2%). Mild or greater aortic regurgitation (AR) at 1 week was not associated with increased all-cause death at 5 years (69.1%) compared with none or trace AR (48.3%) (P=0.184). Patients with high STS score (>8) had higher mortality rate than those with low STS scores (≤8). CONCLUSIONS: The 5-year data from PREVAIL JAPAN show the clinical benefit of TAVR and suggest that balloon-expandable TAVR is an effective treatment option for Japanese patients with severe AS who are not suitable for surgery. (Funded by Edwards Lifesciences Limited; ClinicalTrials.gov number, NCT01113983.).

Clinical Outcomes and Bioprosthetic Valve Function After Transcatheter Aortic Valve Implantation Under Dual Antiplatelet Therapy vs. Aspirin Alone.

BACKGROUND: Dual antiplatelet therapy (DAPT) is commonly used after transcatheter aortic valve implantation (TAVI); however, the supporting evidence is limited. To determine if aspirin alone is a better alternative to DAPT, we compared the outcomes of patients treated with DAPT or aspirin alone after TAVI.Methods and Results:We analyzed a total of 144 consecutive patients (92 females, mean age 83±6 years) who underwent implantation of a balloon-expandable transcatheter valve (SAPIEN or SAPIEN XT, Edwards Lifesciences). Patients were divided into DAPT (n=66) or aspirin-alone treatment groups (n=78). At 1 year after TAVI, the composite endpoint, which consisted of all-cause death, myocardial infarction, stroke, and major or life-threatening bleeding complications, occurred significantly less frequently (Kaplan-Meier analysis) in the aspirin-alone group (15.4%) than in the DAPT group (30.3%; P=0.031). Valve function assessed by echocardiography was similar between the 2 treatment groups with respect to effective orifice area (1.78±0.43 cm2in DAPT vs. 1.91±0.46 cm2in aspirin-alone group; P=0.13) and transvalvular pressure gradient (11.1±3.5 mmHg in DAPT vs. 10.3±4.1 mmHg in aspirin-alone group; P=0.31). CONCLUSIONS: Treatment with aspirin alone after TAVI had greater safety benefits and was associated with similar valve function as DAPT. These results suggest that treatment with aspirin alone is an acceptable regimen for TAVI patients.

Midterm Outcomes With a Self-Expandable Transcatheter Heart Valve in Japanese Patients With Symptomatic Severe Aortic Stenosis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a viable alternative to surgical aortic valve replacement in high-risk or inoperable patients with aortic stenosis (AS). Here we report the midterm outcomes of high-risk Japanese patients with severe AS who underwent TAVI with a self-expandable TAV.Methods and Results:The CoreValve Japan Trial was a prospective, multicenter trial of the CoreValve System. A group of 55 patients (mean age 82.5±5.5 years, 30.9% male, 100% NYHA class III/IV, STS 8.0±4.2%) were enrolled in the 26-mm/29-mm CoreValve study, and 20 patients (mean age 81.0±6.6 years, 5.0% male, 100% NYHA class III/IV, STS 7.0±3.3%) were enrolled in the 23-mm CoreValve study, which started 1 year later. For the 26-mm/29-mm cohort, the 3-year all-cause mortality rate was 32.6%; major stroke was 15.4%. Mean pressure gradient (MPG), effective orifice area (EOA), and NYHA class showed sustained improvement. Paravalvular regurgitation (PVR) at 3 years was 28.6% (none), 25.7% (trace), 40.0% (mild), 5.7% (moderate), and 0.0% (severe). For the 23-mm cohort, the 2-year all-cause mortality rate was 5.0%; major stroke was 5.0%. MPG, EOA, and NYHA class showed sustained improvement. PVR at 2 years was 16.7% (none), 33.3% (trace), 44.4% (mild), 5.6% (moderate), and 0.0% (severe). CONCLUSIONS: TAVI with the CoreValve System was associated with sustained clinical and functional cardiac improvement in high surgical risk Japanese patients with severe AS. (Clinicaltrials.gov Identifiers: NCT01437098 and NCT01634269.).

Early Outcomes in Japanese Dialysis Patients Treated With Transcatheter Aortic Valve Implantation.

BACKGROUND: Although transcatheter aortic valve implantation (TAVI) is a new alternative treatment with acceptable midterm results for high surgical risk patients, at present performing the procedure in dialysis patients is not reimbursed in Japan. METHODS AND RESULTS: The study group of 17 dialysis patients (mean age, 76.7±5.0 years) underwent TAVI with the SAPIEN/SAPIEN XT. EuroSCORE and STS score were 25.0±19.0% and 15.4±12.3%, respectively. Transiliofemoral and transapical approaches were performed in 7 (41.2%) and 10 patients (58.8%), respectively. ICU and hospital stays after TAVI were 1.8±1.6 and 12.9±12.7 days, respectively. Mean transvalvular gradients at discharge significantly decreased from 45.9±13.3 mmHg to 10.7±4.3 mmHg (P<0.0001) and effective orifice area significantly increased from 0.78±0.17 to 1.69±0.37 cm(2)(P<0.0001). Device success was 87.5%. One patient required a valve-in-valve procedure on 187-postoperative-day for an acute increase in paravalvular leakage caused by initial lower implantation of the device. The overall mortality at 1 year was 0% and clinical efficacies at 30 days, 6 months, and 1 year were 93.8%, 83.3%, and 69.2%, respectively. CONCLUSIONS: Satisfactory early results were achieved with TAVI in Japanese dialysis patients with a high surgical risk, indicating it is a safe and effective alternative for the treatment of aortic valve stenosis in such patients.

New Self-Expanding Transcatheter Aortic Valve Device for Transfemoral Implantation- Early Results of the First-in-Asia Implantation of the ACURATE Neo/TF(TM) System.

BACKGROUND: Feasibility and early results of transfemoral aortic valve implantation using the ACURATE neo/TF(TM)self-expanding stent are reported. METHODS AND RESULTS: The study group of 15 patients (mean age 83.3±6.0) was enrolled with a mean EuroSCORE and STS score of 21.9±11.6% and 7.5±3.1%, respectively. Clinical and echocardiographic evaluations were performed at baseline, discharge, 30 days and 6 months. The primary endpoint was all-cause mortality at 30 days. Transcatheter aortic valve implantation (TAVI) using the ACURATE neo/TF device was successful in 14 patients; 1 patient underwent valve-in-valve implantation because the prosthetic valve embolized during withdrawal of the delivery system. Conversion to surgery, coronary obstruction, peri-operative stroke, and pacemaker implantation did not occur at 30 days. Mean transvalvular gradients at discharge significantly decreased from 44.2±10.5 mmHg (preprocedural) to 7.7±3.1 mmHg (P<0.0001) and effective orifice area significantly increased from 0.77±0.12 to 1.69±0.25 cm(2)(P<0.0001). None or trace paravalvular leak was revealed in 50.0%, and no patient exhibited moderate or higher paravalvular leak. The overall mortality at 30 days and 6 months was 0% and 6.7%, respectively. CONCLUSIONS: A new self-expanding TF TAVI device, ACURATE neo/TF, is safe and effective in the treatment of severe aortic stenosis in elderly patients at high risk for surgery.

Chronic invasive sinus and intracerebral aspergillosis controlled by combination therapy with micafungin and a daily dose of 400 mg itraconazole oral solution.

Chronic invasive aspergillosis of the sinus is frequently fatal in the absence of early surgical and chemotherapeutic intervention because of its invasion of vascular tissue. We attempted to control a case of inoperable invasive aspergillosis of the sinus with micafungin and itraconazole oral solution. We prescribed a daily oral dose of 400 mg of itraconazole, which is twice the usual dose, and monitored the serum concentration of the drug. Finally, we were able to control the spread of the lesion. This case indicates that combination therapy with micafungin and a daily dose of 400 mg itraconazole oral solution is an alternative treatment strategy for inoperable invasive aspergillosis of the sinus.

Predictors of Prolonged Hemodynamic Compromise After Valve Deployment During Transcatheter Aortic Valve Implantation.

OBJECTIVE: To identify the risk factors of prolonged hemodynamic compromise caused by rapid pacing for valve deployment during transcatheter aortic valve implantation. DESIGN: A retrospective study. SETTING: Academic hospital. PARTICIPANTS: Forty-seven patients with severe aortic stenosis who underwent transcatheter aortic valve implantation. INTERVENTIONS: The time after the end of rapid pacing until systolic arterial pressure and SvO2 recovery (systolic arterial pressure>90 mmHg and SvO2>65%) was defined as "the hemodynamic recovery time" and was measured from online anesthetic charts. The total study population was divided into 2 groups according to the recovery time (third quartile in all patients; 33 and 14 patients in the early and delayed recovery groups, respectively). Subsequently, the factors associated with prolonged hemodynamic compromise after rapid pacing for valve deployment were identified by univariate and multivariate analyses. MEASUREMENTS AND MAIN RESULTS: Multivariate analysis identified left ventricular end-diastolic diameter (odds ratio, 0.774; 95% confidence interval, 0.608-0.915) and SvO2 (odds ratio, 0.748; 95% confidence interval, 0.590-0.868) as independent factors associated with prolonged hemodynamic compromise after rapid pacing for valve deployment. CONCLUSIONS: SvO2 and left ventricular end-diastolic diameter were found to be significant independent predictors of prolonged hemodynamic compromise immediately after rapid pacing for valve deployment during transcatheter aortic valve implantation.

Urgent transcatheter aortic valve replacement for severe aortic valve stenosis with acute decompensated heart failure: report of a case.

Recent evidence suggests that transcatheter aortic valve replacement (TAVR) is feasible for treating severe aortic valve stenosis (AS) in patients who are considered high risk for elective surgery. However, it is still unclear whether TAVR is a better option than surgical aortic valve replacement for severe AS with acute decompensated heart failure. We report a case of severe AS with acute heart failure, which was treated successfully by urgent TAVR, with cardiopulmonary support.