Urgent versus Non-Urgent Transcatheter Aortic Valve Implantation Outcomes.

INTRODUCTION: There are limited data about the outcomes of nonelective transcatheter aortic valve implantation (TAVI). Some studies suggest that these patients (pts) have worst results. Our purpose was to compare outcomes in pts submitted to urgent versus elective TAVI. METHODS: Retrospective analysis of 298 consecutive pts submitted to TAVI between 2018 and 2021 in a single tertiary center. Baseline characteristics and outcomes were collected and compared between elective and nonelective TAVI. RESULTS: Pts submitted to urgent TAVI (79 pts) had worse baseline characteristics, with higher EuroScore risk (9.26 vs. 5.17%, p < 0.0001), STS score (7.09 vs. 4.4%, p < 0.0001), and NT pro-natriuretic peptide B (10,168 vs. 3,241 pg/mL, p = 0.001), lower left ventricle ejection fraction (45 vs. 52%, p = 0.003), more diabetes (46.8 vs. 32.4%, p = 0.0.22), peripheral artery disease (21.5 vs. 6.8%, p < 0.0001), and poor vascular accesses (18.4 vs. 7.4%, p = 0.007). Urgent TAVI was associated with higher mortality (25.3 vs. 15.1%, p = 0.043), 30-day cardiovascular mortality (17.5 vs. 4%, p = 0.001), life-threatening bleeding (11.5 vs. 4.1%, p = 0.018), vascular complications (11.5 vs. 4.6%, p = 0.031), and longer hospital stay (28 vs. 12 days, p < 0.0001), but not with intensive care unit or post-TAVI hospital stay (5 vs. 4 days, p = 0.197 and 11 vs. 10 days, p = 0.572). When adjusted to differences in baseline characteristics, urgent TAVI was only associated with longer hospital stay (p < 0.0001). CONCLUSION: Pts submitted to urgent TAVI have worse short-term outcomes, but this seems to be attributable to the worse baseline characteristics instead of the urgent nature of the procedure.

Outcomes and predictors of periprocedural stroke after transcatheter aortic valve implantation.

BACKGROUND: Risk factors for stroke after transcatheter aortic valve implantation (TAVI) are currently incompletely understood. PURPOSE: To identify possible predictors of early post-TAVI stroke and explore its short-term outcomes. METHODS: Retrospective analysis of consecutive patients (pts) submitted to TAVI between 2009 and 2020 in a tertiary center. Baseline characteristics, procedural information and stroke in first 30 days after TAVI were collected. In-hospital and 12 months outcomes were analyzed. RESULTS: A total of 512pts (56,1% female, mean age of 82 ± 6years.) were included. In the first 30 days after TAVI 19pts (3,7%) had a stroke. In univariate analysis stroke was associated with higher body mass index (29 vs 27kg/m2, p=0.035), higher triglyceridemia (> 117,5mg/dL, p=0,002), lower high-density lipoprotein (< 38,5mg/dL, p=0,009) and porcelain aorta (36,8% vs 15,5%, p=0,014) and more frequent use of post-dilatation (58,8% vs 32%, p=0,021). In multivariate analysis, triglycerides > 117,5mg/dL (p=0,032, OR = 3,751) and post-dilatation (p=0,019, OR = 3,694) were the independent predictors. Stroke after TAVI was associated with longer intensive care unit stay (12 vs 4 days, p<0,001) and post-TAVI hospital stay (25 vs 10 days, p<0,0001), higher intra-hospital mortality (21,1% vs 4,3%, p=0,003), cardiovascular 30-day mortality (15,8% vs 4,1%, p=0,026) and 1-year stroke (13,2% vs 1,1%, p=0,003). CONCLUSION: Periprocedural and 30-day stroke is a relatively uncommon but potentially devastating complication after TAVI. In this cohort, 30-day stroke rate after TAVI was 3.7%. Hypertriglyceridemia and post-dilatation were found to be the only independent risk predictors. Outcomes after stroke, including 30-day mortality, were significantly worse.

Not all pseudoaneurysms are femoral-A transcaval transcatheter aortic valve replacement rare complication.

We report a case of a 73-year-old male with multiple comorbidities, including postpoliomyelitis severe scoliosis, referred to our tertiary center due to a severe symptomatic aortic stenosis, considered high risk for surgical aortic valve replacement (AVR). Due to unsuitable femoral and subclavian accesses, the patient underwent a transcaval transcatheter AVR (TAVR) procedure, complicated by the development of an iatrogenic infrarenal aortic pseudoaneurysm with aortocaval fistula. Scoliosis can cause varying anatomic relationships between retroperitoneal vessels and intervertebral disk spaces, which increase the difficulty of the procedure and consequently lead to this vascular complication. Although most aortocaval fistulas close spontaneously after 1 year, the risk of pseudoaneurysm rupture in this critical area was crucial in the decision of a new successful percutaneous aortic stent intervention.

Long-Term Follow Up After Successful Percutaneous Balloon Mitral Valvuloplasty.

BACKGROUND: Percutaneous balloon mitral valvuloplasty (PMV) is the cornerstone of rheumatic mitral stenosis treatment in suitable patients. Previous studies have reported low rates of technical failure and few major complications, with good long-term results after successful PMV. The study aim was to assess the very long-term outcome in patients after PMV performed at a single tertiary center. METHODS: Between 1991 and 2010, a total of 213 consecutive patients underwent PMV at the authors' center. The criteria used to define successful procedure were post-procedural mitral valve area ≥1.5 cm2 and mitral regurgitation less than grade III, without in-hospital major cardiac or cerebrovascular events. The primary endpoint evaluated during the follow up period was the occurrence of cardiovascular death and need for mitral reintervention (percutaneous or surgical). Kaplan-Meier curves were generated to determine event rates, and predictors of major cardiac events in patients with successful PMV were determined using Cox regression analysis. RESULTS: A total of 190 patients (89%) underwent a successful PMV; 88% of these are currently being followed up at the authors' center. During a mean follow up of 11.2 ± 7.3 years, at least one major adverse cardiac event occurred in 25.1% of patients (6.6% all-cause death, 6.6% repeated PMV, 21% required mitral valve surgery). Cumulative event-free survival at 20 years was 54.7 ± 6.3%. On univariate analysis, the echocardiographic score [hazard ratio (HR) = 1.25 (1.00-1.70), p <0.05], left atrial diameter [HR = 1.06 (1.01-1.11), p <0.05] and mean mitral valve gradient soon after the procedure [HR = 1.25 (1.02-1.55), p <0.05] were predictors of events. On multivariate analysis, the echocardiographic mitral valve score before PMV was the only independent predictor of primary outcome [HR=1.75 (1.16-2.64), p<0.01]. CONCLUSIONS: Up to 20 years after successful PMV, a sizeable proportion of patients remained event-free, which confirmed the late efficacy of PMV. Among the present patient cohort, echocardiographic score before PMV was the only independent predictor of long term events.

Conventional and Novel Predictors of Permanent Pacemaker after TAVI in Atrial Fibrillation Patients.

BACKGROUND AND AIM OF THE STUDY: Atrial fibrillation (AF) is common in patients submitted for transcatheter aortic valve implantation (TAVI), and these patients are at higher risk of developing conduction system disturbances requiring pacemaker (PM) implantation. Conventional predictors for PM use in this population have limited applicability. It was hypothesized that a post-procedural heart rate reduction could gauge the degree of atrioventricular (AV) node injury, and that this would be a clinically useful predictor of a need for PM. METHODS: All consecutive patients submitted for TAVI between December 2009 and August 2015 were included prospectively in a local registry. Clinical and electrocardiographic data and procedural details were recorded, and patients in sinus rhythm or with pre-existing PM were excluded. Heart rate (HR) at the start and end of the procedure were used to assess post-procedural HR reduction by calculating the HR ratio (HRratio = HRend/HRstart). The relationship between previously described predictors of PM, HRratio and implantation of a permanent PM during the 30 days after TAVI were analyzed using the Wilcoxon ranksum test and receiver operating characteristic (ROC) curve. RESULTS: A total of 102 patients was submitted for TAVI, 24 of whom had AF and no previous PM. Of the latter 24 patients, 10 (41.6%) received a PM during the 30 days after TAVI. Conventional predictors of permanent PM such as male gender, left anterior hemiblock and right bundle branch block were not significantly associated with PM implantation. The HRratio was significantly lower in patients submitted for PM implantation (median 0.76, IQR 0.68-0.86 versus 1.18, IQR 1.10-1.26; p <0.001; Wilcoxon ranksum test). ROC curve analysis of the HRratio showed a good discrimination for the need of PPM with a c-statistic of 0.93. An optimal cut-off value of 0.9 predicted the need for PM implantation with a sensitivity of 90% and specificity of 92.8% CONCLUSIONS: Conventional predictors of PM after TAVI were not associated with PM implantation in patients with AF. The fall in post-procedural HR was significantly associated with PM implantation, with an HRratio cut-off value of 0.9 accurately predicting a need for PM within 30 days.

New-Onset Hemolytic Anemia after Percutaneous Paravalvular Leak Closure.

BACKGROUND AND AIM OF THE STUDY: Despite being usually clinically silent, paravalvular leak can present with congestive heart failure (CHF) or haemolytic anemia. Here, the case is reported of a paravalvular leak presenting with CHF, complicated by new-onset severe hemolytic anemia after percutaneous closure with a large ventricular septal duct (VSD) occlude device. METHODS: A 57-year-old patient presented with infectious endocarditis of a native mitral valve with major mitral regurgitation and was submitted for mitral valvuloplasty. However, one month later failure of the valvuloplasty forced the need for mechanical prosthetic valve implantation. Early endocarditis of the mechanical valve with CHF was noted two months later and led to mechanical valve substitution. One year later the patient presented with a major paravalvular leak and CHF recurrence. Hence, percutaneous paravalvular leak closure was proposed. RESULTS: A 16-mm VSD occluder was used, and clinical and echocardiography success was noticed. However, new-onset hemolytic anemia with acute kidney injury forced surgical re-intervention, with the successful implantation of a third mechanical valve. CONCLUSIONS: Usually, percutaneous paravalvular leak closure is a safe and successful method to treat high-risk surgical patients. However, hemolytic anemia may develop after a technically successful procedure, forcing surgical intervention. Dedicated devices are needed to overcome this important safety issue. Video 1: Periprocedural acquisition of 3-D transesophageal echocardiography showing two AVP II in the left atrium after unsuccessful deployment. Video 2: Periprocedural imaging of a muscular ventricular septal duct (mVSD) occluder (16 mm), with successful closure of the paravalvular leak.

Contribution of Dobutamine Stress Echocardiography to the Diagnosis and Prognosis of Low-Flow/Low-Gradient Aortic Stenosis.

BACKGROUND: Aortic valve replacement (AVR) is the treatment of choice in patients with severe symptomatic aortic stenosis (AS). Patients with a low left ventricular ejection fraction (LVEF) represent a challenge for evaluation and therapeutic decision. Dobutamine stress echocardiography (DSE) allows the distinction to be made between fixed low-flow/low-gradient (LF/LG) AS and pseudosevere AS. METHODS: Between 2001 and 2014 a retrospective analysis was conducted of patients who underwent DSE to investigate severe AS. DSE was performed in 3- to 5-min steps up to a maximum dose of 20 µg/kg/min. Parameters evaluated at baseline and at each step of DSE included: left ventricular enddiastolic volume (LVEDV) and left ventricular endsystolic volume (LVESV), maximum gradient (MaxG), mean gradient (MG) and aortic valve area (AVA). AS was considered to be severe if the AVA at peak dose was ≤1 cm2. Patients were allocated to two groups according to their therapy: group 1 received only medical treatment, while group 2 underwent AVR. The average follow up was 51.5 ± 4.4 months. RESULTS: A total of 41 patients (28 males, 13 females; mean age 71.7 ± 8.3 years) was analyzed. Severe AS was diagnosed in 34 patients (83%). Baseline echocardiographic characteristics were: AVA 0.7 ± 0.2 cm2, MaxG 42.0 ± 9.1 mmHg, MG 25.6 ± 6.4 mmHg, LVEF 33.1 ± 8.4%, LVEDV 149.6 ± 44.5 ml, and LVESV 104.0 ± 42.6 ml. At peak DSE, AVA was 0.8 ± 0.2 cm2, MaxG 62.7 ± 18.2 mmHg, MG 38.1 ± 11.6 mmHg, LVEF 42.2 ± 9.9%, LVEDV 142.6 ± 43.85 ml, and LVESV 89.7 ± 37.4 ml. Nineteen patients were allocated to group 1, and 22 to group 2. In group 2, two patients underwent transcatheter aortic valve implantation (TAVI) and 20 had surgery. Mortality in group 1 was significantly higher than in group 2 (78.9% versus 27.3%). A Cox proportional hazard model analysis showed that no-intervention was the only predictor of mortality (unadjusted to age; hazard ratio (HR) 5.13, 95% confidence interval (CI) 1.96-13.44, p = 0.001; adjusted to age - HR 4.01, 95% CI 1.46-11.01, p = 0.007). CONCLUSIONS: LF/LG AS has a poor prognosis without intervention. DSE allows the lesion severity to be established. In the present study intervention was a predictor of survival during follow up.

A rare case of CardioMEMS™ sensor migration.

The CardioMEMS™ system remotely monitors changes in pulmonary artery pressures, which allows for early detection of heart failure worsening. It is a safe and reliable invasive monitoring system. We report a case in which there was a late migration of the device at 6 months of follow-up to the contralateral pulmonary artery. The mechanisms, consequences, and management of device migration are discussed. To our knowledge, there are very few published data on late sensor migration.

The CardioMEMS™ system keeps track of changes in lung artery pressure from a distance. This helps spot early signs of heart failure getting worse. It is a safe and dependable way to keep an eye on things inside the body. We describe a situation where the sensor moved to the opposite lung artery 6 months later. We talk about why this happens, what it means, and how to handle it. There is not much info out there about sensors moving late, as far as we know.

Permanent pacemaker implantation after alcoholic septal ablation induced complete heart block: Long-term impact.

INTRODUCTION AND OBJECTIVES: Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy often undergo alcohol septal ablation (ASA). One of the most frequent complications is complete heart block (CHB), requiring a permanent pacemaker (PPM) in variable rates of up to 20% of patients. The long-term impact of PPM implantation in these patients remains unclear. This study aimed to evaluate the long-term clinical outcomes in patients who implant PPM after ASA. METHODS: Patients who underwent ASA at a tertiary center were consecutively and prospectively enrolled. Patients with previous PPM or implantable cardio-defibrillator were excluded from this analysis. Patients with and without PPM implantation after ASA were compared based on their baseline characteristics, procedure data and three-year primary endpoint of composite of all-cause mortality and hospitalization and secondary endpoint of composite of all-cause mortality and cardiac cause hospitalization. RESULTS: Between 2009 and 2019, 109 patients underwent ASA, 97 of whom were included in this analysis (68% female, mean age 65.2 years old). 16 patients (16.5%) required PPM implantation for CHB. In these patients, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics of comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with higher mean age (70.6±10.0 years vs. 64.1±11.9 years) and lower beta-blocker therapy rate (56% vs. 84%) in the PPM group. Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692 U/L vs. 1243 U/L), with no significant difference in the alcohol dose. At three years after ASA procedure, there were no differences in the primary and secondary endpoints between the two groups. CONCLUSIONS: Permanent pacemaker after ASA induced CHB do not affect long term prognosis in hypertrophic obstructive cardiomyopathy patients.

Heterotopic caval valve-in-valve procedure for prosthetic migration: two case reports.

Background: Heterotopic bicaval stenting or caval valve implantation (CAVI) either with non-dedicated balloon-expandable Sapien™ valves (Edwards Lifesciences) or with dedicated TricValve™ (Products + Features) has emerged as a safe and effective percutaneous treatment for high-risk patients with severe tricuspid regurgitation (TR). One technical difficulty of CAVI is the lack of native calcified structures to anchor the device, which may lead to paravalvular leak or migration. Cases summary: We describe two patients with severe TR and high surgical risk who underwent CAVI procedures, both of them complicated with device migration to the right atrium (one inferior vena cava device and one superior vena cava device). Both cases were treated with a caval valve-in-valve procedure, with good technical and clinical results. Discussion: With the recent development of several percutaneous interventions for high-risk patients with severe TR, the rate of some possible complications is not well established, and neither are the better managing strategies. Device embolization is a rare complication of transcatheter heart interventions but with potential catastrophic consequences. Less invasive strategies such as the valve-in-valve procedure may be preferable in order to avoid the exposure of these patients to complex heart surgeries with extracorporeal circulation.

Coronary sinus Reducer device for the treatment of refractory angina: A multicenter initial experience.

INTRODUCTION: The coronary sinus Reducer (CSR) device has emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSR in a real-world setting. METHODS: Twenty-six patients with refractory angina (RA) and evidence of myocardial ischemia attributable to the left coronary artery considered unsuitable for revascularization were treated with the CSR at two centers between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at six-month follow-up, were reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7), and reduction in antianginal therapy. RESULTS: Twenty-three patients had end-stage coronary artery disease without revascularization targets and three had microvascular disease without epicardial stenosis. Procedural success was achieved in 23 patients, with two device/procedure-related complications and one anatomically-related failure to deliver the device. A total of 24 patients had the device implanted and entered the efficacy analysis. Eighteen patients (75.0%) had a reduction of at least one CCS class, 41.7% had a reduction of at least two classes, and 16.7% became asymptomatic, with a mean reduction in CCS class of 1.3±0.2 (p=0.001) at six-month follow-up. All SAQ-7 domains improved, notably physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction in anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010). CONCLUSION: In this real-world, multicenter experience, implantation of the CSR was associated with improvement in angina and QoL in patients with RA.

Intracardiac echocardiography-guided left atrial appendage occlusion: The path to independence.

INTRODUCTION AND OBJECTIVES: Transesophageal echocardiography (TEE) has been the standard method for guiding left atrial appendage occlusion (LAAO) procedures. Recently, intracardiac echocardiography (ICE) has emerged as an alternative to TEE due to several advantages, particularly the avoidance of general anesthesia. This analysis aims to assess the safety, feasibility and efficacy of ICE-guided LAAO procedures. METHODS: We performed a retrospective analysis of ICE-guided LAAO procedures, including a comparison of embolic and bleeding events with the predicted standard scores and a comparison with TEE-guided procedures. RESULTS: A total of 88 patients underwent echocardiography-guided percutaneous LAAO (43 patients with TEE and 45 with ICE), mean age 74.9 years, 68.2% male. In the ICE-guided population, the technical success rate was 93% and the major complication rate was 8.8%. During follow-up, yearly stroke and major bleeding rates were 1.4% and 8.4%, respectively, compared to the 4.0% and 8.7% predicted by the CHA2DS2-VASc and HAS-BLED scores. In the TEE versus ICE analysis (similar baseline characteristics), no statistically significant differences were seen regarding technical success (95.3% vs. 93.3%), procedure-related complications (14.0% vs. 8.9%), device thrombus (2.3% vs. 0%), residual minor peridevice leaks (14.0% vs. 24.4%), one-year all-cause mortality (9.3% vs. 4.4%), stroke (9.3% vs. 2.2%) or major bleeding events (9.3% vs. 11.1%). CONCLUSION: ICE-guided LAAO was a safe and effective therapeutic strategy in a high embolic and bleeding risk population, compared to the event rates predicted by the CHA2DS2-VASc and HAS-BLED scores. The ICE-guided procedure compared well to TEE-guided procedures regarding procedure feasibility, safety, and efficacy.

Initial single-center experience of a standardized protocol for invasive assessment of ischemia and non-obstructive coronary artery disease.

INTRODUCTION: Coronary vasomotion disorders (CVDs), including microvascular angina (MVA) and vasospastic angina (VSA), account for significant morbidity among patients with non-obstructive coronary artery disease (NOCAD). However, protocols for CVD assessment in clinical practice are seldom standardized and may be difficult to implement. PURPOSE: To assess the safety and feasibility of a comprehensive coronary function test (CFT) protocol for assessment of CVD and the prevalence of different phenotypes of CVD in patients with angina and NOCAD (ANOCA). METHODS: Patients with persistent angina referred for invasive coronary angiogram and found to have NOCAD were prospectively recruited and underwent a CFT. Functional parameters (fractional flow reserve, coronary flow reserve and index of myocardial resistance) and coronary vasoreactivity were assessed in all patients. RESULTS: Of the 20 patients included, the mean age was 63±13 years and 50% were females. Most patients had persistent typical angina and evidence of ischemia in noninvasive tests (75%). The CFT was successfully performed in all subjects without serious complications. Isolated MVA was found in 25%, isolated VSA in 40%, both MVA and VSA in 10% and noncardiac chest pain in 25% of patients. Antianginal therapy was modified after the results of CFT in 70% of patients. CONCLUSION: A coronary function test was feasible and safe in a cohort of patients with ANOCA. CVD were prevalent in this selected group of patients, and some presented mixed CVD phenotypes. CFT may provide a definitive diagnosis in patients with persistent angina and prompt the stratification of pharmacological therapy.

Remote invasive monitoring of pulmonary artery pressures in heart failure patients: Initial experience in Portugal in the context of the Covid-19 pandemic.

Background: Decompensated heart failure (HF) is associated with poor short- and long-term prognosis. Remote invasive monitoring of pulmonary artery pressures (PAP) enables early detection of HF decompensation before symptoms occur and may improve clinical outcomes. We aimed to describe our initial experience with the use of the CardioMEMS™ remote monitoring system in patients with HF, including its safety and effectiveness. Methods and results: Five patients with HF in New York Heart Association class III and at least one hospitalization due to decompensated HF in last 12 months, who underwent invasive remote monitoring of PAP, were included in this prospective registry. The median age was 66.0 years (interquartile range [IQR] 50.5-77.5 years), 80.0% were men and all had HF with reduced ejection fraction. The pulmonary artery (PA) sensor was placed in a left PA branch in all patients and no major procedural complications occurred. In median follow-up of 40 days (IQR 40-61 days), a total of 271 pressure readings were transmitted, patient compliance was 100% and freedom from sensor failure 98.1%. In three patients, PAP remained within the goal during follow-up. Two patients presented an increase in PAP to values above the targets, despite the absence of symptom worsening. These required dietary and diuretic dose adjustment, without the need for outpatient clinic visits, which reduced PAP. No hospitalizations for HF or deaths occurred during follow-up. Conclusion: Hemodynamic-guided HF monitoring was safe and effective and may be a useful adjunctive tool to the standard-of-care management in selected HF patients, particularly in the context of the COVID-19 pandemic, where a reduction in the number of health care visits may be desirable.

Introdução: A insuficiência cardíaca (IC) descompensada está associada a mau prognóstico em curto e longo prazo. A monitoração remota invasiva da pressão na artéria pulmonar (PAP) possibilita a deteção precoce da descompensação da IC, previamente ao início dos sintomas, pode melhorar os resultados clínicos. Descrevemos a experiência inicial com o uso do sistema de monitoração remota CardioMEMS™ em doentes com IC, inclusive a sua segurança e eficácia. Métodos e resultados: Foram incluídos prospetivamente cinco doentes com IC em classe III da New York Heart Association, com pelo menos uma hospitalização por IC descompensada nos últimos 12 meses, submetidos a implantação de sistema de monitoração remota invasiva da PAP. A mediana de idade foi de 66 anos (intervalo interquartil [IIQ] 50,5-77,5 anos), 80% eram do sexo masculino e todos apresentavam IC com fração de ejeção reduzida. O sensor de PAP foi colocado num ramo da artéria pulmonar esquerda em todos os doentes, não ocorreram complicações major. Durante o follow-up mediano de 40 dias (IIQ 40-61 dias), foram transmitidas 271 leituras, verificou-se uma adesão dos doentes de 100% e taxa de transmissão bem-sucedida de 98,1%. A PAP manteve-se dentro do objetivo em três doentes durante o follow-up. Apesar de continuarem assintomáticos, dois doentes apresentaram valores das PAP acima do alvo. Foi feito ajuste dietético e da dose de diurético, sem necessidade de visitas clínicas presenciais, objetivou-se uma redução efetiva das PAP. Durante o seguimento, não se registaram hospitalizações por IC ou óbitos. Conclusão: A monitoração da IC guiada pela hemodinâmica demonstrou ser segura e eficaz, pode assumir-se como uma ferramenta útil no manejo de doentes com IC, particularmente no contexto da pandemia Covid-19, quando é desejável uma redução do número de consultas presenciais hospitalares.

Transcatheter aortic valve implantation outcomes in patients with low flow low gradient aortic stenosis.

BACKGROUND: Some studies suggest that patients with low flow low gradient (LF-LG) aortic stenosis (AS) may achieve worse results after undergoing transcatheter aortic valve implantation (TAVI). PURPOSE: To compare outcomes between LF-LG AS and high gradient (HG) AS patients submitted to TAVI. METHODS: Inclusion of 480 consecutive patients who underwent TAVI between 2008 and 2020 at a single tertiary center. Patients were divided into high gradient AS and LF-LG AS; and baseline characteristics and outcomes after the procedure were collected and compared between groups. RESULTS: Patients with LF-LG AS had worse baseline characteristics, with higher Society of Thoracic Surgeons score (p=0.008), New Euroscore II (p<0.0001), and NT pro-natriuretic peptide B (p=0.001), more frequent left ventricular ejection fraction (LVEF) <40% (p<0.0001), coronary artery disease (p<0.0001), including previous myocardial infarction (p=0.002) and coronary artery bypass graft (p<0.0001), poor vascular accesses (p=0.026) and periprocedural angioplasty (p=0.038). In a multivariate analysis, adjusted to differences in baseline characteristics, LF-LG AS was associated with worse functional class at one year (p=0.023) and in the long-term (p=0.004) and with heart failure hospitalizations at one year and in the long-term (p=0.001 and p<0.0001). In a sub-analysis including only patients with LF-LG AS, those with LVEF <40% had the worst outcomes, with more global (p=0.035) and cardiovascular (p=0.038) mortality. CONCLUSION: Patients with LF-LG AS have worse short and long-term outcomes, even when adjusted for baseline characteristic differences. The sub-group of patients with LVEF <40% have the most ominous global outcomes.

Cardiac computed tomographic angiography after abnormal ischemia test as a gatekeeper to invasive coronary angiography.

This study aimed to determine the impact of systematic coronary computed tomographic angiography (CCTA) use following an abnormal non-invasive ischemia test (NIST) on patient selection strategy for invasive coronary angiography (ICA). In patients with suspected stable coronary artery disease (CAD), NIST use frequently results in sub-optimal diagnostic and revascularization yields of ICA. This randomized clinical trial, conducted at a single academic tertiary center, selected 220 symptomatic patients with mild-to-moderately abnormal NIST results who were referred for ICA. Patients received either the originally intended ICA (n = 105) or CCTA (n = 115). The primary endpoint was the diagnostic yield of ICA in each group. Revascularization yield and major adverse cardiovascular events at 12 months were also assessed. The patients were 69 ± 9 years old, 60% were men, and 31% had typical angina. Mean pre-test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 37.7% on the index angiographic procedure. In the CCTA group, ICA was cancelled by referring physicians in 83 patients (72.2%) after receiving CCTA results. For those undergoing ICA, diagnostic (84.4% vs. 41.7%, p<0.001) and revascularization (71.9% vs. 38.8%, p = 0.001) yields were significantly higher for CCTA-guided ICA than for standard NIST-guided ICA. Mean cumulative radiation exposure was significantly lower in the CCTA-guided ICA arm than in the NIST-guided ICA arm (12 ± 9 vs. 16 ± 10 mSv, respectively, p = 0.024). There were no significant differences in the primary safety endpoint rates between the strategies (p = 0.439). In patients with suspected CAD and mild-to-moderately abnormal ischemia tests, a diagnostic strategy including CCTA as a gatekeeper is safe and effective and significantly improves diagnostic and revascularization yields of ICA.

Very late coronary stent thrombosis after discontinuation of antiplatelet therapy.

Percutaneous transluminal coronary angioplasty (PTCA) with stent placement is widely used to achieve myocardial revascularization in patients with symptomatic ischemic heart disease and significant coronary artery stenosis. Drug-eluting stents are used in most patients undergoing percutaneous angioplasty. Stent thrombosis is an uncommon but serious complication, manifested mostly by sudden death or acute ST-elevation myocardial infarction. The authors report the case of a 68-year-old patient with acute anterior ST-elevation myocardial infarction. Five years previously, she had had a similar presentation and underwent primary angioplasty of the left anterior descending artery with implantation of a drug-eluting stent. The patient was discharged under antithrombotic therapy. She discontinued antiplatelet therapy and two days later suffered an acute anterior myocardial infarction. Primary angioplasty revealed stent thrombosis.

Stent fracture: case report and literature review.

We report the case of a man presenting with acute myocardial infarction and a history of percutaneous coronary intervention with implantation of a drug-eluting stent, which was now fractured. This case highlights the growing recognition of stent fracture as a potential mechanism for late stent thrombosis in the drug-eluting stent era. Following the case report, we review the literature on the incidence, contributing factors and clinical impact of stent fracture.

Paravalvular leak closure: Still a challenge with unpredictable results.

INTRODUCTION: Paravalvular leak (PVL) is a common serious complication associated with prosthetic valve implantation. OBJECTIVE: The aim of this study was to report our single-center experience in a retrospective review and to analyze possible predictors of success. METHODS: We performed 33 percutaneous PVL closures in 26 patients (54% female, mean age 65±13 years). All mitral prostheses were studied previously with 3D transesophageal echocardiography (TEE), and aortic prostheses with 2D/3D TEE. 3D TEE and fluoroscopy were used for the assessment, planning, and guidance of the interventions. Twelve patients also underwent computed tomography angiography for better characterization of anatomic details. RESULTS: Eighteen patients (69.2%) were admitted due to heart failure (New York Heart Association [NYHA] III or IV, seven (26.9%) because of heart failure and hemolysis, and one (3.8%) due to hemolysis only. Regarding the leaks, 46.2% were in aortic and 53.8% in mitral prostheses, 88.5% in mechanical and 7.7% in biological prostheses, and 3.8% in transcatheter aortic valve implants. All the aortic patients had severe aortic regurgitation. Furthermore, all mitral patients but one had moderate to severe or severe mitral regurgitation. Closure was successful in 17 patients (65.4%), partially successful in four (15.4%) and unsuccessful in five (19.2%). After the procedure, 69% were in NYHA I-II. Hemolysis worsened in three patients despite successful closure; all required further valvular surgery and two died. Regarding angiographic and echocardiographic procedural success, we analyzed age, gender, type of prosthesis (mechanical or biological), location (aortic or mitral), clinical data, maximum leak diameter, anatomic regurgitant orifice, leak location (anterior, posterior, inferior and lateral for mitral leaks and left, right and non-coronary sinus for aortic leaks), and number of devices (plugs) used for closure. No parameters presented a significant relationship with success excepting previous hemolysis. There was a relationship between clinical improvement and reduction of PVL (p=0.0001). In follow-up, cardiac-related events (new hospital admissions, cardiac valvular surgery, need for transfusion) were more frequent in patients with partially successful or unsuccessful closure (p=0.012). There was a relationship between cardiac-related events and death (p=0.029). CONCLUSION: Percutaneous PVL closure has emerged as an alternative treatment for PVL. Predictors of procedural success are difficult to establish. Survival is related to reduction of regurgitation and improvement in NYHA functional class.

Prevalence and prognostic impact of apical sparing contractility pattern in patients with aortic stenosis referred for transcatheter aortic valve implantation.

INTRODUCTION: Prolonged afterload increase in aortic stenosis (AS) may alter left ventricular (LV) contractility, irrespective of LV ejection fraction (LVEF). The prevalence and morbimortality associated with the apical sparing strain pattern (ASP), a typical finding of cardiac amyloidosis (CA), are not fully understood in patients with AS. We assessed the prevalence of the ASP in patients with severe AS and its clinical impact after transcatheter aortic valve implantation (TAVI). METHODS: Eighty-nine consecutive patients with severe AS and LV hypertrophy referred for TAVI were included. Baseline clinical and echocardiographic data were assessed, including the ASP in bull's eye plots (ASPB), relative apical longitudinal strain (RALS) and EF to global longitudinal strain (EF/GLS) ratio. We analysed all-cause mortality; a composite of all-cause mortality, stroke, and heart failure hospitalizations; and the rate of pacemaker implantation, after TAVI. RESULTS: Mean age was 82 ± 6 years and mean LVEF was 57 ± 10%. ASPB and RALS >1 were present in 43.8% and 24.7% of patients, respectively. Over a median follow-up of 13 months (IQR 6-32), ASPB was associated with higher rates of all-cause mortality (log-rank P=0.001) and was an independent predictor of all-cause mortality in multivariate analysis. Combination of the ASPB and GLS or EF/GLS ratio improved the risk stratification. Patients with RALS >1 were more likely to have new BBB and an indication for pacemaker implantation (P=0.048). CONCLUSION: The ASP, as assessed by the ASPB and RALS, was frequent in patients with AS regardless of the diagnosis of CA. The ASPB may refine risk stratification in patients referred for TAVI.