Paravalvular leak closure after TAVI with plugs: A literature review with a specific focus on arterio-arterial loop.

More than mild paravalvular leak (PVL) following transcatheter aortic valve implantation (TAVI) is associated with a twofold increase in all-cause mortality, heart failure hospitalizations, and the need for reintervention. Successfully addressing PVL in TAVIs is more challenging than in surgical valves. The arterial-arterial (A-A) rail technique emerges as a valuable strategy for post-TAVI PVL closure, enhancing success rates by enabling the effective use of lower-profile vascular plug devices. When standard approach is ineffective, generating an A-A loop for post-TAVI PVL closure is probably the most recommended strategy to ensure procedural success.

CACS, CCTA and mCAD-LT score in the pre-transplant assessment of coronary artery disease and the prediction of post-transplant cardiovascular events.

BACKGROUND: The optimal cardiovascular assessment of liver transplant (LT) candidates is unclear. We aimed to evaluate the performance of CT-based coronary tests (coronary artery calcium score [CACS] and coronary CT angiography [CCTA]) and a modification of the CAD-LT score (mCAD-LT, excluding family history of CAD) to diagnose significant coronary artery disease (CAD) before LT and predict the incidence of post-LT cardiovascular events (CVE). METHODS: We retrospectively analysed a single-centre cohort of LT candidates who underwent non-invasive tests; invasive coronary angiography (ICA) was performed depending on the results of non-invasive tests. mCAD-LT was calculated in all patients. RESULTS: Six-hundred-and-thirty-four LT candidates were assessed and 351 of them underwent LT. CACS, CCTA and ICA were performed in 245, 123 and 120 LT candidates, respectively. Significant CAD was found in 30% of patients undergoing ICA. The AUROCs of mCAD-LT (.722) and CCTA (.654) were significantly higher than that of CACS (.502) to predict the presence of significant CAD. Specificity of the tests ranged between 31% for CCTA and 53% for CACS. Among patients who underwent LT, CACS ≥ 400 and mCAD-LT were independently associated with the incidence of CVE; in patients who underwent CCTA before LT, significant CAD at CCTA also predicted post-LT CVE. CONCLUSION: In this cohort, mCAD-LT score and CT-based tests detect the presence of significant CAD in LT candidates, although they tend to overestimate it. Both mCAD-LT score and CT-based tests classify LT recipients according to their risk of post-LT CVE and can be used to improve post-LT risk mitigation.

The Clinical Challenge of Prosthetic Valve Endocarditis: JACC Focus Seminar 3/4.

During the past 6 decades, there have been numerous changes in prosthetic valve endocarditis (PVE), currently affecting an older population and increasing in incidence in patients with transcatheter-implanted valves. Significant microbiologic (molecular biology) and imaging diagnostic (fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography) advances have been incorporated into the 2023 Duke-International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria, thus increasing the diagnostic sensitivity for PVE without sacrificing specificity in validation studies. PVE is a life-threatening disease requiring management by multidisciplinary endocarditis teams in cardiac centers to improve outcomes. Novel surgical options are now available, and an increasing set of patients may avoid surgical intervention despite indication. Selected patients may complete parenteral or oral antimicrobial treatment at home. Finally, patients with prosthetic valves implanted surgically or by the transcatheter approach are candidates for antibiotic prophylaxis before invasive dental procedures.

Comparative histologic features among liver biopsies with biliary-pattern injury and confirmed clinical diagnoses.

Biliary-pattern injury in the liver (eg, duct injury, ductular reaction, cholestasis) can occur in several conditions, including primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), large duct obstruction (LDO), and drug-induced liver injury (DILI). While the histologic changes in these conditions have been individually well described, distinguishing among them remains often challenging, particularly when biopsy samples are limited in size, robust clinical information is unavailable, and/or the pathologist does not feel confident in evaluating liver disease. This study evaluated histologic features that could aid the diagnosis of biliary-pattern injury on biopsy. We reviewed 121 liver biopsies from clinically confirmed cases of PBC, PSC, chronic LDO, or DILI for multiple clinical and histologic parameters. The rates of these histologic findings were then compared among different entities. Onion-skin fibrosis was seen in 14% of PSC in comparison to 0%, 5%, and 0% of PBC, DILI, and chronic LDO (P = 0.031). Florid duct lesions were identified in 21% of PBC compared to 2% of PSC and 0% of DILI and LDO (P = 0.0065). Similarly, 42% of PBC showed lobular granulomas, compared to 7% of PSC, 11% of DILI, and 33% of chronic LDO (P = 0.0001). Cholestasis was more commonly seen in DILI (42%) and chronic LDO (83%) than in PBC (4%) and PSC (16%) (P < 0.0001). Lobular chronic inflammation was found in a significantly higher percentage of PBC and LDO than of PSC and DILI (P = 0.0009). There were significantly fewer cases of PBC showing neutrophils in ductular reaction than PSC, DILI, and LDO (P = 0.0063). Histologic findings that can help suggest a diagnosis in liver biopsies with biliary-pattern injury include florid duct lesions, lobular granulomas, lack of neutrophils in ductular reaction, and lobular chronic inflammation in PBC; onion-skin fibrosis in PSC; cholestasis and feathery degeneration in DILI; and lobular granulomas, lobular chronic inflammation, cholestasis, and feathery degeneration in chronic LDO. These findings are likely most helpful when complicating factors interfere with biopsy interpretation.

Remodelado auricular adverso en atletas de alto rendimiento: Estudio de deformación auricular con speckle tracking 2D / Adverse left atrial remodeling in highly trained athletes: an echocardiography study using 2D speckle tracking

Background: Highly trained athletes are at increased risk of atrial fibrillation (AF) and flutter. Atrial dilatation and dysfunction might be the underlying substrate for the increased risk. The aim of the present study was to relate atrial size and deformation in a selected group of highly trained athletes and patients with paroxysmal atrial fibrillation (PAF). Methods: 20 professional male hand-ball players, 18 patients with PAF and 20 healthy age-matched, non-sportive males were compared. All subjects underwent a transthoracic echocardiogram with evaluation of left atrial (LA) dimensions. Left atrial strain (LASa) and strain rate (LASRa) derived from speckle tracking were used to evaluate LA deformation post atrial contraction. Results: LA volumes were significantly larger in athletes and PAF patients compared to controls (36 + 1.7 ml/m2; 36 ± 2.3 ml/m2 and 24 + 1 ml/m2, respectively, p < 0.01;). LASa and LASRa during active atrial contraction were decreased in PAF patients compared to athletes and controls (-10.6 ± 0.2 %; -12.2 ± 0.4 % and -14.5 ± 0.5 %, p < 0.01 for LASa and -1.2 ± 0.08 sec-1; -1.5 ± 0.12 sec-1; -1.7 ± 0.13 sec-1, p= 0.04 for LASRa respectively). Athletes with LA volume > 40 ml/m2 (n=7) showed reduced LASa compared to athletes with LA volume < 40 mL/m2 (-10.3 ± 0.4% versus -13.0 ± 0.5%, p < 0.01). PAF patients had LASa values similar to those of subjects with normal LA volume. Conclusion: Athletes with increased LA volume exhibit lower strain parameters compared to subjects with PAF. It is postulated that measurement of LA strain may be used to predict development of AF in highly trained athletes.

Introducción: Atletas de alto rendimiento tienen un riesgo aumentado de desarrollar fibrilacion auricular (FA) y flutter. La dilatación y disfunción auricular podrían ser el sustrato subyacente para este incremento en el riesgo. El objetivo fue analizar y relacionar el tamaño y deformación auricular en un grupo seleccionado de atletas y en pacientes con FA paroxística. Métodos: Se incluyeron 20 jugadores de balón-mano profesionales y 20 controles sedentarios, pareados por edad y sexo, junto a 18 pacientes con FA paroxística. En todos los sujetos se realizó un estudio ecocardiográfico bidimensional con evaluación de las dimensiones y de la deformación (post contracción auricular) por strain (Sa) y strain rate (SRa) de la aurícula izquierda (AI). Resultados: El volumen AI fue significativamente mayor en atletas y pacientes con FA respecto de los controles (36 + 1,7 ml/m2; 36 ± 2,3 ml/m2 y 24 + 1 ml/m2, p < 0,01; respectivamente). El SaAI y SRaAI durante la contracción auricular estaban disminuidos en los pacientes con FA paroxística respecto de atletas y controles (-10,6 ± 0,2 %; -12,2 ± 0,4 % y -14,5 ± 0,5 %, p < 0,01 para SaAI y -1,2 ± 0,08 sec-1; -1,5 ± 0,12 sec-1; -1,7 ± 0,13 sec-1, p= 0,04 para SRaAI, respectivamente). Los atletas con un volumen AI > 40 ml/m2 (n=7) mostraron valores reducidos de SaAI comparados con atletas con un volumen AI < 40 mL/m2 (-10,3 ± 0,4% versus -13,0 ± 0,5%, p < 0,01) y éstos fueron similares a los pacientes con FA (-10,3 ± 0,4% versus -10,6 ± 0,2%, p= 0,6). Conclusiones: Una proporción de atletas con dilatación AI presentan evidencia de disfunción contráctil de la AI, caracterizado por valores de strain disminuidos que son similares a los de pacientes con FA paroxística. Esto podría corresponder a un sustrato para el desarrollo posterior de arritmias auriculares en estos atletas.