Computed tomography-derived left atrial volume index, sex, and age to predict the presence and the extent of left atrial low-voltage zones in patients with atrial fibrillation: The ZAQ score.

BACKGROUND: Pulmonary vein isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). However, with advanced left atrial (LA) structural changes, additional targeted catheter ablation of low-voltage zones (LVZs) has produced favorable results. Therefore, with the advent of single-shot techniques, it would be helpful to predict the presence of LVZs before an ablation procedure. OBJECTIVE: We hypothesized that computed tomography (CT)-derived left atrial volume index (LAVI), in combination with other objective parameters, could be used to develop a score able to predict the presence of LVZs. METHODS: In a large cohort of patients undergoing their first AF ablations, comprehensive echocardiographic evaluations and cardiac CT were performed. During the electrophysiological studies, LA geometry and electroanatomic voltage maps were created. LVZs were defined as areas ≥1 cm2 with bipolar peak-to-peak voltage amplitudes ≤0.5 mV. RESULTS: In a derivation cohort of 374 patients, predictors of LVZs were identified by regression analysis and used to build the Zentralklinik Bad Berka and University of L'Aquila (ZAQ) score (age ≥65 years; female sex; and CT-LAVI ≥57 mL/m2 ). The ZAQ score of 2 points accurately identified the presence and the extent of LVZs (area under the curve [AUC], 0.809; 95% confidence interval [CI], 0.758-0.861; P < .001 and 3 [interquartile range, IQR, 1.5-4.5] vs 7 cm2 [IQR 4-9]; P = .001). In a validation cohort of 103 patients, the predictive value of the score was confirmed (AUC, 0.793; 95% CI, 0.709-0.878; P < .001 and 4 [IQR, 2-7] vs 11.5 cm2 [IQR, 8-16.5]; P = .001). CONCLUSIONS: The ZAQ score identifies LVZs and may be useful for planning the ablation strategy ahead of time.

Functional impairment assessed by the Barthel Index influenced outcomes after transcatheter aortic valve implantation.

Objective. We investigated the influence of functional impairment assessed by the Barthel index (BI) on the three-month outcomes after transfemoral-transcatheter aortic valve intervention (TF-TAVI) under general anesthesia. Design. We included retrospectively analyzed 336 patients undergoing TAVI between January 2017 and January 2018 in central hospital, Bad Berka, Germany. All patients were followed up at three-month in our center's outpatient clinic. We stratified the patients according to the BI. Results. At baseline, 76 patients had a BI <80. Patients with a BI <80 were characterized by advanced age (80.6 ± 5.6 vs. 83 ± 4.1 years. p = .027), diabetes mellitus on insulin and higher surgical risk scores. A prior cerebral ischemic event was recorded more in patients with a BI ≥80. Regarding intermediate outcomes, three-month mortality was significantly higher in patients with a BI <80. Patients with a BI <80 developed significantly more postoperative cardiac decompensation, delirium and strokes. Patients with BI <80 had lower hemoglobin level preoperative and needed more blood transfusion postoperative. Other valve academic research consortiums (VARCs) complications were equally distributed in both groups. A BI <80 was associated with prolonged postoperative hospital stay and was an independent predictor of FT protocol failure (OR 4; CI 95% 1.3-11. p .02). Conclusions. A BI <80 is associated with increased mortality and risk of neurological events and cardiac decompensations after TF TAVI. A BI <80 is an independent predictor of failure in fast track TAVI.

Interaction between shock coils increased the incidence of inappropriate therapies and lead failure in implantable cardioverter defibrillator.

AIMS: Shock coil interaction in patients with multiple implantable cardioverter defibrillator (ICD) leads is occasionally observed. We aimed to evaluate the incidence of shock coil interaction and its clinical relevance. METHODS AND RESULTS: All ICD patients (646 patients) who came to follow up control in our ICD ambulance between January 1, 2011, and December 31, 2011 in the department of cardiology in Bad Berka hospital were retrospectively evaluated in this study. All baseline demographic, clinical, and procedural characteristics and postoperative chest x ray in postero-anterior and lateral view as well as clinical and ICD follow up data were evaluated. Among 646 patients 42 had multiple ICD leads (6.5%) of whom 36 patients (5.5% of total cohort patients and 85.7% of patients with multiple ICD leads) had shock coil interaction and presented the study group (Group I). The control group (Group II) consisted of 610 patients without coil-coil interaction including patients with single shock lead (604 patients) or patients with multiple leads but without interaction between shock coils (6 patients). Inappropriate anti-tachycardia therapies and RV lead revisions were more frequent in patients with interaction between shock coils (Group I vs Group II: 27.7% and 5.7%; p = 0.049 and 30.6% vs 6.4; p = 0.0001, respectively). CONCLUSIONS: Interaction between shock coils may be one of possible causes of lead failure and resulted in inappropriate therapies and subsequent lead revision.

Pathophysiological Factors Associated with Left Ventricular Perforation in Transcatheter Aortic Valve Implantation by Transfemoral Approach.

BACKGROUND AND AIM OF THE STUDY: Left ventricular (LV) perforation is one of the rare and most serious complications of transcatheter aortic valve implantation (TAVI). The study aim was to determine the pathophysiological factors associated with this serious complication. METHODS: A retrospective study was conducted of pathophysiological factors shown in echocardiograms and computed tomography angiograms performed preoperatively in patients who developed LV perforation during transfemoral TAVI (study group) with regards to anatomic and functional variables. Results were then compared with data acquired from a randomly selected sample of patients without perforation (control group). Among 963 TAVI cases, LV perforation occurred in 11 patients (three males, eight females; mean age 79 years). These patients showed complications of LV perforation that required emergency sternotomy and repair of injury to the left ventricle. Ten patients were rescued by the procedure, but one patient died during surgery. RESULTS: Focus on preoperative factors and intraoperative steps was established in favor to identify possible predictors of LV perforation. A LV cavity size <4.2 cm and a hypercontractile ventricle were identified in 10 patients (90%). Only one patient had a dilated cardiomyopathic left ventricle, with a cavity size of 6.1 cm and an ejection fraction of 10%. The present study results revealed other specific patient-related factors, namely a narrow aorto-mitral angle and a thin ventricular muscular wall despite long-standing aortic stenosis. All 11 patients had an average mid-LV muscular wall thickness of 5 mm. An inverse proportional relationship between the aorto-mitral angle and the incidence of perforation was noted, where in all 11 patients the wire had directed itself towards the anterior free wall of the left ventricle, where it induced injury. CONCLUSIONS: A small LV cavity, a hypercontractile state, a thin muscular wall, and a narrow aorto-mitral angle may be considered potential predictors of the occurrence of LV perforation during TAVI.

Transcatheter Aortic Valve Replacement as a bridge to minimally invasive endoscopic mitral valve surgery in Elderly Patients in the era of ERAS and Fast Track TAVI concepts.

In this bicentric study, we report the outcomes of combined transcatheter aortic valve replacement combined with minimally invasive mitral valve surgery. We included a cohort of six patients (79.6 ± 3.2 years, 83% women) with high-risk profiles and deemed to be non-operable with combined mitral and aortic valvular disease. All patients had unsuitable anatomies for transcatheter mitral valve edge-to-edge repair (TEER). Moreover, most of the patients (5/6) suffered a combined aortic valve lesion, which complicates the efficiency of cardioplegia in the case of CBP through minimally invasive incisions. The first stage was implanting a TAVI valve to achieve aortic valve competency and hence facilitate the infusion of cardioplegia after clamping the aorta during endoscopic mitral valve surgery. After one week, we performed the minimally invasive mitral valve repair. Most patients (n = 5; 83%) underwent successful endoscopic mitral valve repair. Intraoperatively, the mean ischemic time was 42 min, and the total bypass time was 72 min. Postoperatively, the mean intubation time was 0 h. Postoperative complications included reoperation for bleeding in one patient (16.7%) and a new heart block requiring pacemaker implantation in one patient (16.7%). There was neither in-hospital mortality nor 1-year mortality.

Transcatheter Mitral Valve Repair via MitraClip in Patients Aged <65 Years: Multicentre 2-year Outcomes.

Background: Transcatheter mitral valve repair (TMVR) using the MitraClip has become a well-established interventional therapy and is usually performed in elderly patients. The objective of this study was to assess 2-year clinical outcomes of TMVR in patients aged <65 years at three heart centres with severe mitral regurgitation (MR) and no surgical options. Methods: A retrospective study analysed data of 36 patients aged <65 years treated with TMVR . All patients were refused surgery by Heart Team decision. Baseline MR was assessed by biplane vena contracta width in two perpendicular views (mean 8.35 ± 1.87 mm). Degenerative MR was detected in 11 patients (30.6%); functional MR was detected in 25 patients (69.4%). Results: Acute procedural success was accomplished in 88.9% of patients. No procedure-related mortality during the first 30 days was detected. Over an average of 2 years of follow-up, all-cause mortality was 19.4% and cardiovascular death was 11.1% owing to advanced heart failure. The average follow-up period was 25.8 months (median was 20 months). Statistically significant difference (p-value <0.01) was detected for N-terminal prohormone of brain natriuretic peptide (pg/ml) at baseline (mean 9,870 ± 10,819; median 7,748) compared to follow-up visits (mean 7,645 ± 11,292; median 3,263). New York Heart Association functional class improvement was achieved in 69% of patients. A second intervention (reclipping) was required in two patients to correct recurrent significant MR. Conclusion: TMVR in patients aged <65 years refused surgical repair provides satisfactory clinical outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort.

Aortic valve calcium volume as measured by native versus contrast-enhanced computer tomography and the implications for the diagnosis of severe aortic stenosis in TAVR patients with low-gradient aortic stenosis.

BACKGROUND: Most of TAVR centers evaluate the calcium score in contrast-enhanced (ce) CT. We compared in this study between different methodologies to measure calcium score. We studied also the difference between patients with low-gradient (LG) and high-gradient (HG) severe aortic stenosis (AS) as regard the burden of aortic valve calcium (AVC). RESULTS: We measured the calcium volume and score using Agatston methodology in non-contrast (nc) CT and with modified and fixed 850 Hounsfield unit (HU) thresholds in ce CT. The calcium score and volume in ceCT using even with modified thresholds is significantly lower than the assessed score and volume in ncCT. The median (IQR) of calcium score in nc CT and in cc CT were 1288 AU (750-1815) versus 947 HU (384-2202). The median (IQR) of calcium volume in nc CT and in cc CT with modified thresholds were 701 mm3 (239-1632) versus 197 mm3 (139-532). Agatston score and calcium volume were lower in patients with LG AS than HG AS; 2069 AU (899-2477) versus 928AU (572-1284) and 1537 mm3 (644-1860) versus 286 mm3 (160-700), respectively. Only 20% of patients with LGAS had Agatston score higher than the previously supposed AVC score threshold for the diagnosis of severe AS (> 2000AU in men and > 1200 in women). CONCLUSIONS: The diagnosis of severe LGAS should not depend on a single parameter as calcium score. In these patients, calcium score should be measured in nc CT and not in ce CT.

Contemporary results of transcatheter mitral valve procedures: bi-centric retrospective analysis.

BACKGROUND: Transcatheter mitral valve-in-valve (TMVIV) or valve-in-ring (TMVIR) replacement offer an alternative therapy for high risk patients. We aimed to highlight the operative and postoperative results of TMVIV and TMVIR procedures. RESULTS: We included all patients underwent TMVIV and TMVIR procedures between 2017 and 2020 at two heart centers in Germany. We included a total of 36 high risk patients in our study where 12 received TMVIV and 24 received TMVIR. All patients underwent TMVIV or TMVIR with Edwards Sapien XT or S3 transcatheter valves (Edwards Lifesciences). The mean age was 79 (75-83 years old). The median (IQR) preoperative STS score was 9 (7-13)% and EuroSCORE II was 14.5% (12-16). The majority of our patients were operated via transapical approach (n = 26) and the minority via transseptal approach (n = 10). Out of our records, none of our patients required reopening for bleeding or any other surgical complications. None of our patients required reintervention during the 6 months follow-up period. One mortality was recorded on fifth postoperative day due to low cardiac output syndrome (obviously because of LVOT obstruction by the anterior mitral leaflet). The average blood loss was 200 ml in the first 24 h in patients underwent transapical approach. Average operative time was 93 min and all patients were immediately extubated after the procedure in the operating room (even the patient with echocardiographically documented LVOT obstruction who died on the fifth postoperative day). Length of Intensive Care Unit stay was 2 ± 1.2 days and length of hospital stay was 4.1 ± 1.2 days. In the follow up period, echocardiograms showed normal prosthetic valve function with low transvalvular gradients, no LVOT obstruction in TMVIR cases and no evidence of valve migration or thrombosis (except in one patient). Concerning 6 months readmission, it was recorded in 2 patients due to right sided heart failure symptoms due to preexisting high degree of tricuspid valve regurge which did not disappear or even decrease after the operation and the other patient due to gastrointestinal bleeding. CONCLUSIONS: TMVIV and TMVIR offer an efficient, safe and less invasive alternative in high surgical risk patients.

Pre-procedural predictors for multiple clips in percutaneous edge-to-edge mitral valve repair.

BACKGROUND: Percutaneous mitral valve (MV) clipping for mitral regurgitation (MR) revolutionized MV repair; however, valve anatomies and pathologies vary. Often multiple clips are required, and predicting this pre-procedurally would be useful. We evaluated pre-procedural predictors for multiple clips. RESULTS: We retrospectively analyzed 127 severe MR patients treated by mitral clipping between January 2011 and August 2018. Patients were grouped according to the use of a single (group I) or multiple clips (group II) and pre-procedure echocardiographs compared. No demographic differences existed except group II had more males (68.1%) than group I (48.3%). Mean left atrial diameter was larger in group II, 51 ± 9 mm, than group I, 48 ± 5 mm, p = 0.026. Mean mitral annular diameter differed: 34 ± 4mm (group II) versus 33 ± 3 mm (group I), p = 0.017. The vena contracta was broader in group II than group I (6.6 ± 1 mm vs. 6 ± 0.9 mm, p = 0.001). Severe mitral annular calcification occurred more in group I (36.2%) than group II (10.1%), p = 0.0001. On multivariate analysis, vena contracta width correlated positively with multiple clips (B 0.125, p = 0.013), but severe annular calcification correlated inversely (B - 0.35, p = 0.002). CONCLUSIONS: Vena contracta width and severe annular calcification are factors to consider when planning MV clipping.

Transcatheter Aortic Valve Replacement Without the Use of Contrast Medium: An Alternative Safe Implantation Technique.

BACKGROUND: New transcatheter equipment and accumulated experience have stimulated further refinements in implantation techniques. We aimed to compare the outcomes of transfemoral transcatheter aortic valve replacement (TF-TAVR) with and without the use of contrast medium (CM) in patients with glomerular filtration rate (GFR) <30 mL/min/1.73 m². METHODS: This single-center, retrospective study included all patients who underwent TF-TAVR procedure with Edwards Sapien balloon-expandable bioprostheses between September 2017 and September 2018 at the Zentralklinik Bad Berka Germany, and compared outcomes of TF-TAVR with and without the use of CM. RESULTS: A total of 98 consecutive patients were included in this study; 25 patients underwent TF-TAVR without the use of CM and 73 patients underwent TF-TAVR with the use of CM. Acute kidney injury was significantly higher in patients who received CM (15 patients [20.5%] in the control group vs 1 patient [4%] in the study group; P=.04). Other procedure-related complications were equally distributed between both groups. CONCLUSION: TF-TAVR without the use of CM can be considered a safe and reproducible alternative technique. Furthermore, it reduced the incidence of postoperative acute kidney injury in patients with GFR <30 mL/min/1.73 m².

Bare metal or drug-eluting stent versus drug-coated balloon in non-ST-elevation myocardial infarction: the randomised PEPCAD NSTEMI trial.

AIMS: Drug-coated balloons (DCB) may avoid stent-associated long-term complications. This trial compared the clinical outcomes of patients with non-ST-elevation myocardial infarction (NSTEMI) treated with either DCB or stents. METHODS AND RESULTS: A total of 210 patients with NSTEMI were enrolled in a randomised, controlled, non-inferiority multicentre trial comparing a paclitaxel iopromide-coated DCB with primary stent treatment. The main inclusion criterion was an identifiable culprit lesion without angiographic evidence of large thrombus. The primary endpoint was target lesion failure (TLF; combined clinical endpoint consisting of cardiac or unknown death, reinfarction, and target lesion revascularisation) after nine months. Secondary endpoints included total major adverse cardiovascular events (MACE) and individual clinical endpoints. Mean age was 67±12 years, 67% were male, 62% had multivessel disease, and 31% were diabetics. One hundred and four patients were randomised to DCB, 106 to stent treatment. In the stent group, 56% of patients were treated with BMS, 44% with current-generation DES. In the DCB group, 85% of patients were treated with DCB only whereas 15% underwent additional stent implantation. During a follow-up of 9.2±0.7 months, DCB treatment was non-inferior to stent treatment with a TLF rate of 3.8% versus 6.6% (intention-to-treat, p=0.53). There was no significant difference between BMS and current-generation DES. The total MACE rate was 6.7% for DCB versus 14.2% for stent treatment (p=0.11), and 5.9% versus 14.4% in the per protocol analysis (p=0.056), respectively. CONCLUSIONS: In patients with NSTEMI, treatment of coronary de novo lesions with DCB was non-inferior to stenting with BMS or DES. These data warrant further investigation of DCB in this setting, in larger trials with DES as comparator (ClinicalTrials.gov Identifier: NCT01489449).

Implantation of Perceval in Trifecta ring: A new perspective.

We report a case of a 67-year-old woman who underwent an aortic valve replacement with a 23-mm Trifecta prosthesis (St. Jude Medical, St. Paul, MN, USA). We implanted Perceval S (LenoNova, London, UK) after resecting the degenerated leaflets three years later after the first operation. This strategy enabled us to reduce the ischemic time and hence simplify the surgical procedure in addition to providing excellent postoperative hemodynamics. .