Direct aortic transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is a safe and effective alternative to surgical valve replacement in intermediate and even in low-risk patient cohorts. Direct aortic (DAo) route may be used in patients with severe peripheral vascular disease. Here, we present an 88-year old patient hospitalized with cardiogenic shock. Echocardiography revealed severe aortic valve stenosis with aortic valve area 0.5 cm², mean gradient of 55 mmHg, and peak gradient 92 mmHg. TAVI was considered by the Institutional Heart Team. Multislice computed tomography (MSCT) revealed severe peripheral vascular disease, decreased calibration of abdominal aorta, and multiple large vulnerable atherosclerotic plaques. The patient was scheduled for a DAo TAVI. A 26-mm Medtronic CoreValve Evolut R valve was implanted after predilatation with median sternotomy. The patient was discharged after 96 hours. Although transfemoral (TF) access is used as the default approach for TAVI, it was contraindicated in our patient owing to severe peripheral vascular disease and decreased calibration of the abdominal aorta at its narrowest point (4.5 mm) with multiple large vulnerable atherosclerotic plaques. Careful preprocedural MSCT evaluation is essential and directly affects the success of the procedure. MSCT is also mandatory to confirm the best cannulation zone that must be met for a successful DAo TAVI.

Comparison of non-vitamin K antagonist oral anticoagulants and well-controlled warfarin in octogenarians with non-valvular atrial fibrillation: Real-world data from a single tertiary center.

OBJECTIVE: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, and its prevalence increases with age. Nevertheless, data about the use of oral anticoagulants (OACs) among patients with ≥80 years remains limited. This study aimed to evaluate the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in octogenarians with non-valvular AF (NVAF). METHODS: Medical records of 387 patients who were ≥80 years and diagnosed with NVAF in our hospital between January 2017 and December 2019 were evaluated retrospectively. Patients with NVAF were divided into 2 groups (NOACs and warfarin), and the incidence of stroke/systemic embolism and major bleeding were analyzed. RESULTS: A total of 322 patients were included in the study. The median follow-up duration was 10.9 months for the NOACs group and 12.1 months for the warfarin group. The primary efficacy outcome was stroke/systemic embolism, and the primary safety outcome was major bleeding. A total of 220 patients were taking NOACs, and the most preferred NOACs were apixaban (53.6%), rivaroxaban (29.5%), dabigatran (13.2%), and edoxaban (3.6%) in this order. During a mean follow-up of 302.7 patient-years, the incidence of stroke or systemic embolic events was slightly higher among patients with warfarin but the difference was not statistically significant (p=0.862). The incidence rates of major bleeding events were similar between the treatment groups (p=0.824). CONCLUSION: Our study revealed that the safety and efficacy outcomes are similar between the 2 treatment groups in octogenarians with NVAF.

The Effect of Renal Transplantation on Cardiac Functions.

Chronic renal failure is a well-known risk factor for cardiovascular poor outcome. Despite advances in dialysis and renal transplantation, these patients still have high cardiovascular morbidity and mortality. The aim of our study was to evaluate the changes in blood parameters and echocardiographic parameters of patients undergoing renal transplantation in our center. One hundred and eighty-three patients who underwent renal transplantation between September 2012 and January 2016 were included in the study. Pre- and postoperative hemoglobin values, lipid profiles, ejection fractions, presence of left ventricular hypertrophy, presence of diastolic dysfunction, and valve pathologies were retrospectively scanned. Data were obtained from all patients in terms of blood parameters, but we compared 92 patients' echocardiographic data because of lack of both pre- and postoperative echocardiography records. In our study, 124 patients (67.8%) were male, and the mean age was 42.6 ± 14.4 years. Hemoglobin levels (11.2 ± 1.98, 12.7 ± 2.2 mg/dL, P <0.001) and high-density lipoprotein (HDL) values (37.6 ± 10.5, 46.6 ± 13.6 mg/dL, P <0.001) were found to be different significantly. In echocardiographic evaluation, there was no difference between pre- and postoperative ejection fractions in 92 patients. However, patients with preoperative ejection fraction <50% had a significant increase in postoperative ejection fraction (40.1 ± 6.2, 48.4% ± 9.4%, P = 0.012). Renal transplantation can improve left ventricle ejection fraction in patients with basal ejection fraction less than 50% and also provide a significant increase in hemoglobin and HDL levels in all patients. This suggests that renal transplantation may reverse the process for dilated cardiomyopathy and may improve cardiac function in patients with low ejection fraction. However, transplantation should be performed as early as possible in these patients.

Risk factors for left atrial appendage thrombus.

Background: Atrial fibrillation (AF) is the most common persistent rhythm disorder that has been shown to be associated with a significant increase in stroke risk. Left atrial appendage (LAA) thrombi are responsible for most of strokes of cardiac origin. CHA2DS2-VASc is a risk scoring system to identify patients' indications for anticoagulation in nonvalvular AF patients. The aim of our study was to investigate CHA2DS2-VASc score, the other risk factors, echocardiographic data and blood parameters for LAA thrombus.Methods: Two hundred and sixty-four patients who were admitted to our adult cardiology outpatient clinic and who underwent a transesophageal echocardiography procedure between June 2017 and June 2019 included in our study. Patient's demographic data, transthoracic echocardiographic examinations, and laboratory results were recorded retrospectively.Results: LAA thrombus was detected in 39 (14.7%) patients. The rates of coronary artery disease and systolic dysfunction were significantly higher in patients with LAA thrombus (p = .017, p = .016, respectively). When AF subtypes were examined in detail, thrombus rate was significantly higher in persistent AF (51 vs. 25.7%, p = .002). Although the CHA2DS2-VASc score was slightly higher in the thrombus group, there was no statistically significant difference between the two groups (3.0 ± 1.65 vs. 2.78 ± 1.66).Conclusions: In conclusion, CHA2DS2-VASc score system itself was not informative about LAA thrombus formation although some of its components were related with LAA thrombus formation. According to a multiple regression analysis, the independent determinants of LAA thrombus were the presence of AF and coronary artery disease.

Incidence of Cardiovascular Events After Renal Transplantation.

OBJECTIVES: Renal transplant recipients may present with transplant-specific risk factors related to end-stage renal disease. Although cardiovascular disease-related deaths may be reduced in renal transplant recipients, this disease is still the leading cause of death in patients with a functioning allograft. In this study, our aim was to determine the incidence of cardiovascular events after renal transplant. MATERIALS AND METHODS: This observational retrospective cohort study analyzed renal transplant recipients seen at Baskent University Hospital from 2014 to 2017. Posttransplant cardiovascular events were defined as presence of myocardial infarction, percutaneous coronary interventions, new-onset angina, and death. Patient characteristics, traditionals cardiovascular risk factors, routine biochemistry, and other comorbidities were included in our analyses. RESULTS: In total, 56 renal transplant recipients older than 18 years were included (mean age of 48.4 ± 11.3 years; 21.4% were female patients). In the patient group, 14.2% had coronary artery disease pre-transplant, and 1 patient had an acute myocardial infarction. Mean time from transplant to incidence of cardiovascular events (as shown by coronary angiography) was 9.34 ± 5.2 years. Thirty-six recipients (64.2%) had a cardiovascular event during this posttransplant period, and 6 patients who developed cardiovascular events were women. Five patients (8.9%) required bypass surgery after coronary angiography. Stent implantations were needed in 14 patients. The remaining patients received medical treatment decisions. Twenty-one patients had no acute or chronic cardiovascular events. One patient died because of noncardiac reasons (pulmonary aspergillosis). Two patients died after cardiac surgery, and 1 patient died because of decompensated heart failure. CONCLUSIONS: The presence of symptoms of cardiovascular disease is an important prognostic marker that requires cardiac evaluation. As with the general population, modifiable risk factors can reduce the incidence of cardiovascular events in renal transplant recipients.

Coronary Angiography for Follow-up of Heart Transplant Recipients: Usefulness of the Gensini Score.

OBJECTIVES: Posttransplant cardiac allograft vasculo-pathy affects long-term survival after heart transplant. Because cardiac transplant recipients do not feel angina pectoris as a result of denervation of the transplanted heart graft, early diagnosis is difficult. The Gensini score, a widely used and simple scoring system, can determine the severity of coronary artery disease by angiography. Although this system has been widely used to evaluate natural coronary atherosclerosis, its use in heart transplant recipients has not been studied. Here, we evaluated cardiac allograft vasculo-pathy using the Gensini score. MATERIALS AND METHODS: We retrospectively analyzed 105 heart transplant patients seen between February 2004 and April 2018, including their immunosuppressive therapies. The Gensini score was calculated to determine severity score for each coronary stenosis according to degree of luminal narrowing and location. RESULTS: Of 105 heart transplant patients, 21 were diagnosed with cardiac allograft vasculopathy. Most patients received tacrolimus, prednisolone, and mycophenolate mofetil as standard therapy. Of 63 included patients, 21 (33.3%) showed cardiac allograft vasculopathy on coronary angiography. In accordance with the International Society of Heart and Lung Transplantation rating system, 42 of 63 patients (66.6%) were rated as 0 (no detectable angiographic lesions). Mean Gensini score was 34.8 ± 26. In the 21 patients with cardiac allograft vasculopathy, Gensini score showed mild cardiac allograft vas-culopathy (score ≤ 10) in 8 patients (38%), moderate (score > 10 and ≤ 40) in 6 patients (28.5%), and severe (score > 40) in 7 patients (33.3%). Angiographic coronary artery disease burden using Gensini was strongly correlated with cardiac allograft vasculopathy severity. CONCLUSIONS: The Gensini score could provide valid assessment of cardiac allograft vasculopathy burden for use in clinical practice. However, more research is needed to identify and treat cardiac allograft vasculopathy for successful long-term survival of heart transplant patients.

Relation of Preoperative and Postoperative Echocardiographic Parameters With Rejection and Mortality in Liver Transplant Patients.

OBJECTIVES: Survival in liver transplant after end-stage liver disease is associated with major cardiac functions. In a significant number of patients with end-stage liver disease, cardiac dysfunctions may be observed, which can include high-output heart failure, cardiac valve disease, and pulmonary venous and arterial hypertension. All of these affect perioperative survival. The aim of our study was to determine whether preoperative and postoperative echocardiographic parameters, specifically right heart-related tricuspid regurgitation, estimated systolic pulmonary arterial pressure, and tricuspid annular plane systolic excursion, are associated with rejection and mortality in liver transplant patients. MATERIALS AND METHODS: Adult patients (> 18 years old) who underwent liver transplant at our center between January 2011 and March 2017 were included in the study, with 64 patients retrospectively screened. The echocardiographic images that were taken immediately before and immediately after liver transplant were evaluated. The patients were divided into 2 groups according to rejection data and mortality. All parameters were analyzed for both variables. RESULTS: For the 24 patients with liver rejection and 40 patients without liver rejection, there were no statistically significant differences in terms of demographic data, echocardiographic parameters, and laboratory data. However, when patients were evaluated according to survival, there was a statistically significant difference between these 2 groups concerning the echocardiography parameters of systolic pulmonary arterial pressure (P = .005), tricuspid annular plane systolic excursion (P = .001), and postoperative right ventricular width (P = .01). CONCLUSIONS: Echocardiography, being a simple and easily accessible technique that is reliable in excluding pulmonary hypertension diagnosis, can be used as a guide in the evaluation of right ventricular function and tricuspid regurgitation, particularly in patients who are not hemodynamically stable before and after liver transplant.

Preoperative Cardiac Risk Assessment in Renal Transplant Recipients: A Single-Center Experience.

OBJECTIVES: Cardiovascular disease is the major cause of morbidity and mortality in patients on renal replacement therapy and in kidney transplant recipients. There are no specific recommendations for preoperative cardiac risk assessment before renal transplant. The aim of our study was to analyze preoperative cardiac test frequencies, test results, patient characteristics, and relations between cardiac stress test results and severe coronary artery disease. MATERIALS AND METHODS: We retrospectively examined patients who underwent renal transplant between December 2011 and December 2016 in our hospital (Ankara, Turkey). Our study group included 216 patients. All patients had preoperative echocardiography. We recorded results of exercise stress tests, myocardial perfusion scintigraphy, and coronary angiography. For all patients, preoperative complete blood cell count, creatinine, high-density lipoprotein, triglycerides, low-density lipoprotein, and red cell distribution width values were obtained and recorded. RESULTS: We classified patient groups according to presence or absence of severe coronary artery disease. Fourteen of 66 patients had severe coronary artery disease. In univariate analyses, age, having a history of familial coronary artery disease, diabetes mellitus, presence of coronary artery disease, and triglyceride levels were risk factors for severe coronary artery disease. In multivariate analysis, diabetes mellitus, presence of coronary artery disease, and having a history of familial coronary artery disease were statistically significant. CONCLUSIONS: Renal transplant recipients are a special patient population, and there must be specific suggestions for this population. If patients present with more than 1 risk factor, a stress test should be performed to evaluate cardiovascular risk. In some patients, especially those whose risk factors include prior cardiovascular disease or diabetes mellitus, stress tests should be skipped and patients should directly undergo coronary angiography to look for severe coronary artery disease.

Successful Treatment of a Rare Complication in a Heart Transplant Recipient: Spontaneous Axillary Artery Bleeding.

Spontaneous atraumatic axillary artery bleeding is an unusual clinical entity. Axillary artery bleeding is associated with a high mortality rate. Vascular fragility is defined as a decrease in blood vessel resistance, and increased vascular fragility is one of the reasons for arterial bleeding. In this report, we present a case of spontaneous axillary artery bleeding in a heart transplant recipient.