Transcatheter valve-in-valve or valve-in-ring implantation with a novel balloon-expandable device in patients with bioprosthetic left side heart valves failure: 1-year follow-up from a multicenter experience.

BACKGROUND: Transcatheter aortic and mitral valve-in-valve (ViV) or valve-in-ring (ViR) implantation into failed bioprosthetic heart valves (BHVs) or rings represents an appealing, less invasive, treatment option for patients at high surgical risk. Nowadays, few data have been reported on the use of balloon-expandable Myval (Meril Life Science, Vapi, India) transcatheter heart valve (THV) for the treatment of degenerated BHVs or rings. We aimed at evaluating the early and mid-term clinical outcomes of patients with left side heart bioprosthesis deterioration treated with transcatheter ViV/ViR implantation using Myval THV. METHODS: 97 consecutive patients with symptomatic, severe aortic(n=33) and mitral(n=64) BHVs/ring dysfunction underwent transcatheter aortic ViV and mitral ViV/ViR implantation with Myval THV. RESULTS: Technical success was achieved in 95 (98%) of the patients. Two cases of acute structural trans-catheter mitral ViV/ViR dysfunction requiring a second THV implantation were reported. At 30-day, a significant reduction in prosthetic trans-valvular pressure gradients and increase in valve areas were seen following both aortic and mitral ViV/ViR implantation. Overall survival at 15 months (IQR 8-21) was 92%. Patients undergoing mitral ViV/ViR had a relatively worse survival compared with those undergoing aortic ViV implantation (89% vs. 97% respectively; HR:2.7,CI:0.33-22.7;p=0.34). At longest follow-up available a significant improvement in NYHA functional class I and II was observed in patients with aortic and mitral ViV/ViR implantation(93.8% and 92.1%). CONCLUSIONS: Despite high surgical risk, transcatheter ViV/ViR implantation for failed left side heart bioprosthesis can be performed safely using Myval THV with a high success rate and low early and mid-term mortality and morbidity.

Transcatheter leadless permanent pacemaker in complex congenital heart disease with interrupted inferior vena cava: A challenging implantation.

31 years lady with complete atrioventricular canal defect, large primum atrial septal defect (ASD), inlet ventricular septal defect (VSD) and Eisenmenger syndrome, presented with atrial flutter and complete heart block. She was not suitable for corrective cardiac surgery and not yet indicated for heart-lung transplantation. She was advised single chamber permanent pacemaker and eventually Micra VR transcatheter leadless pacemaker was finalised for her. Transcatheter leadless pacemaker was deployed in her RV septum despite some unforeseen technical problems. This patient had intrahepatic interruption of IVC with Azygous continuation draining into SVC but this altered venovascular course was detected only fluoroscopically midway during the pacemaker implantation procedure and this was not detected in the preprocedural transthoracic echocardiography. This abnormal venous course was clearly demonstrated in the cardiac CT which was performed only after completion of the pacemaker implantation procedure in this patient. The technical challenges encountered mainly were mostly during the manipulation of the 27F delivery catheter of Micra through this altered cardiovascular anatomy via transfemoral approach and also due to the presence of septal defects. Thus, transcatheter leadless permanent pacemaker was implanted successfully through transfemoral access in this complex congenital heart disease with interrupted IVC and azygous continuation. Besides transthoracic echocardiography, it may be better to perform transesophageal echocardiography or even preferably radiological imaging like cardiac CT or MRI prior to transcatheter leadless pacemaker implantation in patients with complex congenital heart disease to understand the cardiovascular anatomy and plan the procedure.

The principles of ultra-low contrast percutaneous coronary intervention.

Ultra-low contrast percutaneous coronary intervention (ULCPCI) can be performed electively in advanced chronic kidney disease. Engage guide catheter and advance guidewire into the coronary artery without using contrast. IVUS-guided PCI can reduce the contrast load. Perform co-registration of distal and proximal radio-opaque marker bands of intravascular ultrasound (IVUS) catheter. Deploy the stent at the target lesion under fluoroscopic guidance of these co-registered position of the IVUS-marking images. Complete the ULCPCI procedure with a final angiography using minimal contrast. Newer contrast sparing techniques and intravascular imaging technologies provide opportunities to perform ULCPCI efficiently with good results and the least complications.

Long-term follow-up of BVS from a prospective multicenter registry: Impact of a dedicated implantation technique on clinical outcomes.

OBJECTIVES: The aim of this study was to evaluate the impact of a consistent and dedicated implantation strategy on long-term outcomes after implantation of bioresorbable vascular scaffold (BVS) in a real-world cohort of patients with a high prevalence of complex lesions. BACKGROUND: Bioresorbable vascular scaffolds may result in a reduced incidence of late and very-late scaffold thrombosis (ScT) after the complete reabsorption of the scaffold, but this hypothesis is hampered by data from RCTs that showed a higher than expected incidence of late events. However, these studies did not adopt a dedicated implantation technique, that proved to be fundamental in reducing the incidence of adverse events. METHODS: 573 consecutive patients (912 lesions) treated with bioresorbable scaffolds between May 2012 and December 2014 were enrolled in 3 high-volume centers that used a dedicated implantation strategy from the beginning. Primary endpoints were target-lesion failure (TLF) and definite and probable ScT. Secondary endpoints included myocardial infarction, target-lesion and target-vessel revascularization. RESULTS: The registry enrolled a high complexity subset of lesions (69.4% of type B2 or C lesions; 10.3% of severe calcific lesions; 26.1% of bifurcations). Predilatation was performed in almost all cases (99.2%); intracoronary imaging was liberally adopted (37.3%). Mean scaffold length was 42.9 ±â€¯27.4 mm per patient, and post-dilation with a 1:1 high-pressure (22 ±â€¯3.5 atm) balloon was performed in 99.9% of lesions. Median follow-up (available for 98.6% of patients) was 981 days (IQR 802-1133). Overall incidence of ScT was reassuringly low: three thrombotic events occurred during the first year (0.5%), while only one event ensued in the second year of follow-up, and ScT rate remained stable thereafter up to the fourth year (0.7%). Cumulative TLF rates at 1, 2, 3 and 4 years were 3.0%, 6.0%, 7.8% and 12.2%. CONCLUSIONS: These long-term results from a complex "real-world" population appear to be reassuring as regards to the incidence of ScT and TLF when BVS are implanted by experienced operators with a dedicated implantation technique.

Everolimus-eluting bioresorbable vascular scaffolds for treatment of complex chronic total occlusions.

AIMS: Bioresorbable vascular scaffolds (BVS) represent a novel therapeutic option for the treatment of coronary artery diseases. The objective of this study was to evaluate the feasibility of BVS implantation in complex chronic total occlusions (CTO). METHODS AND RESULTS: The present report is a multicentre registry evaluating results after BVS deployment in challenging CTO lesions, defined as J-CTO score ≥2 (difficult or very difficult). A total of 105 patients were included in the present analysis. The mean J-CTO score was 2.61 (difficult 52.4%, very difficult 47.6%). Device success and procedural success rates were 98.1% and 97.1%, respectively. The retrograde approach was used in 25.7% of cases. After wire crossing, predilatation was performed in all cases with a mean predilatation balloon diameter of 2.73±0.43 mm. The mean scaffold length was 59.75±25.85 mm, with post-dilatation performed in 89.5% of the cases and a mean post-dilatation balloon diameter of 3.35±0.44 mm. Post-PCI minimal lumen diameter was 2.50±0.51 mm and percentage diameter stenosis 14.53±10.31%. At six-month follow-up, a total of three events were reported: one periprocedural myocardial infarction, one late scaffold thrombosis and one additional target lesion revascularisation. CONCLUSIONS: The present report suggests the feasibility of BVS implantation in complex CTO lesions, given adequate lesion preparation and post-dilatation, with good acute angiographic results and midterm clinical outcomes.

Cardiac syndrome X: Clinical characteristics revisited.

BACKGROUND: Cardiac syndrome X includes a heterogenous group of patients with angina but normal epicardial coronaries in angiography. OBJECTIVE: Our objective was to study the clinical characteristics of patients with cardiac syndrome X. METHODS: Data of patients who underwent coronary angiography over a period of one year was retrospectively analyzed. Those with normal or non-obstructive coronaries in angiography with chest pain were included in this study. RESULTS: 1203 patients underwent coronary angiography during the study period. 105 (8.7%) patients fulfilled the inclusion criteria. There were 52 (49.5%) males and 53 (50.5%) females including 31 (29.5%) postmenopausal women. Many patients had atherosclerotic risk factors. Typical angina and atypical chest pain were reported by 63 (60%) and 42 (40%) patients, respectively. ECG was normal in 46 (43.8%) and abnormal in 59 (56.2%) patients. The most common abnormal finding in ECG was ST-T changes seen in 49 (46.7%) patients. Regional wall motion abnormality with mild left ventricular systolic dysfunction was seen in 4 (3.8%) patients while 101 (96.2%) patients had normal ventricular function in echocardiography. TMT was positive for inducible ischemia in 35 (33.3%) patients and inconclusive in 10 (9.5%) patients. Angiography showed normal epicardial coronaries in 85 (80.9%) patients. CONCLUSIONS: Cardiac syndrome X constitutes a significant subset of patients undergoing coronary angiography. It is essential to identify and treat them specifically for microvascular angina. Many of them have atherosclerotic risk factors but their presentation is different from those with obstructive coronaries.

Angiographic prevalence and pattern of coronary artery disease in women.

BACKGROUND: There are not many studies describing the prevalence and pattern of "coronary artery disease" (CAD) in women undergoing "coronary angiography" (CAG). Hence, uncertainty thrives with regard to the angiographic prevalence and pattern of CAD in women. OBJECTIVE: Our objective was to study the prevalence and pattern of CAD among women undergoing CAG. METHODS: Data of 500 women who underwent CAG for suspected CAD over 3 years were retrospectively analyzed. They were classified into young group (age < 55 years) and elderly group (age ≥ 55 years). Angiographic profile of "left main disease" (LMD) was also studied. RESULTS: There was greater prevalence of obstructive CAD especially double vessel disease and triple vessel disease in elderly group while normal coronaries were more prevalent in young group. There was equal distribution of non-significant lesions and intermediate lesions between the two groups. The prevalence of LMD is 3.4%, obstructive CAD is 45.4%, and multivessel disease is 28%. The prevalence of LMD and multivessel disease is 31.4%. The pattern of involvement of coronary arteries was same between the two groups; left anterior descending artery is the most commonly affected vessel. Chronic total occlusion mostly involved right coronary artery. Bifurcation lesion involving distal left main coronary artery is the most prevalent pattern of LMD. CONCLUSION: There has been a change with regard to clinical presentation and onset of risk factors for CAD at young age, but the load of atherosclerotic burden and pattern of involvement of coronary arteries have not changed in women.

Coronary sinus diameter by echocardiography to differentiate atrioventricular nodal reentrant tachycardia from atrioventricular reentrant tachycardia.

BACKGROUND: Coronary sinus (CS) has been shown to be larger in patients with atrioventricular nodal reentrant tachycardia (AVNRT). We sought to determine if echocardiographically measured CS diameter can help identify the mechanism of tachycardia in patients with narrow complex tachycardia without preexcitation before the invasive electrophysiology study. METHODS: Forty four patients with documented narrow complex, short RP tachycardia who were scheduled for an electrophysiology study were included. Based on the electrophysiology study, patients were divided into those with AVNRT and those with a concealed accessory pathway and atrioventricular reentrant tachycardia (AVRT). Proximal CS diameter (CSp) measured at the ostium and mid CS diameter (CSm) 1 cm distal to the ostium using transthoracic echocardiography. RESULTS: CSp was significantly larger in patients with AVNRT than AVRT (14.1 ± 5 vs. 9.9 ± 2 mm, p < 0.0001). CSm diameter was not significantly different between the two groups. A cut-off of CSp > 11.2 mm identified AVNRT with a sensitivity of 92.6% and specificity of 76.9%. CSp was a better discriminant (AUC 0.89, 95% CI 0.75-0.97) compared to age (AUC 0.74, 95% CI 0.58-0.87) or tachycardia rate (AUC 0.60, 95% CI 0.44-0.76). CONCLUSIONS: Echocardiographic measurement of the diameter of CS ostium can help in identifying the mechanism of the tachycardia before the invasive electrophysiology study.

Effects of subcutaneously infiltrated nitroglycerin on diameter, palpability, ease-of-puncture and pre-cannulation spasm of radial artery during transradial coronary angiography.

BACKGROUND: The success of transradial catheterization depends on meticulous access of radial artery which in turn depends on palpating a good radial pulse. OBJECTIVES: Our objectives were to analyze the effects of subcutaneously infiltrated nitroglycerin on diameter of radial artery, palpability of radial pulse, ease-of-puncture and pre-cannulation spasm of radial artery during transradial coronary angiography. METHODS: Patients undergoing transradial coronary angiography were randomized to Group NL or Group SL. In Group NL, 3 ml of solution containing nitroglycerin and lignocaine was infiltrated subcutaneously at the site intended for puncture of radial artery. Similarly, saline and lignocaine were infiltrated in Group SL. Diameter of radial artery was objectively assessed by ultrasonography. Measurements were performed at baseline and repeated at 1 min after injecting the solutions. The ease-of-puncture was evaluated by the number of punctures and the time needed for successful access of radial artery. RESULTS: Both groups had 100 patients each. Baseline diameter of radial artery was similar between two groups. The post-injection diameter of radial artery increased by 26.3% in Group NL and 11.4% in Group SL. Nitroglycerin significantly improved the palpability of radial pulse, reduced the number of punctures and shortened the time needed for successful access of radial artery. Pre-cannulation spasm of radial artery occurred in 1% of Group NL and 8% of Group SL. CONCLUSIONS: Subcutaneously infiltrated nitroglycerin leads to significant vasodilation of radial artery. This avoids pre-cannulation spasm of radial artery, enhances palpability of the radial pulse and thus makes the puncture of radial artery easier.

Comparison of diagnostic utilities of ankle-brachial index and carotid intima-media thickness as surrogate markers of significant coronary atherosclerosis in Indians.

AIM: We aimed to compare Ankle-brachial index (ABI) and Carotid intima-media thickness (CIMT) as surrogate markers of significant coronary atherosclerosis in South Indians with coronary artery disease (CAD). METHODS AND RESULTS: There were two groups: CAD group (n = 59) and Control group (n = 55). Mean ABI (0.82 ± 0.06 vs. 1.16 ± 0.11, p < 0.0001) and mean CIMT (0.74 ± 0.22 mm vs. 0.45 ± 0.09 mm, p < 0.0001) were statistically different between two groups. ABI < 0.9 (sensitivity: 91.53%, specificity: 100%) and CIMT > 0.63 mm (sensitivity: 61.02%, specificity: 98.18%) implied significant CAD. ABI and CIMT were negatively correlated to one another. With increasing severity of CAD, ABI decreased but CIMT increased. CONCLUSION: ABI and CIMT are simple noninvasive tools providing insight into coronary atherosclerosis. They can be done at bedside and easily repeated than coronary angiography. ABI < 0.9 is a better surrogate marker of significant coronary atherosclerosis than CIMT > 0.63 mm in South Indians with CAD.