BACKGROUND: Coronary obstruction (CO) following transcatheter aortic valve replacement (TAVR) is a life-threatening complication, scarcely studied. OBJECTIVES: The authors analyzed the incidence of CO after TAVR, presentation, management, and in-hospital and 1-year clinical outcomes in a large series of patients undergoing TAVR. METHODS: Patients from the Spanish TAVI (Transcatheter Aortic Valve Implantation) registry who presented with CO in the procedure, during hospitalization or at follow-up were included. Computed tomography (CT) risk factors were assessed. In-hospital, 30-day, and 1-year all-cause mortality rates were analyzed and compared with patients without CO using logistic regression models in the overall cohort and in a propensity score-matched cohort. RESULTS: Of 13,675 patients undergoing TAVR, 115 (0.80%) presented with a CO, mainly during the procedure (83.5%). The incidence of CO was stable throughout the study period (2009-2021), with a median annual rate of 0.8% (range 0.3%-1.3%). Preimplantation CT scans were available in 105 patients (91.3%). A combination of at least 2 CT-based risk factors was less frequent in native than in valve-in-valve patients (31.7% vs 78.3%; P < 0.01). Percutaneous coronary intervention was the treatment of choice in 100 patients (86.9%), with a technical success of 78.0%. In-hospital, 30-day, and 1-year mortality rates were higher in CO patients than in those without CO (37.4% vs 4.1%, 38.3% vs 4.3%, and 39.1% vs 9.1%, respectively; P < 0.001). CONCLUSIONS: In this large, nationwide TAVR registry, CO was a rare, but often fatal, complication that did not decrease over time. The lack of identifiable predisposing factors in a subset of patients and the frequently challenging treatment when established may partly explain these findings.
Coronary Occlusion , Transcatheter Aortic Valve Replacement , Humans , Transcatheter Aortic Valve Replacement/adverse effects , Treatment Outcome , Catheters , Registries
BACKGROUND: Transcatheter aortic valve replacement (TAVR)-related coronary artery obstruction prediction remains unsatisfactory despite high mortality and novel preventive therapies. OBJECTIVES: This study sought to develop a predictive model for TAVR-related coronary obstruction in native aortic stenosis. METHODS: Preprocedure computed tomography and fluoroscopy images of patients in whom TAVR caused coronary artery obstruction were collected. Central laboratories made measurements, which were compared with unobstructed patients from a single-center database. A multivariate model was developed and validated against a 1:1 propensity-matched subselection of the unobstructed cohort. RESULTS: Sixty patients with angiographically confirmed coronary obstruction and 1,381 without obstruction were included. In-hospital death was higher in the obstruction cohort (26.7% vs 0.7%; P < 0.001). Annular area and perimeter, coronary height, sinus width, and sinotubular junction height and width were all significantly smaller in the obstructed cohort. Obstruction was most common on the left side (78.3%) and at the level of the coronary artery ostium (92.1%). Coronary artery height and sinus width, but not annulus area, were significant risk factors for obstruction by logistic regression but performed poorly in predicting obstruction. The new multivariate model (coronary obstruction IF cusp height > coronary height, AND virtual valve-to-coronary distance ≤4 mm OR culprit leaflet calcium volume >600 mm3) performed well, with an area under the curve of 0.93 (sensitivity = 0.93, specificity = 0.84) for the left coronary artery and 0.94 (sensitivity = 0.92, specificity = 0.96) for the right. CONCLUSIONS: A novel computed tomography-based multivariate prediction model that can be implemented routinely in real-world practice predicted coronary artery obstruction from TAVR in native aortic stenosis.
Aortic Valve Stenosis , Coronary Occlusion , Transcatheter Aortic Valve Replacement , Humans , Hospital Mortality , Treatment Outcome , Heart
OBJECTIVES: The aim of this study was to determine if modifying the classical implantation technique for self-expanding (SE) transcatheter aortic valve replacement to a novel cusp-overlapping projection (COP) technique results in a higher implantation depth (ID) and subsequently reduces the rate of permanent pacemaker implantation (PPMI). BACKGROUND: The COP technique presents the potential benefit of an optimized ID to reduce the rate of PPMI. However, only a few studies have compared clinical outcomes with those achieved using the standard technique. This is the first study to systematically evaluate this approach for SE transcatheter heart valves (THVs) in different populations METHODS: Beginning in February 2015, 444 patients were consecutively included. Propensity score matching was used to control baseline characteristics because of the observational nature of the study. In total, 161 pairs of patients were analyzed. Three methods were used to measure ID (noncoronary cusp [NCC] to the THV, mean of the NCC and the left coronary cusp [LCC] to the THV, and the deepest edge from the LCC and the NCC to the THV). RESULTS: ID was significantly higher in COP cases when measuring from the NCC (4.2 mm vs 5.3 mm; P < 0.001) and the mean from the NCC and the LCC (5.3 mm vs 5.9 mm; P = 0.04), but not from the deepest edge. The PPMI rate was lower in the COP group: 19 (11.8%) vs 35 (21.7%) (P = 0.03; relative risk: 0.54; 95% CI: 0.32-0.91). CONCLUSIONS: The present study showed that the COP technique significantly reduces PPMI in SE THV implantation compared with the classical implantation technique, with similar rates of complications.
Aortic Valve Stenosis , Heart Valve Prosthesis , Pacemaker, Artificial , Transcatheter Aortic Valve Replacement , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/surgery , Humans , Propensity Score , Prosthesis Design , Transcatheter Aortic Valve Replacement/adverse effects , Transcatheter Aortic Valve Replacement/methods , Treatment Outcome
Background and study aims Assessment of endoscopic ultrasonography (EUS)-elastography of the liver and spleen may identify patients with portal hypertension secondary to chronic liver disease. We aimed to evaluate use of EUS-elastography of the liver and spleen in identification of portal hypertension in patients with chronic liver disease. Patients and methods This was a single-center, diagnostic cohort study. Consecutive patients with liver cirrhosis and portal hypertension underwent EUS-elastography of the liver and spleen. Patients without a history of liver disease were enrolled as controls. The primary outcome was diagnostic yield of liver and spleen stiffness measurement via EUS-elastography in prediction of portal hypertension secondary to chronic liver cirrhosis. Cutoff values were defined through Youden's index. Overall accuracy was calculated for parameters with an area under the receiver operating characteristic (AUROC) curve ≥â80â%. Results Among the 61 patients included, 32 had cirrhosis of the liver. Liver and spleen stiffness was measured by the strain ratio and strain histogram, with sensitivity/(1 - specificity) AUROC values ≥â80â%. For identification of patients with cirrhosis and portal hypertension, the liver strain ratio (SR) had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 84.3â%, 82.8 %, 84.4â%, and 82.8â%, respectively; the liver strain histogram (SH) had values of 87.5â%, 69.0â%, 75.7â%, and 83.3 %, respectively. EUS elastography of the spleen via the SR reached a sensitivity, specificity, PPV, and NPV of 87.5â%, 69.0â%, 75.7â%, and 83.3â%, respectively, whereas the values of SH were 56.3â%, 89.7â%, 85.7â%, and 65.0â%, respectively. Conclusion Endoscopic ultrasonographic elastography of the liver and spleen is useful for diagnosis of portal hypertension in patients with cirrhosis.
Introducción y objetivos: La prótesis aórtica Mitroflow es una válvula de pericardio bovino especialmente diseñada para aumentar el área valvular. Hay controversia en relación con su patrón de degeneración estructural valvular (DEV). El objetivo es conocer la incidencia acumulada de DEV, los factores que influyen en su aparición y su impacto sobre la mortalidad. Métodos: Se siguió a 1.028 pacientes clínica y ecocardiográficamente. Puesto que se trata de una población cardiópata y anciana, se realizó un análisis de riesgos competitivos. Resultados: El porcentaje de DEV a los 5 años fue 4,22% (IC95%, 2,96-5,81) y a los 8 años 15,77% (IC95%, 12,46-19,43). La incidencia fue superior para las válvulas de tamaños pequeños (19 y 21 mm). A los 5 años llegó al 6,43% (IC95%, 4,48-8,84) y a los 8 años al 20,06% (IC95%, 15,53-25,01). El desajuste paciente-prótesis (DPP) grave influyó en la incidencia de DEV (sHR = 3,53; IC95%, 2,20-5,66; p < 0,001). Sin embargo, el DPP moderado no tuvo ningún impacto. La presencia de DEV fue el mayor predictor de mortalidad (HR = 4,59; IC95%, 2,91-7,22; p < 0,001). Conclusiones: Utilizando una definición basada en el aumento del gradiente transprotésico, la incidencia de DEV de la prótesis Mitroflow es superior a la indicada por otras series, especialmente para las de tamaños pequeños (19 y 21 mm) o en pacientes con DPP grave. Aumenta exponencialmente a partir del quinto año y desde que se diagnostica aumenta por 4,5 el riesgo de muerte (AU)
Introduction and objectives: The Mitroflow aortic prosthesis is a bovine pericardial bioprosthesis specially designed to increase the valve area in relation to its size. There is controversy regarding the pattern of structural valve deterioration (SVD). Our aim was to determine the cumulative incidence of SVD, risk factors influencing its occurrence, and its impact on mortality. Methods: A total of 1028 patients were clinically and echocardiographically followed up. Because the study population was elderly and had heart disease, we used a competing risk analysis. Results: The percentage of patients with SVD at 5 years was 4.22% (95%CI, 2.96-5.81) and was 15.77% at 8 years (95%CI, 12.46-19.43). The incidence was higher for small valves (19 mm and 21 mm) reaching 6.43% at 5 years (95%CI, 4.48-8.84) and 20.06% at 8 years (95%CI, 15.53-25.01). Severe patient-prosthesis mismatch (PPM) influenced the incidence of SVD (sHR, 3.53; 95%CI, 2.20-5.66; P < .001) but moderate PPM had no impact. The most powerful predictor of mortality was the presence of SVD (HR, 4.59; 95%CI, 2.91-7.22; P < .001). Conclusions: This study used a definition based on the increase in the transprosthetic gradient and found a higher incidence of SVD of the Mitroflow prosthesis than that reported by other series, especially for sizes 19 mm and 21 mm and in patients with severe PPM. The incidence of SVD increased exponentially from the fifth year after implantation and its occurrence led to a 4.5-fold increase in the risk of death (AU)
Humans , Bioprosthesis/standards , Bioprosthesis , Aortic Valve , Aortic Valve/surgery , Risk Assessment/methods , Bioprosthesis/adverse effects , Echocardiography/methods , Echocardiography , Risk Management/standards , 28599
En este artículo se resume la evidencia disponible para el empleo del implante valvular aórtico transcatéter como tratamiento de elección para los pacientes con estenosis aórtica grave sintomática considerados inoperables y con esperanza de vida superior a 1 año. También se resume la evidencia disponible acerca de la no inferioridad del implante valvular aórtico transcatéter en comparación con el recambio valvular aórtico en pacientes de elevado riesgo quirúrgico, por lo que se lo considera una alternativa válida a la cirugía. Finalmente se expone la experiencia reportada respecto a la aplicabilidad de este tratamiento en otros escenarios clínicos en los que se puede convertir, en un futuro cercano, en una alternativa terapéutica sólida al recambio valvular aórtico quirúrgico (AU)
This article summarizes the evidence available on the use of percutaneous transcatheter aortic valve implantation (TAVI) as the treatment of choice for patients with severe symptomatic aortic stenosis who are considered inoperable but have a life-expectancy greater than 1 year. In addition, there is a summary of evidence for the noninferiority of TAVI relative to aortic valve replacement in patients at a high surgical risk - a finding that has led to TAVI being regarded as a viable alternative to surgery. Finally, there is a discussion of reported experience with the application of this procedure to other clinical scenarios in which it could, in the near future, become a sound therapeutic alternative to surgical aortic valve replacement (AU)
Humans , Aortic Valve Stenosis/surgery , Transcatheter Aortic Valve Replacement , Risk Factors , Patient Selection , Practice Patterns, Physicians' , Diseases Registries/statistics & numerical data
Introducción y objetivos. Hay escasa información sobre la utilización del implante valvular aórtico transcatéter en pacientes con estenosis aórtica grave y aorta de porcelana. El objetivo primario del estudio es analizar la mortalidad total tras el implante de una válvula percutánea CoreValve® en pacientes con estenosis aórtica grave, con y sin aorta de porcelana. Métodos. Estudio multicéntrico, observacional y prospectivo. Se implantó una válvula aortica percutánea a 449 pacientes con estenosis aórtica grave calcificada en tres hospitales. De ellos, 36 (8%) reunían criterios de aorta de porcelana. El objetivo primario fue la mortalidad total a 2 años. Resultados. El grupo con aorta de porcelana presentó con mayor frecuencia arteriopatía extracardiaca (11 [30,6%] frente a 49 [11,9%]; p = 0,002), revascularización coronaria previa (15 [41,7%] frente a 98 [23,7%]; p = 0,017) y dislipemia (26 [72,2%] frente a 186 [45%]; p = 0,02). En este grupo se utilizó con mayor frecuencia anestesia general (15 [41,7%] frente a 111 [16,9%]; p = 0,058) y acceso axilar (9 [25%] frente a 34 [8,2%]; p = 0,004). El porcentaje de éxito del procedimiento (el 94,4 frente al 97,3%; p = 0,28) y la incidencia de complicaciones (7 [19,4%] frente a 48 [11,6%]; p = 0,20) fueron similares en ambos grupos. No hubo diferencias estadísticamente significativas en el objetivo primario a los 24 meses de seguimiento (8 [22,2%] frente a 66 [16%]; p = 0,33). La presencia de complicaciones durante el implante (hazard ratio = 2,6; intervalo de confianza del 95%, 1,5-4,5; p = 0,001) fue la única variable predictora del objetivo primario. Conclusiones. El implante percutáneo con la prótesis autoexpandible CoreValve® en pacientes con estenosis aórtica y aorta de porcelana rechazados para cirugía de recambio valvular, es factible y seguro (AU)
Introduction and objectives. There is little information on the use of transcatheter aortic valve implantation in patients with severe aortic stenosis and porcelain aorta. The primary aim of this study was to analyze death from any cause after CoreValve® implantation in patients with severe aortic stenosis, with and without porcelain aorta. Methods. In this multicenter, observational prospective study, carried out in 3 hospitals, percutaneous aortic valves were implanted in 449 patients with severely calcified aortic stenosis. Of these, 36 (8%) met the criteria for porcelain aorta. The primary end-point was death from any cause at 2 years. Results. Patients with porcelain aorta more frequently had extracardiac vascular disease (11 [30.6%] vs 49 [11.9%]; P=.002), prior coronary revascularization (15 [41.7%] vs 98 [23.7%]; P=.017), and dyslipidemia (26 [72.2%] vs 186 [45%]; P=.02). In these patients, there was greater use of general anesthesia (15 [41.7%] vs 111 [16.9%]; P=.058) and axillary access (9 [25%] vs 34 [8.2%]; P=.004). The success rate of the procedure (94.4 vs 97.3%; P=.28) and the incidence of complications (7 [19.4%] vs 48 [11.6%]; P=.20) were similar in both groups. There were no statistically significant differences in the primary end point at 24 months of follow-up (8 [22.2%] vs 66 [16%]; P=.33). The only predictive variable for the primary end point was the presence of complications during implantation (hazard ratio=2.6; 95% confidence interval, 1.5-4.5; P=.001). Conclusions. In patients with aortic stenosis and porcelain aorta unsuitable for surgery, percutaneous implantation of the CoreValve® self-expanding valve prosthesis is safe and feasible (AU)
Humans , Male , Aged , Aged, 80 and over , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/surgery , Arterial Occlusive Diseases/complications , Arterial Occlusive Diseases/diagnosis , Hospital Mortality , Aortic Valve Stenosis/physiopathology , Aortic Valve Stenosis , Prospective Studies , Sternotomy/methods , Aortography
No disponible
Humans , Female , Aged , Aged, 80 and over , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/therapy , Fluoroscopy/methods , Fluoroscopy , Aortic Valve Stenosis , Fluoroscopy/trends
The differentiation between a solid and cystic lesion is not always easy. EUS has provided a minimally invasive approach to the diagnosis of benign mediastinal cysts. Our report describes two cases of intramural bronchogenic cysts and reviews the role of EUS in dealing with such cases. We conclude that the bronchogenic cysts are still a challenge despite evolution of the imaging studies.
Introducción y objetivos. La implantación de prótesis valvular aórtica por vía transfemoral con los dispositivos Edwards-SAPIEN (ES) y Medtronic-CoreValve (MCV) es una alternativa al reemplazo quirúrgico en pacientes con estenosis aórtica severa y alto riesgo quirúrgico. Nuestro objetivo es comparar los resultados obtenidos con uno y otro dispositivo. Métodos. Estudio prospectivo de las prótesis implantadas por vía transfemoral en nuestro centro. Resultados. De los 76 pacientes (edad, 83±6 años; el 63% mujeres; EuroSCORE logístico, 18±9), Se seleccionó a 50 para ES y a 26 para MCV. No se observaron diferencias entre grupos en edad, sexo, clase funcional, área valvular, enfermedades asociadas o EuroSCORE. Se consiguió implantar la prótesis en el 84% del grupo ES y el 100% del grupo MCV (p=0,04); hubo 3 casos de taponamiento, 2 disecciones aórticas y 1 malposición en la serie ES. Las complicaciones vasculares fueron similares (el 26 frente al 23%), pero la necesidad de marcapasos fue mayor con la MCV (el 10 frente al 39%; p=0,003). Las mortalidades totales a 30 días fueron del 12 y el 20% (sin diferencia significativa) y a 1 año, del 24 y el 20% en los grupos ES y MCV respectivamente. Tras un seguimiento de 367±266 días para ES y 172±159 para MCV, 3 pacientes fallecieron; los demás mantienen la mejoría clínica y no se observan cambios ecocardiográficos. Conclusiones. La mortalidad hospitalaria, la tasa de complicaciones y la evolución a medio plazo han sido similares con ambos dispositivos; las únicas diferencias encontradas han sido una tasa de implantación con éxito mayor con la MCV, aunque a expensas de una mayor frecuencia de bloqueo auriculoventricular (AU)
Introduction and objectives: Transfemoral implantation of an Edwards SAPIEN (ES) or Medtronic CoreValve (MCV) aortic valve prosthesis is an alternative to surgical replacement for patients with severe aortic stenosis and a high surgical risk. The studys aim was to compare results obtained with these two devices. Methods: Prospective observational study of transfemoral prosthesis implantation performed at our center. Results: Of the 76 patients (age 83 +/- 6 years, 63% female, logistic EuroSCORE 18 +/- 9) included, 50 were assigned the ES and 26 the MCV device. There was no difference between the groups in age, sex, functional class, valve area, associated conditions, or EuroSCORE. Implantation was successful in 84% of the ES group and 100% of the MCV group (P = .04). There were three cases of tamponade, two aortic dissections and one valve malposition in the ES group. The two groups had similar vascular access complication rates (26% vs. 23%; P = NS), but pacemaker need was greater with the MCV (10% vs. 39%; P = .003). Mortality rates at 30 days were 12% and 20% (P = NS) in the ES and MCV groups, respectively, and at 1 year, 24% and 20% (P = NS), respectively. After a follow-up of 367 +/- 266 days in the ES group and 172 +/- 159 days in the MCV group, three patients died. Clinical improvement was maintained in other patients and no echocardiographic changes were observed. Conclusions: In-hospital mortality, the complication rate and medium-term outcomes were similar with the two devices. The only difference observed was a higher implantation success rate with the MCV, although at the expense of a greater frequency of atrioventricular block (AU)
Humans , Male , Female , Aged, 80 and over , Prostheses and Implants , /methods , Pacemaker, Artificial/trends , Pacemaker, Artificial , Catheterization/instrumentation , Catheterization/methods , Aortic Stenosis, Subvalvular/surgery , Aortic Valve Stenosis/surgery , Hospital Mortality/trends , Data Collection/methods , 28599
