Clinical and hemodynamic results after direct transcatheter aortic valve replacement versus pre-implantation balloon aortic valvuloplasty: A case-matched analysis.

OBJECTIVES: To evaluate the safety and midterm hemodynamic results of direct transcatheter aortic valve replacement (TAVR) without pre-implantation balloon aortic valvuloplasty (BAV). BACKGROUND: BAV was considered a mandatory previous step in TAVR procedures. METHODS: A total of 339 consecutive patients who underwent transfemoral TAVR were prospectively selected. A 1:1 matching was conducted, pairing age, prosthesis type (self-expandable or balloon expandable) and size, and valve calcification grade (48% with moderate to severe valve calcification). Finally, 102 pairs (102 patients with previous BAV and 102 without BAV) were obtained. RESULTS: Direct TAVR was feasible in all patients without any crossover to BAV group. Device success was achieved in 91.2% and 90.2% of cases in direct TAVR and pre-BAV groups (P = 0.810), respectively, without any differences in balloon postdilation rate and residual aortic regurgitation. The amount of contrast agent, acute kidney injury and myocardial injury was significantly lower in the direct implantation group (P < 0.05). No differences were found in 30-day and 1-year mortality between both groups (4.9% vs. 9.8%, P = 0.177 and 14.0% vs. 23.8%, P = 0.771, respectively). Hemodynamic parameters remained stable after 1-year follow-up in both groups. CONCLUSIONS: Direct transfemoral TAVR without prior BAV was safe in patients with calcified severe aortic stenosis. Pre-implantation BAV could be omitted in patients undergoing TAVR, without influence in procedure success rate, and subsequent patients' clinical course and valve hemodynamic performance. © 2016 Wiley Periodicals, Inc.

Reparación percutánea combinada de válvula mitral: cierre de fuga paravalvular e implante de prótesis transcatéter en paciente de alto riesgo con insuficiencia mitral grave / Combined percutaneous mitral valve implantation and paravalvular leak closure in a high-risk patient with severe mitral regurgitation

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Incidence, Causes, and Predictors of Early (≤30 Days) and Late Unplanned Hospital Readmissions After Transcatheter Aortic Valve Replacement.

OBJECTIVES: The aim of this study was to determine the incidence, causes, and predictors of unplanned hospital readmissions after transcatheter aortic valve replacement (TAVR). BACKGROUND: Data regarding unplanned hospital readmissions after TAVR in a real-world all-comers population are scarce. METHODS: A total of 720 consecutive patients undergoing TAVR at 2 centers who survived the procedure, were included. Median follow-up was 23 months (interquartile range [IQR]: 12 to 39 months), available in 99.9% of the initial population. The occurrence, timing, and causes of hospital readmission within the first year post-TAVR were obtained in all cases. Early and late readmissions were defined as those occurring ≤30 days and >30 days to 1 year post-TAVR, respectively. RESULTS: There were 506 unplanned readmissions in 316 patients (43.9%) within the first year post-TAVR (median time: 63 days; IQR: 19 to 158 days post-discharge). Of these, early readmission occurred in 105 patients (14.6%), and 118 patients (16.4%) had multiple (≥2) readmissions. Readmissions were due to noncardiac and cardiac causes in 59% and 41% of cases, respectively. Noncardiac readmissions included, in order of decreasing frequency, respiratory, infection, and bleeding events as the main causes, whereas heart failure and arrhythmias accounted for most cardiac readmissions. The predictors of early readmission were periprocedural major bleeding complications (p = 0.001), anemia (p = 0.019), lower left ventricular ejection fraction (p = 0.042), and the combined presence of antiplatelet and anticoagulation therapy at hospital discharge (p = 0.014). The predictors of late readmission were chronic obstructive pulmonary disease (p = 0.001), peripheral vascular disease (p = 0.023), chronic renal failure (p = 0.013), and atrial fibrillation (p = 0.012). Early readmission was an independent predictor of mortality during the follow-up period (hazard ratio: 1.56, 95% confidence interval: 1.02 to 2.39, p = 0.043). CONCLUSIONS: The readmission burden after TAVR in an all-comers population was high. Nearly one-fifth of the patients were readmitted early after hospital discharge, increasing the risk of mortality at follow-up. Reasons for readmission were split between noncardiac and cardiac causes, with respiratory causes and heart failure as the main diagnoses in each group, respectively. Whereas early readmissions were mainly related to periprocedural bleeding events, most late readmissions were secondary to baseline patient comorbidities. These results underscore the importance of and provide the basis for implementing specific preventive measures to reduce readmission rates after TAVR.

Giant and thrombosed left ventricular aneurysm.

Left ventricular aneurysms are a frequent complication of acute extensive myocardial infarction and are most commonly located at the ventricular apex. A timely diagnosis is vital due to the serious complications that can occur, including heart failure, thromboembolism, or tachyarrhythmias. We report the case of a 78-year-old male with history of previous anterior myocardial infarction and currently under evaluation by chronic heart failure. Transthoracic echocardiogram revealed a huge thrombosed and calcified anteroapical left ventricular aneurysm. Coronary angiography demonstrated that the left anterior descending artery was chronically occluded, and revealed a big and spherical mass with calcified borders in the left hemithorax. Left ventriculogram confirmed that this spherical mass was a giant calcified left ventricular aneurysm, causing very severe left ventricular systolic dysfunction. The patient underwent cardioverter-defibrillator implantation for primary prevention.

Usefulness of echocardiographic criteria for transcatheter aortic valve implantation without balloon predilation: a single-center experience.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an alternative therapy for high-risk patients with symptomatic aortic stenosis. TAVI without balloon aortic predilation (BPD) has been found to be as feasible and safe as the standard approach with predilation. The aim of this study was to show the usefulness of transesophageal echocardiographic (TEE) criteria during patient selection for TAVI without BPD and compare the results with those from a control group. METHODS: Two hundred forty-nine consecutive patients with severe symptomatic aortic stenosis underwent echocardiographic evaluation before TAVI. Two-dimensional and three-dimensional TEE imaging was used to evaluate the aortic annulus and root, leaflet mobility and degree of calcification, orifice characteristics, valve area, and aortic regurgitation. After TEE data were reviewed, patients were considered to be favorable candidates, or not, for TAVI without BPD on the basis of specific echocardiographic criteria. RESULTS: The mean age was 82 ± 5 years. Seventy-nine patients underwent TAVI without BPD, and 170 patients underwent TAVI with BPD. The mean aortic valve area was 0.61 ± 0.16 cm(2), and the mean aortic annular diameter was 2.2 ± 0.25 cm. In the group without BPD, Edwards SAPIEN XT valves were implanted in 64.6% (n = 51) and Medtronic CoreValve prostheses in 35.4% (n = 28). In this group, residual paravalvular aortic regurgitation immediately after valve deployment was seen in 53.2% of patients, without differences from those who underwent TAVI with BPD. Permanent pacemaker implantation was less frequent in the group of patients without BPD (6.3% vs 14.1%, P = .030). Procedure-related mortality was significantly lower in patients without BPD (2.5% vs 11.8%, P = .018). CONCLUSIONS: Thorough TEE assessment of aortic valve features permits the selection of patients with ideal conditions for TAVI without BPD, regardless of the type of prosthesis. Using the echocardiographic criteria described here, it is possible to achieve a good rate of procedural success with a low complication rate in patients undergoing TAVI without BPD.

Thromboembolic risk in atrial fibrillation: association between left atrium mechanics and risk scores. A study based on 3D wall-motion tracking technology.

BACKGROUND/OBJECTIVES: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a significantly high risk of stroke and systemic embolism. The aim of our study was to assess the association between left atrium (LA) mechanics measured by 3D wall-motion tracking (3DWMT) technology and the most common thromboembolic risk scores (CHADS2, CHA2DS2-VASc). METHODS: A total of 101 consecutive patients with permanent AF referred were included. Conventional bidimensional (2D) LA parameters, and LA mechanics by means of 3DWMT were studied. Association between LA 2D and 3DWMT parameters and both risk scores was evaluated as well as its correlation with every component of the score individually. RESULTS: Mean age was 78 ± 10 years. Mean CHADS2 was 2.7 ± 1.3 and mean CHA2DS2-VASc was 4.4 ± 1.7. Values of 2D and 3DWTM LA parameters were: 2D area 26.4 ± 9.7 cm(2) , 2D volume index 49.4 ± 10.1 mL/m(2) , 3DWMT left atrial emptying fraction (LAEF) 15.9 ± 8.4%, longitudinal strain 9.1 ± 4.5% and area strain 14.9 ± 8.8%. Linear regression analysis showed statistically significant correlation between LA longitudinal strain and LAEF with CHADS2 and CHA2DS2-VASc scores. For each 10% variation in longitudinal strain, CHADS2 and CHA2DS2-VASc scores change in 0.7 and 0.8 points, respectively. CONCLUSIONS: Left atrial longitudinal strain and emptying fraction assessed by 3D WMT technology have correlation with both CHADS2 and CHA2DS2-VASc scores. Each 10% of variation in longitudinal strain represents a 0.7 and 0.8 points change in those risk scores. LA mechanics evaluation might provide additional value to risk scores and could be considered to be a predictor of stroke in patients with AF.

Relationship between endothelin-1 levels and pulmonary arterial hypertension in HIV-infected patients.

OBJECTIVE: Pulmonary arterial hypertension (PAH) is a progressive, fatal disease with average survival of less than 3 years if left untreated. It is most common in patients infected with HIV. Although the pathogenesis in this population is not fully understood, it is thought that HIV infection, through the immune response and release of different inflammatory mediators such as endothelin-1, may contribute directly to endothelial damage. Our objective was to quantify endothelin-1 levels in HIV-infected patients and determine whether or not there is an association between this marker and PAH. DESIGN: A case-control study in patients attending an infectious diseases clinic. METHODS: The sample was composed of 79 patients divided into three groups: 23 HIV patients with PAH (HIV+/PAH+), 45 HIV patients without PAH (HIV+/PAH-) and a control group of 11 healthy individuals. The ratio between the HIV+/PAH- and HIV+/PAH+ groups was 2 : 1. Patients were matched by age, sex, risk group and viral load; the control group by age and sex. All patients had blood taken for endothelin-1 plasma quantification. RESULTS: We found lower endothelin-1 levels in the controls than in the HIV+/PAH- group [0.71 pg/ml (interquartile range, IQR 0.54-0.94) vs. 1.13 pg/ml (IQR 0.87-1.38); P = 0.005] and the HIV+/PAH+ cohort [1.16 pg/ml (IQR 0.86-2.37); P = 0.003]. Patients with severe PAH had higher endothelin-1 levels [2.94 pg/ml (IQR 1.81-6.33)] than patients with mild and moderate PAH. CONCLUSION: Plasma endothelin-1 levels are higher in HIV patients with PAH than in the HIV-noninfected population and levels increase with the severity of the PAH.

Determinants of clinical improvement after surgical replacement or transcatheter aortic valve implantation for isolated aortic stenosis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) and high surgical risk. Hemodynamic performance after TAVI is superior, but the impact of reverse remodeling on clinical improvement is controversial. We aim to address the differences in hemodynamic changes between SAVR and TAVI, and its correlation with LV remodeling and clinical improvement at 6 months follow-up. METHODS: Forty-two patients treated by TAVI were compared with 45 SAVR patients with a stented bioprosthesis. Clinical, 2D and 3D echocardiographic data were prospectively obtained before and six months after intervention. RESULTS: Patients had similar distribution for sex, body surface area and AS severity. TAVI patients were older, more symptomatic and had more comorbidities. They also had higher LV filling pressures, larger 3D indexed left atrium volume, but similar 3D indexed LV mass. At 6 months, TAVI patients had greater clinical improvement and higher effective orifice area index (EAOI), but only SAVR patients already had a significant decrease in 3D indexed LV mass and diastolic volume. In univariate analysis older age, NYHA class ≥ III, increase in EAOI and TAVI were related with functional class improvement. After multivariate analysis only NYHA class ≥ III (OR 8.81, CI:2.13-36.52; p=0.003) and an increase in EAOI ≥ 105% (OR 3.87, CI:1.02-14.70; p=0.04) were predictors of clinical improvement. CONCLUSIONS: At 6 months, functional class improvement was greater after TAVI. Higher initial NYHA class and an increase in EAOI ≥ 105% were independently associated with functional enhancement. It is debatable if left ventricular remodeling is determinant for functional class improvement.

Three-dimensional color Doppler transesophageal echocardiography for mitral paravalvular leak quantification and evaluation of percutaneous closure success.

BACKGROUND: Three-dimensional (3D) color Doppler transesophageal echocardiography (TEE) enables accurate planimetry of the effective regurgitant orifice (ERO) of a mitral paravalvular leak (PVL). The aim of this study was to evaluate the usefulness of this method to quantify paravalvular regurgitation and to assess percutaneous PVL closure success, compared with 3D planimetry of PVLs without using color-flow images (3D anatomic regurgitant orifice [ARO]). METHODS: Forty-six patients (59 mitral PVLs) who underwent 3D TEE to evaluate the indication of PVL closure procedure were retrospectively included. Receiver operating characteristic curves were compared to identify degree III and IV paravalvular regurgitation of 3D color ERO and 3D ARO measures. Forty patients underwent percutaneous PVL closure procedures; analysis was conducted to determine whether the undersizing of the closure devices according to 3D color ERO and 3D ARO measures was associated with PVL closure failure. RESULTS: Three-dimensional ERO measures showed better areas under the curve than 3D ARO measures and correlated better with the degree of paravalvular regurgitation. Three-dimensional color ERO major diameter ≥ 0.65 cm showed a positive predictive value of 87.1% and a negative predictive value of 94% to diagnose degree III and IV paravalvular regurgitation. For the 40 patients who underwent PVL closure procedures, the immediate technical success rate was 76.9%, and 1-year estimated survival was 69.5%. Closure device undersizing according to 3D color ERO length, but not other PVL measurements, was significantly associated with PVL closure failure (P = .007). CONCLUSION: Three-dimensional ERO was superior to 3D ARO at identifying the presence of degree III and IV paravalvular regurgitation. The undersizing of closure devices according to 3D color ERO length was associated with failed closure procedures. Confirmatory prospective studies are encouraged.

Proximal flow convergence method by three-dimensional color Doppler echocardiography for mitral valve area assessment in rheumatic mitral stenosis.

BACKGROUND: The two-dimensional (2D) proximal isovelocity surface area (PISA) method has important technical limitations for mitral valve orifice area (MVA) assessment in mitral stenosis (MS), mainly the geometric assumptions of PISA shape and the requirement of an angle correction factor. Single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions or the requirement of an angle correction factor. The aim of this study was to validate this method in patients with rheumatic MS. METHODS: Sixty-three consecutive patients with rheumatic MS were included. MVA was assessed using the transthoracic 2D and 3D PISA methods. Planimetry of MVA (2D and 3D) and the pressure half-time method were used as reference methods. RESULTS: The 3D PISA method had better correlations with the reference methods (with 2D planimetry, r = 0.85, P < .001; with 3D planimetry, r = 0.89, P < .001; and with pressure half-time, r = 0.85, P < .001) than the conventional 2D PISA method (with 2D planimetry, r = 0.63, P < .001; with 3D planimetry, r = 0.66, P < .001; and with pressure half-time, r = 0.68, P < .001). In addition, a consistent significant underestimation of MVA using the conventional 2D PISA method was observed. A high percentage (30%) of patients with nonsevere MS by 3D planimetry were misclassified by the 2D PISA method as having severe MS (effective regurgitant orifice area < 1 cm(2)). In contrast, the 3D PISA method had 94% agreement with 3D planimetry. Good intra- and interobserver agreement for 3D PISA measurements were observed, with intraclass correlation coefficients of 0.95 and 0.90, respectively. CONCLUSIONS: MVA assessment using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.

Cierre percutáneo de CIV y TAVI transfemoral asociado a la exclusión de la orejuela: potenciales beneficios del intervencionismo estructural combinado / Percutaneous Closure of VSD and TAVI With Left Atrial Appendage Exclusion in a Single Procedure: Potential Benefits of a Combined Structural Interventional Procedure

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