Percutaneous Coronary Intervention before or after Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis Involving 1531 Patients.

Background: The optimal timing to perform percutaneous coronary interventions (PCIs) in patients undergoing transcatheter aortic valve replacement (TAVR) is not well established. In this meta-analysis, we aimed to compare the outcomes of patients undergoing PCI before versus after TAVR. Methods: A comprehensive literature search was performed including Medline, Embase, and Cochrane electronic databases up to 5 April 2024 for studies that compared PCI before and after TAVR reporting at least one clinical outcome of interest (PROSPERO ID: CRD42023470417). The analyzed outcomes were mortality, stroke, and myocardial infarction (MI) at follow-up. Results: A total of 3 studies involving 1531 patients (pre-TAVR PCI n = 1240; post-TAVR PCI n = 291) were included in this meta-analysis following our inclusion criteria. Mortality was higher in the pre-TAVR PCI group (OR: 2.48; 95% CI: 1.19-5.20; p = 0.02). No differences were found between PCI before and after TAVR for the risk of stroke (OR: 3.58; 95% CI: 0.70-18.15; p = 0.12) and MI (OR: 0.66; 95% CI: 0.30-1.42; p = 0.29). Conclusions: This meta-analysis showed in patients with stable CAD undergoing TAVR that PCI after TAVR is associated with lower mortality compared with PCI before TAVR.

Surgical Aortic Valve Replacement and Renal Dysfunction: From Acute Kidney Injury to Chronic Disease.

Background: Surgical aortic valve replacement (SAVR) is often complicated by acute kidney injury (AKI). Identifying patients at risk of AKI is important to start nephroprotective strategies or renal replacement therapy (RRT). This study investigated the incidence and risk factors of post-operative AKI in SAVR patients. Chronic kidney disease (CKD) developed in the post-cardiac-surgery follow-up period was also assessed. Methods: A total of 462 SAVR patients were retrospectively enrolled. The primary endpoint was the occurrence rate of AKI after surgery. Kidney recovery, during two planned outpatient clinic nephrological visits within 12 months after the surgery, was assessed. Results: A total of 76 patients experienced an AKI event. A Kaplan-Meier analysis revealed that subjects with CKD stage IV had a time to progression of 2.7 days, compared to patients with stages I-II, who were characterized by the slowest progression time, >11.2 days. A Cox regression indicated that CKD stages predicted a higher risk of AKI independently of other variables. During their ICU stay, 23 patients died, representing 5% of the population, most of them requiring RRT during their ICU stay. A severe CKD before the surgery was closely related to perioperative mortality. During the follow-up period, 21 patients with AKI worsened their CKD stage. Conclusions: AKI represents a common complication for SAVR patients in the early post-operative period, prolonging their ICU stay, with negative effects on survival, especially if RRT was required. Pre-operative CKD >3 stage is an independent risk factor for AKI in patients undergoing SAVR.

Left Ventricular Mass Index Predicts Renal Function Decline in Patients with Chronic Kidney Disease.

Background and Objectives: Several studies revealed a relation between abnormal cardiac remodeling and glomerular filtration rate (GFR) decline, but there are limited data regarding echocardiographic changes in chronic kidney disease (CKD). This study evaluated the abnormal cardiac structures characterizing patients with CKD, assessing the independent association between echocardiographic parameters and the risk of decline in renal function. Materials and Methods: In total, 160 patients with CKD were studied. All patients underwent an echocardiographic exam and 99mTc-DTPA renal scintigraphy to measure the GFR. After the baseline assessments, patients were followed prospectively for 12 months, or until the endpoint achievement, defined as a worsening in renal function (doubling of baseline serum creatinine, GFR decline ≥25%, the start of dialysis). Results: Patients with GFR values of 34.8 ± 15 mL/min, identifying stages III-IV of CKD, were associated with high levels of left ventricular mass index (LVMi) (101.9 ± 12.2 g/m2), which was related to proteinuria, systolic blood pressure, and pulmonary artery systolic pressure in a multiple regression model. During the observational period, 26% of patients reached the endpoint. Regression analysis revealed LVMi as a predictor of change in renal function after adjusting for kidney and cardiac risk factors. Multiple Cox regression indicated that an increase in LVMi was associated with a 12% increased risk of kidney disease progression (HR: 1.12; 95% CI: 1.04-1.16; p = 0.001). Conclusions: In patients with CKD, high LVMi represents an independent predictor of the progressive decline of the renal function, until the start of renal replacement therapy. Echocardiography can help identify patients at high risk for renal disease worsening in patients with CKD independently of clinical cardiac involvement.

Acute Kidney Injury and Sepsis after Cardiac Surgery: The Roles of Tissue Inhibitor Metalloproteinase-2, Insulin-like Growth Factor Binding Protein-7, and Mid-Regional Pro-Adrenomedullin.

BACKGROUND: Identifying a panel of markers detecting kidney injury before the glomerular filtration rate reduction is a challenge to improving the diagnosis and management of acute kidney injury (AKI) in septic patients. This study evaluated the roles of tissue inhibitor metal proteinase-2, insulin growth factor binding protein-7 (TIMP2*IGFBP7), and mid-regional pro-adrenomedullin (MR-proADM) in patients with AKI. PATIENTS AND METHODS: This study was prospectively conducted in an intensive care unit (ICU) enrolling 230 patients who underwent cardiac surgery. Biomarkers were evaluated before and after 4 h of the cardiac surgery. RESULTS: Whereas urine and creatinine alterations appeared at 23.2 (12.7-36.5) hours after cardiac surgery, urinary TIMP2*IGBP7 levels were higher at 4 h in AKI patients (1.1 ± 0.4 mg/L vs. 0.08 ± 0.02 mg/L; p < 0.001). Its concentration > 2 mg/L increases AKI risk within the following 24 h, clearly identifying the population at high risk of renal replacement therapy (RRT). In patients with sepsis, MR-proADM levels were 2.3 nmol/L (0.7-7.8 nmol/L), with the highest values observed in septic shock patients (5.6 nmol/L (3.2-18 nmol/L)) and a better diagnostic profile than procalcitonin and C-reactive protein to identify septic patients. MR-proADM values > 5.1 nmol/L and urine TIMP2*IGBP7 levels > 2 mg/L showed a significantly faster progression to RRT, with a mean follow-up time of 1.1 days. CONCLUSIONS: TIMP2*IGBP7 and MR-proADM precociously diagnose AKI in septic patients after cardiac surgery, giving prognostic information for RRT requirement.

A Very Late Atrial Septal Erosion After an Ostium Secundum Percutaneous Closure.

Complications after device closure of ostium secundum defects are rare but possible. We present a very late erosion of the interatrial septum after a percutaneous closure of an ostium secundum defect. Identification of early clinical and imaging clues associated with this condition is fundamental for a timely diagnosis and treatment. (Level of Difficulty: Intermediate.).

Left Atrial Appendage Closure Device Embolization under the Anterior Leaflet of Mitral Valve: Echocardiographic Diagnosis and Management.

A 76-year-old man with history of previous coronary artery bypass grafting, permanent atrial fibrillation in novel oral anticoagulation therapy, and gastrointestinal bleedings underwent percutaneous left atrial appendage closure. The procedure was complicated by intraoperative device embolization, which caused a dynamic obstruction of the left ventricular outflow tract leading to severe hemodynamic instability. Transesophageal echocardiography showed a device in the ventricle site of the mitral anterior leaflet. The coronary angiography showed also patency of both arterial grafts in stable coronary artery disease. After failing the percutaneous retrieval with a snare, emergent surgery was planned. A moderate calcified aortic valve stenosis was also found, but in consideration of the unstable clinical conditions of the patient, we thought of performing a transcatheter aortic valve replacement (TAVR) in a second time. We have carefully planned the surgical retrieval of the device embolized paying attention of his several comorbidities. The strategy to remove the device with cardiopulmonary bypass without cross-clamping the aorta through a right mini-thoracotomy has been preferred.

Virtually Wall-Less versus Standard Thin-Wall Venous Cannula in the Minimally Invasive Mitral Valve Surgery: Single-Center Experience.

Background and Objectives: Minimally invasive cardiac surgery (MICS) has been developing since 1996. Peripheral cannulation is required to perform MICS, and good venous drainage and a bloodless field are crucial for the success of this procedure. We assessed the benefits of using a virtually wall-less cannula in comparison with the standard thin-wall cannula in clinical practice. Materials and Methods: Between January 2021 and December 2022, we evaluated 65 elective patients, who underwent isolated minimally invasive mitral valve surgery. Both the virtually wall-less and the thin-wall cannulas were placed through a surgical cut-down. Patients' characteristics at baseline were similar in the two groups, except for the body surface area (BSA), which was greater in the virtually wall-less group compared to the thin-wall one. In the standard group, the size of the cannula was chosen depending on the patient's BSA, and the choice of the Smartcannula was based on their height. Results: There were no significant differences between the two groups in terms of negative pressure applied, target flow achieved, hemolysis, the need for blood transfusion, and the post-operative increases in liver and renal enzymes. However, in all the patients, the estimated target flow was achieved, thereby showing the better hemodynamic performance of the virtually wall-less cannula, since, in this group, the patients' BSA was significantly greater compared to the thin-wall group. Ultimately, the mean cross-clamp time, as an indirect index of the effectiveness of the venous drainage, is shorter in the virtually wall-less group compared with the thin-wall group. Conclusions: The virtually wall-less cannula should be preferred in minimally invasive mitral valve surgery due to its superior performance in terms of venous drainage compared with the standard thin-wall cannula.

Chest Pain and the Dynamic Evolution of Spontaneous Coronary Artery Hematoma.

Spontaneous coronary intramural hematoma (SCIH) is a rare but underdiagnosed condition, with dynamic evolution. We present a patient with acute chest pain and normal coronary angiogram undergoing work-up for myocardial infarction with nonobstructive coronary arteries. Cardiac magnetic resonance revealed an ischemic pattern, and subsequent angiography revealed coronary occlusion by SCIH. (Level of Difficulty: Intermediate.).

Replacement of Ascending Aortic Aneurysm with Anomalous Origin of the Right Coronary Artery: Multidisciplinary Imaging for the Diagnosis.

This case report presents a rare scenario involving a congenital anomaly of the right coronary artery's (RCA) origin in association with an ascending aortic aneurysm. While both anomalies are individually recognized in the literature, their coexistence and potential interplay remain understudied. The aim of this report is to emphasize the challenges and implications associated with such a combination. A 78-year-old male patient with an enlarged ascending aortic aneurysm necessitating surgical intervention was found to have an anomalous origin of the RCA during preoperative coronary angiography, confirmed by computed tomography scan. Transesophageal echocardiography further elucidated the coronary abnormality. Intraoperatively, successful aortic replacement was performed, and careful repositioning of the anomalous right coronary ostium was achieved. This case raises important considerations regarding the potential complications arising from coronary anomalies and their impact on the surgical management of ascending aortic aneurysms. The rarity of this combination limits our understanding of their association, making a multidisciplinary approach crucial for optimal patient care. Further research and comprehensive evaluation of similar cases are necessary to better understand the relationship between coronary anomalies and ascending aortic aneurysms. Such investigations will help in improving treatment strategies and outcomes for patients with these complex conditions.

Analysis of changes in "mitral valve reserve" after coronary artery bypass grafts in patients with functional mitral regurgitation.

INTRODUCTION: The treatment of moderate functionalmitral regurgitation (FMR) during coronary artery bypass grafting (CABG) is still debated. Our primary end point was to assess the improvement of "mitral valve reserve" (MVR) after CABG alone as a clinical demonstration of left ventricular (LV) recovery. MATERIALS AND METHODS: Between June 2019 and June 2021, we prospectively enrolled 104 consecutive patients undergoing CABG with moderate FMR. Inclusion criteria were inferior-posterior-lateral wall hypokinesia and revascularization of the circumflex or right coronary artery. MVR was calculated as the ratio between anterior and posterior leaflets' straight length. All patients were followed for 1 year. The improvement of MVR has been considered as a reduction of the ratio between anterior and posterior leaflets straight length. RESULTS: Compared to baseline, mean MVR was significantly reduced both at 6 (2.24 ± 0.95 vs. 1,91 ± 0.6; p = 0,047) and 12 months follow-up (2.24 ± 0.95 vs. 1,69 ± 0.49; p = 0,006). Left ventricular (LV) reverse remodeling, meant as improvement of LV ejection fraction and reduction of LV end-systolic volume index and mitral anulus diameter were evaluated at 6 months and 1 year. Mitral regurgitation grade were also significantly reduced at 6 months (p < .001). CONCLUSION: The benefits of myocardial revascularization in term of improvement of mitral regurgitation's degree can be explained by the changes of MVR. The patients with FMR, who could have more advantages from CABG alone, should be the ones who have LVESVi just moderately increased.

In-stent restenosis of superficial femoral artery: use all arrows in the quiver.

In-stent restenosis (ISR) is a common superficial femoral artery (SFA) stenting complication, occurring in more than one third of patients within 2-3 years after the index procedure. Moreover, there is no standard treatment for ISR, and although many options are available, there is still limited data regarding its optimal management. We report a paradigmatic case report of a patient complaining of symptomatic peripheral arterial disease, underwent multiple endovascular revascularizations for recurrent femoro-popliteal ISR. A step-by-step approach was followed. At the time of the first presentation, the ISR was treated by drug-eluting balloon (DEB) angioplasty. The repeated ISR was treated by laser debulking, achieving a good angiographic result. Finally, after the third repeated restenosis, a combined approach with laser debulking and DEB angioplasty guaranteed a good acute angiographic result. Long-term duplex-scan follow-up demonstrated the good patency of the femoro-popliteal target lesion.

Optimizing the Outcomes of Percutaneous Coronary Intervention in Patients with Chronic Kidney Disease.

Percutaneous coronary intervention (PCI) is one of the most common procedures performed in medicine. However, its net benefit among patients with chronic kidney disease (CKD) is less well established than in the general population. The prevalence of patients suffering from both CAD and CKD is high, and is likely to increase in the coming years. Planning the adequate management of this group of patients is crucial to improve their outcome after PCI. This starts with proper preparation before the procedure, the use of all available means to reduce contrast during the procedure, and the implementation of modern strategies such as radial access and drug-eluting stents. At the end of the procedure, personalized antithrombotic therapy for the patient's specific characteristics is advisable to account for the elevated ischemic and bleeding risk of these patients.

Aortic intramural hematoma and classic aortic dissection: two sides of the same coin within the acute aortic syndrome for an interventional radiologist.

Management of acute type B aortic intramural haematoma (AIH) still represents a challenging issue. Although most resolve spontaneously or with conservative therapy, several cases of AIH may complicate into classic aortic dissection with subsequent risk of aortic rupture and visceral malperfusion, thus needing urgent or preemptive thoracic endovascular aneurysm repair (TEVAR). Despite the long-term aorta-related survival, TEVAR might lead to graft obstruction, migration, infection, stroke/paraplegia, visceral ischemia, endoleak and, last but not least, retrograde aortic dissection (AD), frequent in the acute phase and associated with a high mortality risk. In order to highlight such a close relationship between AIH and AD and the possibility to perform endovascular treatment, we report the experience of an adult female patient with an aortic intramural haematoma evolving into a classic aortic dissection. Despite successful thoracic endovascular aneurysm repair (TEVAR), our patient developed an aortic dissection type A at one month with subsequent indication for cardiac surgery still representing the elective approach in case of pathologies including the ascending aorta. Thus, the aim of our discussion is to create a debate on the most appropriate management for the treatment of descending AIH.

Echocardiographic Evolution of PosteroLateral Left Ventricular Aneurysm with Normal Coronary Arteries in Patient Recently COVID-19 Vaccinated: A Complicated Atypical Case of Takotsubo Syndrome Vaccine-related?

A 72-year-old woman, recently COVID-19 vaccinated with a third dose, was referred to our center for acute chest pain and dyspnea. On admission, the electrocardiography showed a STEMI on inferior derivations and the dyskinesia of the inferior wall was found at the first transthoracic echocardiogram. The coronary angiography did not show coronary artery disease. After 1 week, a huge posterolateral left ventricular (LV) aneurysm with initial signs of rupture was found and the patient underwent a Dor's procedure to exclude the LV aneurysm. As far as we know, this is the first reported case of Takotsubo following the COVID-19 vaccination requiring cardiac surgery.

Intraoperative Assessment of Coronary Resistances: A New Quality Marker and Potential Tool to Predict Early Graft Failure after Coronary Artery Bypass Grafting?

Intraoperative assessment of graft patency is pivotal for successful coronary revascularization. In the present study we aimed to propose a new, easy to perform tool to assess anastomotic quality intraoperatively, and to investigate its potential reliability in predicting early graft failure. Intraoperative graft flowmetry of 63 consecutive patients undergoing CABG were prospectively collected. Transit time flowmetry and its derivatives were recorded. Coronary resistances were calculated according to Hagen-Poiseuille equation both during cardioplegic arrest and after withdrawal from cardiopulmonary bypass. Angiographic evidence of graft occlusion at follow-up was cross-checked with intraoperative recordings. After a mean follow-up of 10.4 ± 6.0 months, 22 grafts were studied, and occlusion was documented in five (22.7%). Occluded grafts showed lower flows and higher resistances recorded during aortic cross-clamping. Coronary resistances, recorded during aortic cross-clamping, greater than 2.0 mmHg/mL/min, showed a sensitivity of 80% and a specificity of 100% to predict graft failure. We propose the routine recording of coronary resistances during aortic cross-clamping as an additional tool to overcome the acknowledged limitation of TTF to predict graft occlusion at 1 year.

Dynamic right ventricular outflow tract obstruction by cardiac hydatic cysts: A multimodality imaging study.

We report the case of massive hydatic heart disease in a 50-year-old male patient referred to hospital for recent-onset dyspnea, atypical chest, and hypotension. Right ventricular outflow tract obstruction was demonstrated to be caused by hypoechogenic formations at Doppler-echocardiography and confirmed to be hydatic cysts at cardiac magnetic resonance. These cysts developed within the right ventricular wall and the septum, and caused hemodynamic instability.

Malignant right coronary artery origin from the left sinus of Valsalva: Complementary role for transesophageal echocardiography upon the cath-lab diagnosis.

Anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva is a rare but clinically relevant congenital anomaly, since the RCA may be subjected to cyclical compression due to its interarterial course. At least in the past, most patients experienced bad outcomes before being diagnosed with a malignant variant. Chronic (often subclinical) myocardial ischemia and possible arrhythmias are common complications. Once symptoms or electrocardiographic signs of myocardial ischemia become apparent, a quick diagnosis is mandatory. We report the case of a late symptomatic woman in whom RCA originated from the opposite sinus of Valsalva. The malignant variant was confirmed at transesophageal echocardiography directly in the catheterization laboratory, soon after angiographic diagnosis of aberrant origin.