Development of atrioventricular and intraventricular conduction disturbances in patients undergoing transcatheter aortic valve replacement with new generation self-expanding valves: A real world multicenter analysis.

BACKGROUND: High degree cardiac conduction disturbances (HDCD) remain a major complication after transcatheter aortic valve replacement (TAVR), especially with self-expandable valves (SEV). Our aim was to investigate peri-procedural and in-hospital modification of atrioventricular and intracardiac conduction associated to new generation SEV implantation, and the development of new HDCD resulting in permanent pacemaker implantation (PPM) in patients undergoing TAVR. METHODS AND RESULTS: Three-hundred forty-four consecutive patients with severe aortic stenosis who underwent TAVR with a new generation SEV [Evolut-R/Pro (n = 130), Acurate-neo (n = 79), Portico (n = 75) and Allegra (n = 60)] were included. An analysis of baseline, post-TAVR and pre-discharge ECG and procedural aspects were centrally performed. A significant increase in baseline PR interval (169.6 ± 28.2 ms) and QRS complex width (101.7 ± 25.9 ms) was noted immediately post-TAVR (188.04 ± 34.49; 129.55 ± 30.02 ms), with a partial in-hospital reversal (179.4 ± 30.1; 123.06 ± 30.94 ms), resulting in a net increase at hospital discharge of 12.6 ± 38.8 ms and 21.4 ± 31.6 ms (p < 0.001), respectively. The global incidence of new onset persistent HDCD at hospital discharge was 46.3%, with 17.7% of patients requiring PPM. Independent predictors of new onset HCDC at hospital discharge were valve recapture (OR: 2.8; 95% IC: 1.1-7.2, p = 0.033) and implantation depth ≥ 6 mm (OR: 1.9 05% IC 1.1-3.3, p = 0.015), while higher implantation (<3 mm (OR: 0.3, 95% IC 0.1-0.7, p = 0.014) and use of Acurate-Neo valve (OR: 0.4; 95% IC 0.2-0.8, p = 0.009) were protective factor. CONCLUSIONS: New generation self-expanding aortic valves were associated with a significant increase in PR and QRS interval at hospital discharge leading to a very high rate of HDCD. While valve recapture and implantation depth were independent predictors for the occurrence of HDCD, use of Accurate-Neo valve was a protective factor.

Angiographically Based Direct Implantation of the Bioresorbable Vascular Scaffold in Non-ST Segment Elevation Acute Coronary Syndrome: Feasibility and Outcome.

BACKGROUND: Direct implantation of metallic drug-eluting stents is recommended for lesions with high thrombotic burden; however, this can't be applied to bioresorbable scaffold for which adequate lesion preparation is recommended. AIM: We aimed at assessing the feasibility and safety of direct scaffold implantation based only on angiographic assessment in patients presented with non-ST segment elevation acute coronary syndrome. METHODS: The study was a retrospective two-centre study conducted over patients diagnosed with NSTE-ACS presented to cardiology department at Juan Ramon Hospital, Spain and critical care department, Cairo University in the period between February 2016 to May 2017. We included patients for whom we depend only on angiographic assessment for decision making whether to directly implant the scaffold or predilate the lesion and we excluded patients for whom intracoronary imaging was used at the index procedure either for pre or post-implantation. The primary outcome of interest was the device-oriented composite endpoints (DOCE) including cardiac death, and MI attributed to the target vessel and TLR. The secondary endpoints were the broader patient-oriented composite outcome (POCE) and scaffold/stent thrombosis. POCE includes all-cause mortality, any MI and any revascularisation (including TLR, TVR and revascularisation of non- target vessel). RESULTS: Among 46 patients with NSTE-ACS treated with BVS, we did direct implantation in 20 patients (group A), and we used pre dilatation in 26 patients (group B). The two groups have similar demographics and clinical criteria. Procedural success was obtained in all study population. Mean follow up duration was 12 months. We have total of 10% device-oriented composite endpoints in group A versus 15% in group B (p-value = 0.684). We didn't document any cardiac death in both groups. In group B we had one (3.8%) non-fatal MI while there was no MI in group A (P-value = 1). In group A we had 2 cases (10%) of TLR while in group B there were 3 cases (11.5%) TLR (P-value = 1). We have two cases (7.7%) of TVR in group B and one in group A p-value = 1. All cases were planned staged PCI. Scaffold thrombosis occurred in one case in group A (5%) and two cases in group B (7.7%) p-value = 1. CONCLUSION: With proper lesion selection, direct BVS implantation in all-comers NSTE-ACS patients is feasible and safe even without the aid of intracoronary imaging.