Emergent Conversion to Open Heart Surgery during Transcatheter Aortic Valve Implantation: The Presence of a Rescue Team Improves Outcomes.

OBJECTIVE: Transcatheter aortic valve implant (TAVI) is the gold standard for the high-surgical-risk group of patients with aortic valve disease and it is an alternative to surgery in patients at intermediate risk. Lethal complications can occur, and many of these are manageable only with emergent conversion to open heart surgery. We retrospectively evaluate the outcome of all patients undergoing TAVI in our departments and the impact of a complete cardiac rescue team to reduce 30-day mortality. METHODS: Data from all patients undergoing TAVI between January 2020 and August 2023 in our center were analyzed. An expert complete rescue was present in catheter laboratory. Primary outcomes were in-hospital and at 30-day mortality and evaluation of all cases needed for emergent conversion to open heart surgery. RESULTS: 825 patients were enrolled. The total mortality was 19/825 (2.3%). Eleven of the total patients (1.3%) required emergent conversion to open heart surgery. Among them, eight were alive (73%), with a theoretical decrease of 0.98% in overall mortality. CONCLUSIONS: surgical treatment is rare during TAVI. The presence of an expert complete rescue team as support means an increase in survival. Surgery must be used only to restore circulatory and to treat complication while percutaneous approaches should complete the procedure.

Transcatheter Valve-in-Valve Implantation in an Aortic Bioprosthesis With Severe Regurgitation and a Challenging Aortic Anatomy.

Valve-in-valve transcatheter aortic valve replacement for failing surgical bioprosthetic valves becomes troublesome if a stiff vascular prosthesis replaces the ascending aorta. We report the off-label use of a new transcatheter aortic valve for treatment of a patient with a bioprosthetic valve with central regurgitation, a horizontal aorta, and kinking of the aortic prosthesis. (Level of Difficulty: Intermediate.).

Transcatheter Therapies in Challenging Aortic Ailments: TAVR in Extreme Horizontal Aortic Root With CoA Stenting.

Transcatheter aortic valve replacement (TAVR) for severe aortic stenosis in older adults may be challenging because of additional aortic comorbidities such as aortic coarctation (CoA). We report successful snared-assisted transfemoral TAVR in a patient with an extremely horizontal ventriculoaortic axis that was worsened by a previous endovascular repair of complex CoA. (Level of Difficulty: Advanced.).

Mechanical circulatory support and intravascular lithotripsy in high-risk patients undergoing percutaneous coronary intervention and transcatheter aortic valve replacement: a case series.

BACKGROUND: Patients undergoing transcatheter aortic valve replacement (TAVR) usually have multiple comorbidities, such as severely impaired left ventricular function (LVF) and heavily calcified coronary lesions. When they undergo pre-TAVR high-risk percutaneous coronary interventions (HR-PCIs) for severely calcified left main (LM) lesions, potential life-threatening intra-procedural complications associated with the different techniques available to treat calcified lesions can arise. In this setting, mechanical circulatory support proves its usefulness. However, the choice of device can be troublesome. CASE SUMMARY: We report two clinical scenarios of intravascular lithotripsy (IVL) for the treatment of heavily calcified LM coronary lesions, wherein peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO), alone or combined with an intra-aortic balloon pump (IABP), were used as an upfront strategy to support the procedure. The use of these techniques was particularly effective during multi-vessel HR-PCIs and TAVR, and no complications occurred, which suggested their safety. DISCUSSION: These cases provide multiple insights into the strategy of using IVL + VA-ECMO, alone or with IABP, to treat heavily calcified LM coronary lesions in patients with severely compromised LVF undergoing TAVR. IVL safely and effectively overcame shortcomings related to other plaque ablation techniques, and VA-ECMO proved to be effective when facing the combination of high-risk coronary and valve interventions.

Intracoronary Lithoplasty in Percutaneous Treatment of Challenging Calcified Coronary Lesions.

Unexpanded stents in calcified coronary stenosis is a problem where intravascular lithotripsy could be effectively employed. In these 2 cases, we report possible issues associated with the use of this technology. (Level of Difficulty: Intermediate.).

Safe and Effective Management of Antiplatelet Therapy in a Clopidogrel-Naive Patient Undergoing "Ad Hoc" Complex Coronary Intervention: A Case Report.

BACKGROUND: "Ad hoc" percutaneous coronary intervention (PCI) is a frequent practice as reported in large real-life registries, but most of the patients undergo PCI without being on full and effective dual antiplatelet therapy or clopidogrel is administered orally only a few minutes before the beginning of the procedure. This practice, especially in complex PCI, could be affected by a higher rate of peri-procedural adverse events. CASE SUMMARY: We present the case of a 72-year old male diabetic, hypertensive and hyperlipidemic, clopidogrel-naïve, with stable angina who underwent coronary angiography showing several tight stenoses on the left descending artery (LAD) and followed by a chronic total occlusion (CTO) of the vessel. The two main diagonal branches were severely stenosed at the origin as well. Due to patient's decision an ad hoc complex PCI (CTO and multiple Bifurcations) was successfully performed using cangrelor, instead of cath-lab clopidogrel pretreatment, in order to reduce the incidence of peri-procedural myocardial infarction risk, as suggested by recent evidence. Finally, the patient was started on dual antiplatelet therapy with ticagrelor, as guidelines recommend to consider in complex procedures, and discharged 48 h later without complications or significant increases of myocardial enzymes. DISCUSSION: Current Guidelines recommend loading dose (I/A) or pre-treatment with clopidogrel, nevertheless trials have not demonstrated its benefit, unlike cangrelor. This case highlights the role of aggressive antiplatelet therapy administered in the cath lab to reduce periprocedural ischemic events during elective treatment of complex lesions requiring multiple stenting in clopidogrel-naïve patients.

Role of plasma glucose level on myocardial perfusion in ST-segment elevation myocardial infarction patients.

AIMS: Hyperglycemia is frequent in patients with ST elevation myocardial infarction (STEMI) and is associated with adverse outcome. Aim of our study was to evaluate the correlation between admission plasma glucose level (PGL) and coronary arteries flow velocity. METHODS: We enrolled 149 STEMI patients successfully treated with primary percutaneous coronary intervention (pPCI). The study population was divided into two groups based on PGL (< or >140 mg/dl) and on history of diabetes, and the groups compared in terms of corrected TIMI frame count (cTFC). RESULTS: Hyperglycemic patients had a significantly higher cTFC in both the culprit (p < 0.0001) and non-culprit vessel (p: 0.0002); diabetes history impairs as well cTFC of the culprit (p < 0.0001) and non-culprit vessel (p: 0.0001). Within the subpopulation of diabetic patients hyperglycemic ones showed higher cTFC in both the culprit (p 0.0013) and non-culprit vessel (p: 0.0006). Moreover in the whole population cTFC values of both arteries increase linearly with the increment of admission PGL. CONCLUSIONS: Admission PGL affects coronary flow of both culprit and non-culprit vessel. The impairment of coronary flow is also demonstrated in known diabetic patients, suggesting to consider hyperglycemia an additional risk factor. We finally demonstrated for the first time a positive linear relationship between PGL and cTFC.