Supraclavicular Subclavian access for Sapien Transcatheter aortic valve replacement- a novel approach.

BACKGROUND: Within the trans-subclavian approach, procedural techniques can vary widely, and reported access generally refers to an infraclavicular axillary approach. We describe and report the use of a novel supraclavicular true subclavian approach for transcatheter aortic valve replacement (TAVR) exclusively for implantation of Sapien 3 valves. CASE PRESENTATION: We report our first five consecutive patients undergoing TAVR with a Sapien 3 valve using a standardized subclavian approach at a single center. In-hospital and 30-day complications were reported. The use of this approach resulted in successful implantation in 100% of patients in a safe manner with 0% mortality, stroke, and vascular injury during hospitalization and at 30 day follow-up. The in-hospital pacemaker implantation rate was 20%. The average length of stay was 3 days. CONCLUSIONS: TAVR with Sapien implant can be safely performed with a standardized supraclavicular subclavian approach in patients with unfavorable femoral access.

Comparison of left ventricular ejection fraction and exercise capacity as predictors of two- and five-year mortality following acute myocardial infarction.

This study evaluated exercise capacity and left ventricular ejection fraction (LVEF) as predictors of long-term mortality in patients with ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention. LVEF is a well-established predictor of mortality in patients with STEMI. Exercise capacity, expressed as milliliters per kilogram per minutes or METs (1 MET = 3.5 ml/kg/min), may also serve as an independent predictor of mortality in this cohort. However, it is unclear whether these variables used together more accurately define mortality risk than either alone. In the Primary Angioplasty in Acute Myocardial Infarction-2 trial, 330 patients with long-term mortality data underwent radionuclide ventriculography at rest and cycle ergometer stress testing 6 weeks after percutaneous coronary intervention for STEMI. We used this database to evaluate the ability of LVEF at rest and exercise capacity to predict 2- and 5-year mortality. Exercise capacity <4 METs was a significant predictor of 5-year mortality (odds ratio [OR] 4.54, p = 0.0016). In contrast, decreased LVEF demonstrated a trend toward higher mortality but was not statistically significant at 2- (OR 2.22, p = 0.22) or 5-year (OR 2.04, p = 0.20) follow-up. When evaluated in combination, there was a statistically significant 2-year mortality risk for those with a decreased LVEF and decreased exercise capacity (OR 6.03, p = 0.018). Exercise capacity was a better predictor of 2- and 5-year mortality than LVEF in patients with STEMI treated with percutaneous intervention. In conclusion, when combined with LVEF, exercise capacity provides independent and additive information regarding long-term prognosis.

Left ventricular remodeling and systolic deterioration in acute myocardial infarction: findings from the Stent-PAMI Study.

BACKGROUND: Left ventricular systolic deterioration (LVSD) develops in some patients despite successful percutaneous intervention and medical therapy for myocardial infarction (MI). We sought to determine predictors of LVSD by comparing demographic, procedural, angiographic variables, and 6-month major adverse cardiac events (MACE) in patients with and without LVSD after MI. METHODS: We performed a posthoc analysis of patients prospectively enrolled in the Stent-PAMI trial if they had successful percutaneous intervention for MI (<50% residual stenosis and TIMI-3 grade flow), normal left ventricular systolic function on index ventriculogram, and protocol driven coronary angiography with ventriculography at 6 months. We defined LVSD as an absolute decrease in ejection fraction > or =15% compared to baseline value. RESULTS: Of the 900 patients enrolled in Stent-PAMI, 187 patients met the inclusion criteria. LVSD developed in 30 patients (16%) and occurred independent of demographic, procedural, angiographic variables, and 6-month MACE. Multivariate predictors of LVSD were higher baseline ejection fraction (P = 0.0065, OR 1.09; 95% CI = 1.02-1.16) and peak creatine phosphokinase (CPK) level (P = 0.0022, OR 1.04; 95% CI = 1.02-1.07). CONCLUSIONS: LVSD occurs in a minority of patients despite successful mechanical reperfusion and occurred independent of procedural, angiographic variables, target vessel revascularization, reinfarction, and combined MACE. Infarct size (determined by peak CPK) and high baseline ejection fraction predicted development of LVSD at 6 months. LVSD in this population likely occurred by negative left ventricular remodeling.