Prevalence of Posttranscatheter Aortic Valve Implantation Vascular Complications in Real Life.

BACKGROUND: Vascular complications (VCs) are commonly observed after transfemoral transcatheter aortic valve implantation (TAVI) procedures. Closure devices for the access site were developed to reduce their incidence. We aim to evaluate the prevalence, predictors, and outcomes of the occurrence of post-TAVI VCs. MATERIALS AND METHODS: A retrospective study was conducted on 1336 consecutive patients who underwent TAVI at the University Hospital of Toulouse, France, between January 2016 and March 2020. All included procedures were performed through the common femoral artery, and ProGlide® was the used closure device. The studied population was divided into two groups depending on the occurrence of VCs defined according to Valve Academic Research Consortium-2 criteria. RESULTS: The mean age of the studied population was 84.4 ± 6.9, and 48% were male. 90% of TAVI interventions were performed through the right femoral artery. The prevalence of VCs was 18.8%, and 3.7% were major. Prolonged procedure duration was an independent predictor of VCs. Using the right access site and smaller introducer size (14 Fr) were preventive factors. No significant difference in mortality rate was detected between the two groups. CONCLUSION: This study showed a low prevalence for post-TAVI VCs, especially for the major type. An increase in bleeding events and prolonged cardiac care unit stay were the common adverse outcomes.

Conduction disturbances in low-surgical-risk patients undergoing transcatheter aortic valve replacement with self-expandable or balloon-expandable valves.

Despite a considerable improvement in TAVR devices and procedures, together with a reduction in procedural complications, the rate of conduction disturbances (CD) remained stable over the years. Indeed, the CD rate is still significantly higher than in surgical aortic valve replacement, and represents one of the main limitations to the expansion of TAVR to younger low-risk patients. The aim of the present study was to assess the incidence and predictors of CD in low-risk patients undergoing TAVR. Among 637 patients without preexisting CD who underwent TAVR, 116 (18.2%) were considered at low surgical risk. Up to 25% of low-risk patients presented with persistent CD at discharge. The pacemaker implantation rate was similar in the low-risk group compared to the intermediate-/high-risk group (8.7% vs 10.6%, p = 0.55). Moreover, the rate of new persistent left bundle branch block (LBBB) following TAVR was also similar between both groups (18.1% vs 22.1%, p = 0.34). At 1-year follow-up, LBBB was persistent in 62.5% of patients and 3 of them required a pacemaker implantation. Depth of valve implantation, baseline QRS duration and mean aortic transvalvular gradient were identified as independent predictors of CD in low-risk patients. Patients at low surgical risk showed an equivalent CD rate than intermediate-/high-risk patients. The depth of valve implantation was the main predictor of CD in low-risk patients undergoing TAVR. Baseline QRS duration and mean aortic transvalvular gradient were also associated with increased CD.

Participating in Sports After Mitral Valve Repair for Primary Mitral Regurgitation: A Retrospective Cohort Study.

OBJECTIVE: Participating in either competitive or leisure sports is restrictive after surgical mitral valve repair (MVR). In this study, we examine the impact of sports on outcomes after MVR. DESIGN: Retrospective cohort study. SETTING: Patients aged 18 to 65 years who underwent a first-time MVR for primary mitral regurgitation (MR) in a tertiary care center. PATIENTS: One hundred twenty-one consecutive patients were included in the study. The exclusion criteria were as follows: other concomitant procedures, early perioperative death or repeat intervention, noncardiac death or endocarditis during follow-up, and general contraindications for normal physical activity. ASSESSMENT OF RISK FACTORS: Participation in sports was quantified by the number of hours per week during the past 6 months, classified according to the Mitchell classification and assessed with the International Physical Activity Questionnaire (IPAQ) short form. MAIN OUTCOME MEASURES: The primary composite endpoint was MVR failure defined as MR grade ≥2 or mean transmitral gradient ≥8 mm Hg, signs and symptoms of heart failure, or late-onset postoperative AF (>3 months). RESULTS: The mean age was 50 ± 11 years, and there were 85 (71%) men. The median follow-up was 34 months [interquartile range (IQR): 20-50]. Fifty-six (46%) patients participated in sports regularly (median of 3 h/wk; IQR: 2-5). Twenty (17%) patients reached the primary composite endpoint with no correlation with participation in sports (P = 0.537), IPAQ categories (P = 0.849), in any of the Mitchell classification subgroups and a high level of participation in sports ≥6 hours (P = 0.679). CONCLUSIONS: Sports seem to be unrelated to the worst outcome after MVR.

Comparison of the Frequency of Thrombocytopenia After Transfemoral Transcatheter Aortic Valve Implantation Between Balloon-Expandable and Self-Expanding Valves.

Thrombocytopenia after transcatheter aortic valve implantation (TAVI) is common and has been related to worse clinical outcomes. Comparison of platelet kinetics among different types of valves is limited. Our objectives were to analyze the differences in drop platelet count (DPC) between balloon-expandable valves (BEVs) and self-expanding valves and their prognostic implications after TAVI. Patients who underwent transfemoral TAVI from 2008 to 2016 were included. Exclusion criteria were severe baseline thrombocytopenia and periprocedural death. Postprocedural platelet counts were collected. Two groups were created: DPC ≤30 and DPC >30%. Valve Academic Research Consortium-2 criteria were used to define outcomes. Study population included 609 patients (age 84.7 ± 6.0, 46.6% males). The mean DPC was 32.5 ± 13.9%. The DPC was higher in the BEV arm (33.9 ± 14.2 vs 30.7 ± 13.4%, p = 0.006), and the nadir was reached later in comparison to the self-expanding valve arm (3.0 ± 1.3 vs 2.5 ± 1.1 days, p <0.001). After multivariable analysis, the use of BEV, known coronary artery disease, and left ventricle ejection fraction were the factors associated with a higher rate of DPC >30%. At 30 days, the DPC >30% was related with a higher rate of life-threatening and/or major bleeding (6.8 vs 2.1%, p = 0.009) and death (3.5 vs 0.8%, p = 0.036). At 1 year, the difference in mortality disappeared. In conclusion, in this cohort of patients, the use of BEV seems to be associated with a higher risk of DPC after TAVI. A DPC ≥30% was related with increased risk of life-threatening and/or major bleeding and death at 30 days. Larger and prospective studies are needed to understand this phenomenon.

Late Right Coronary Obstruction Following TAVR in a Degenerated Surgical Aortic Bioprosthetic Valve.

We present a case of an 80-year-old woman with severe aortic insufficiency due to a degenerated 21-mm biological prosthetic aortic valve implanted 9 years earlier, treated by using a transcatheter aortic valve replacement valve-in-valve procedure and who experienced a delayed right coronary obstruction. (Level of Difficulty: Beginner.).

Tamoxifen elicits atheroprotection through estrogen receptor α AF-1 but does not accelerate reendothelialization.

Based on both experimental and clinical data, tamoxifen has been proposed to have cardiovascular benefits, although the mechanism(s) contributing to that protective effect are still poorly understood. In vitro experiments demonstrated that tamoxifen elicits its transcriptional effect through estrogen receptor (ER) α, but other targets can participate in its actions. However, although tamoxifen selectively activates the activating function (AF)-1 of ERα, we recently showed that this ERα subfunction is dispensable for the atheroprotective action of 17ß-estradiol (E2), the main ligand of ERs. The goal of the present work is to determine to which extent ERα and its AF-1 mediate the vasculoprotective action of tamoxifen. Our data confirm that tamoxifen exerts an atheroprotective action on low density lipoprotein receptor (LDL-r(-/-)) female mice, but, in contrast to E2, it fails to accelerate reendothelialization after carotid electric injury. Tamoxifen and E2 elicit differences in gene expression profiles in the mouse aorta. Finally, the atheroprotective action of tamoxifen is abrogated in ERα(-/-)LDL-r(-/-) mice and in LDL-r(-/-) mice selectively deficient in ERαAF-1 (ERαAF-1(0/0)LDL-r(-/-)). Our results demonstrate, for the first time to our knowledge, that tamoxifen mediates its actions in vivo through the selective activation of ERαAF-1, which is sufficient to prevent atheroma, but not to accelerate endothelial healing.

Initial experience with a new technique of endoscopic and ultrasonographic access for biopsy of para-aortic (station 6) mediastinal lymph nodes without traversing the aorta.

OBJECTIVES: All lymph node stations but the para-aortic are accessible by a combination of endoscopic ultrasound and endobronchial ultrasound. We recently described an echographic-endoscopic technique for the biopsy of para-aortic (station 6) lymph nodes without traversing the thoracic aorta. This study reviewed our initial experience with this new technique. METHODS: This first-in-human evaluation of the biopsy of station 6 mediastinal lymph nodes with curvilinear endoscopic ultrasound without arterial puncture used a retrospective case series design to study 12 consecutive patients who underwent this new technique. Station 6 lymph nodes were approached with a long fine needle aspiration approach (6-8 cm) through the proximal esophagus. The needle was passed through the esophagus into the mediastinum just medial to the left subclavian artery. It was then directed toward the para-aortic location (6-8 cm trajectory) to reach and enter the para-aortic lymph nodes without piercing the aorta or great vessels. RESULTS: Successful cytologic diagnoses of station 6 lymph nodes were obtained in all cases (lymphocytes in all samples). No morbidity resulted from the procedure, nor was any observed at 30 days after the procedure. Patient anatomy may preclude safe access in certain situations. CONCLUSIONS: Endoscopic ultrasound access of para-aortic (station 6) lymph nodes allows complete, minimally invasive mediastinal lymph node staging and diagnosis without traversal of the aorta. This technique, the final piece of the puzzle required for complete staging of the mediastinum with nonsurgical endoscopic techniques, is reproducible and safe.