TAV-in-TAV in patients with prosthesis embolization: Impact of commissural alignment and global outcomes.

BACKGROUND: Optimal strategies to manage embolization of transcatheter aortic valve implantation (TAVI) devices are unclear; valve-in-valve (ViV) is often used. We aimed to describe through one-single center experience its rate, causes, consequences, and management as well as the rate and relevance of commissural alignment (CA) in this context. METHODS: We identified across 1038 TAVI cases, those cases requiring ViV for the management of first device embolization. CA (absence or mild misalignment) after first and second device was assessed by CT or fluoroscopy. RESULTS: A total of 23 cases (2.2%) were identified, 52.3% embolized towards the aorta and 47.7% towards the ventricle. Suboptimal implant height (38%) and embolization at the time of post-dilation (23%) were the most frequent mechanisms together with greater rate of bicuspid valve (p < 0.001) and a trend to greater annular eccentricity. Procedural and 1-year death occurred in 13% and 34%, respectively (vs. 1.1% and 7.8% in the global cohort, p < 0.001). CA was present in 76.9% of the prostheses initially implanted but was only spontaneously achieved in 30.8% of the second ViV device. Adequate CA of both prostheses was identified in only two cases (8.7%). There were no cases of coronary obstruction. CONCLUSIONS: TAVI device embolization mechanisms can often be predicted and prevented. Mortality following bail-out ViV is higher than in regular TAVI procedures but 2/3 of these patients survived beyond 1-year follow-up. In them, valve degeneration or coronary re-access might be particularly challenging since CA was rarely achieved with both devices suggesting that greater efforts should be made in this regard.

Application of Mixed Reality to Ultrasound-guided Femoral Arterial Cannulation During Real-time Practice in Cardiac Interventions.

Mixed reality opens interesting possibilities as it allows physicians to interact with both, the real physical and the virtual computer-generated environment and objects, in a powerful way. A mixed reality system, based in the HoloLens 2 glasses, has been developed to assist cardiologists in a quite complex interventional procedure: the ultrasound-guided femoral arterial cannulations, during real-time practice in interventional cardiology. The system is divided into two modules, the transmitter module, responsible for sending medical images to HoloLens 2 glasses, and the receiver module, hosted in the HoloLens 2, which renders those medical images, allowing the practitioner to watch and manage them in a 3D environment. The system has been successfully used, between November 2021 and August 2022, in up to 9 interventions by 2 different practitioners, in a large public hospital in central Spain. The practitioners using the system confirmed it as easy to use, reliable, real-time, reachable, and cost-effective, allowing a reduction of operating times, a better control of typical errors associated to the interventional procedure, and opening the possibility to use the medical imagery produced in ubiquitous e-learning. These strengths and opportunities were only nuanced by the risk of potential medical complications emerging from system malfunction or operator errors when using the system (e.g., unexpected momentary lag). In summary, the proposed system can be taken as a realistic proof of concept of how mixed reality technologies can support practitioners when performing interventional and surgical procedures during real-time daily practice.

3D Virtual modelling, 3D printing and extended reality for planning of implant procedure of short-term and long-term mechanical circulatory support devices and heart transplantation.

Introduction: The use of three-dimensional (3D) reconstruction and printing technology, together with extended reality applied to advanced heart failure adult patients with complex anatomy, is rapidly spreading in clinical practice. We report practical experience with application to acute and chronic heart failure: planning and performing mechanical circulatory device insertion or heart transplantation. Methods: From November 2019 until February 2022, 53 3D virtual biomodels were produced for intervention planning (using Virtual/Augmented Reality and/or 3D printing), following a specific segmentation and preprocessing workflow for biomodelling, in patients with advanced heart failure due to structural heart disease or cardiomyopathies. Four of those patients were complex cases requiring mechanical circulatory support implant procedures in our center. Results: One short-term and three long-term ventricular assist device system were successfully clinically implanted after application of this technique. In other two cases with extremely high procedural risk, visualized after application of this multimodality imaging, heart transplantation was elected. Conclusion: 3D printing based planning and virtual procedure simulation, are of great importance to select appropriate candidates for mechanical circulatory support in case of complex patient anatomy and may help to diminish periprocedural complications. Extended reality represents a perspective tool in planification of complex surgical procedures or ventricular assist device insertion in this setting.

Factibilidad del alineamiento comisural y coronario precisos con TAVI balón-expandible / Feasibility of precise commissural and coronary alignment with balloon-expandable TAVI

Introducción y objetivos: Nuestro objetivo fue describir la factibilidad y resultados preliminares de una estrategia de alineamiento comisural preciso (ACP) con implante percutáneo de válvula aórtica balón-expandible. Métodos: Se analizó la relación entre las comisuras nativas y las neocomisuras en 10 pacientes consecutivos con estenosis aórtica grave trivalva y sintomática tras orientar el implante de TAVI basándose en la tomografía computarizada (TC) a través de un programa de análisis específicamente desarrollado. El ACP se predijo en base a modelos in silico que permitieron estimar cuantos grados había que girar la prótesis en el momento del crimpado. El grado de ACP y de solapamiento con los ostium coronarios se midió mediante TC al mes. Se recogieron gradientes transvalvulares y fuga perivalvular. Resultados: El mal alineamiento medio fue de 16,7±8°. Cuatro pacientes presentaron mal alineamiento ligero, pero ninguno moderado o grave. El análisis in silico predijo la posición final de las neocomisuras con un coeficiente de correlación de 0,983 (IC95%, 0,966-0,992), p <0,001. Se produjo solapamiento coronario severo con el ostium de la coronaria derecha en 3 casos en relación con excentricidad de su origen, pero en ningún caso con el ostium coronario izquierdo. El gradiente transaórtico medio fue de 6,1±3,3mmHg y no hubo casos de fuga perivalvular moderada o grave. Conclusiones: Es posible calcular una rotación paciente-específica de la prótesis balón-expandible en el momento del crimpado basándose en la TC preprocedimiento. De este modo, se logró evitar el mal alineamiento moderado o grave de las neo-comisuras y el solapamiento con el ostium coronario izquierdo en todos los casos.(AU)

Introduction and objectives: We aimed to describe the feasibility and preliminary outcomes of commissural alignment (CA) for the balloon-expandable transcatheter heart valve. Methods: The relationship among native commissures and transcatheter aortic valve implantation neocommissures was analyzed in 10 consecutive patients with tricuspid severe aortic stenosis undergoing transcatheter aortic valve implantation after guided implantation based on computed tomography analysis with a self-developed software. CA was predicted by in silico bio-modelling in the 10 patients and the calculated rotation was applied during crimping. Degrees of CA and coronary overlap (CO) were measured through 1-month follow up computed tomography. Transvalvular residual gradients and the rate of paravalvular leak were also analyzed. Results: Mean commissural misalignment was 16.7±8°. Four patients showed mild misalignment but none of them showed a moderate or severe degree of misalignment. The in silico model accurately predicted the final in vivo position with a correlation coefficient of 0.983 (95%CI, 0.966-0.992), P <.001. Severe CO with right coronary ostium occurred in 3 patients likely due to ostial eccentricity, and CO was not present with the left coronary artery in any of the patients. Mean transaortic gradient was 6.1±3.3mmHg and there were no moderate-severe paravalvular leaks. Conclusions: Patient-specific rotation during valve crimping based on preprocedural computed tomography is feasible with balloon-expandable devices and is associated with the absence of moderate or severe commissural misalignment and left main CO.(AU)

Feasibility of precise commissural and coronary alignment with balloon-expandable TAVI.

INTRODUCTION AND OBJECTIVES: We aimed to describe the feasibility and preliminary outcomes of commissural alignment (CA) for the balloon-expandable transcatheter heart valve. METHODS: The relationship among native commissures and transcatheter aortic valve implantation neocommissures was analyzed in 10 consecutive patients with tricuspid severe aortic stenosis undergoing transcatheter aortic valve implantation after guided implantation based on computed tomography analysis with a self-developed software. CA was predicted by in silico bio-modelling in the 10 patients and the calculated rotation was applied during crimping. Degrees of CA and coronary overlap (CO) were measured through 1-month follow up computed tomography. Transvalvular residual gradients and the rate of paravalvular leak were also analyzed. RESULTS: Mean commissural misalignment was 16.7±8°. Four patients showed mild misalignment but none of them showed a moderate or severe degree of misalignment. The in silico model accurately predicted the final in vivo position with a correlation coefficient of 0.983 (95%CI, 0.966-0.992), P <.001. Severe CO with right coronary ostium occurred in 3 patients likely due to ostial eccentricity, and CO was not present with the left coronary artery in any of the patients. Mean transaortic gradient was 6.1±3.3mmHg and there were no moderate-severe paravalvular leaks. CONCLUSIONS: Patient-specific rotation during valve crimping based on preprocedural computed tomography is feasible with balloon-expandable devices and is associated with the absence of moderate or severe commissural misalignment and left main CO.

Accurate commissural alignment during ACURATE neo TAVI procedure. Proof of concept.

INTRODUCTION AND OBJECTIVES: Final position of the neo-commissures is uncontrolled during transcatheter aortic valve implantation (TAVI), potentially hindering coronary access and future procedures. We aimed to develop a standard method to achieve commissural alignment with the ACURATE neo valve. METHODS: The relationship between native and TAVI neo-commissures was analyzed in 11 severe aortic stenosis patients undergoing TAVI. Based on computed tomography analysis, an in silico model was developed to predict final TAVI commissural posts position. A modified implantation technique, accurate commissural alignment (ACA) and a dedicated delivery system were developed. TAVI implants were tested in 3-dimensional (3D) printed models and in vivo. Commissural misalignment and coronary overlap (CO) were analyzed. RESULTS: The in silico model accurately predicted final position of commissural posts irrespective of the implantation technique performed (correlation coefficient, 0.994; 95%CI, 0.989-0.998; P<.001). TAVI implant with patient-specific rotation was simulated in 3D printed models and in 9 patients. ACA-oriented TAVI implants presented adequate commissural alignment in vivo (mean commissural misalignment of 7.7 ±3.9°). None of the ACA oriented implants showed CO, whereas in silico conventional implants predicted CO in 6 of the 9 cases. CONCLUSIONS: Accurate commissural alignment of the ACURATE neo device is feasible by inserting the delivery system with a patient-specific rotation based on computed tomography analysis. This is a simple and reproducible method for commissural alignment that can be potentially used for all kinds of TAVI devices.

Exercise Ventilatory Inefficiency in Post-COVID-19 Syndrome: Insights from a Prospective Evaluation.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is a systemic disease characterized by a disproportionate inflammatory response in the acute phase. This study sought to identify clinical sequelae and their potential mechanism. METHODS: We conducted a prospective single-center study (NCT04689490) of previously hospitalized COVID-19 patients with and without dyspnea during mid-term follow-up. An outpatient group was also evaluated. They underwent serial testing with a cardiopulmonary exercise test (CPET), transthoracic echocardiogram, pulmonary lung test, six-minute walking test, serum biomarker analysis, and quality of life questionaries. RESULTS: Patients with dyspnea (n = 41, 58.6%), compared with asymptomatic patients (n = 29, 41.4%), had a higher proportion of females (73.2 vs. 51.7%; p = 0.065) with comparable age and prevalence of cardiovascular risk factors. There were no significant differences in the transthoracic echocardiogram and pulmonary function test. Patients who complained of persistent dyspnea had a significant decline in predicted peak VO2 consumption (77.8 (64-92.5) vs. 99 (88-105); p < 0.00; p < 0.001), total distance in the six-minute walking test (535 (467-600) vs. 611 (550-650) meters; p = 0.001), and quality of life (KCCQ-23 60.1 ± 18.6 vs. 82.8 ± 11.3; p < 0.001). Additionally, abnormalities in CPET were suggestive of an impaired ventilatory efficiency (VE/VCO2 slope 32 (28.1-37.4) vs. 29.4 (26.9-31.4); p = 0.022) and high PETCO2 (34.5 (32-39) vs. 38 (36-40); p = 0.025). INTERPRETATION: In this study, >50% of COVID-19 survivors present a symptomatic functional impairment irrespective of age or prior hospitalization. Our findings suggest a potential ventilation/perfusion mismatch or hyperventilation syndrome.

Big data and new information technology: what cardiologists need to know.

Technological progress in medicine is constantly garnering pace, requiring that physicians constantly update their knowledge. The new wave of technologies breaking through into clinical practice includes the following: a) mHealth, which allows constant monitoring of biological parameters, anytime, anyplace, of hundreds of patients at the same time; b) artificial intelligence, which, powered by new deep learning techniques, are starting to beat human experts at their own game: diagnosis by imaging or electrocardiography; c) 3-dimensional printing, which may lead to patient-specific prostheses; d) systems medicine, which has arisen from big data, and which will open the way to personalized medicine by bringing together genetic, epigenetic, environmental, clinical and social data into complex integral mathematical models to design highly personalized therapies. This state-of-the-art review aims to summarize in a single document the most recent and most important technological trends that are being applied to cardiology, and to provide an overall view that will allow readers to discern at a glance the direction of cardiology in the next few years.

Self-expandable transcatheter heart valves for aortic stenosis. Short-term outcome and matched hemodynamic performance.

INTRODUCTION AND OBJECTIVES: Aortic self-expandable (SE) transcatheter aortic valve implantation (TAVI) devices are particularly useful for patients with aortic stenosis and small/tortuous vessels, small aortic annuli, or low coronary ostia. However, it is unclear whether the growing range of SE devices shows comparable hemodynamic and clinical outcomes. We aimed to determine the differential hemodynamic (residual valve area and regurgitation) and clinical outcomes of these devices in comparable scenarios. METHODS: All patients were enrolled from 4 institutions and were managed with 4 different SE TAVI devices. Baseline and follow-up clinical data were collected and echocardiographic tests blindly and centrally analyzed. Patients were compared according to valve type and a 1:1 matched comparison was performed according to degree of calcification, aortic annulus dimensions, left ventricular ejection fraction, and body surface area. RESULTS: In total, 514 patients were included (Evolut R/PRO, 217; ACURATE neo, 107; ALLEGRA, 102; Portico, 88). Surgical risk scores were comparable in the unmatched population. No differences were observed in the post-TAVI regurgitation rate and in in-hospital mortality (2.7%). The rate of pacemaker implantation at discharge was significantly different among devices (P=.049), with Portico showing the highest rate (23%) and ACURATE neo the lowest (9.5%); Evolut R/PRO and ALLEGRA had rates of 15.9% and 21.2%, respectively. The adjusted comparison showed worse residual TAVI gradients and aortic valve area with ACURATE neo vs ALLEGRA (P=.001) but the latter had higher risk of valve embolization and a tendency for more cerebrovascular events. CONCLUSIONS: A matched comparison of 4 SE TAVI devices showed no differences regarding residual aortic regurgitation and in-hospital mortality.

Twitter and the pursuit of global health-care during COVID-19 pandemic / Twitter y la búsqueda de una atención sanitaria global durante la pandemia COVID-19

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Comparison of Figulla Flex® and Amplatzer™ devices for atrial septal defect closure: A meta-analysis.

BACKGROUND: Atrial septal defect (ASD) is one of the most common congenital heart diseases. Percutaneous closure is the preferred treatment, but certain complications remain a concern. The most common devices are AMPLATZER™ (ASO) (St. Jude Medical, St. Paul, MN, USA) and Figulla Flex® septal occluders (FSO) (Occlutech GmbH, Jena, Germany). The present study aimed to assess main differences in outcomes. METHODS: A systematic search in Pubmed and Google scholarship was performed by two independent reviewers for any study comparing ASO and FSO. Searched terms were "Figulla", "Amplatzer", and "atrial septal defect". A random-effects model was used. RESULTS: A total of 11 studies including 1770 patients (897 ASO; 873 FSO) were gathered. Baseline clinical and echocardiographic characteristics were comparable although septal aneurysm was more often reported in patients treated with ASO (32% vs. 25%; p = 0.061). Success rate (94% vs. 95%; OR: 0.81; 95% CI: 0.38-1.71; p = 0.58) and peri-procedural complications were comparable. Procedures were shorter, requiring less fluoroscopy time with an FSO device (OR: 0.59; 95% CI: 0.20-0.97; p = 0.003). Although the global rate of complications in long-term was similar, the ASO device was associated with a higher rate of supraventricular arrhythmias (14.7% vs. 7.8%, p = 0.009). CONCLUSIONS: Percutaneous closure of ASD is a safe and effective, irrespective of the type of device. No differences exist regarding procedural success between the ASO and FSO devices but the last was associated to shorter procedure time, less radiation, and lower rate of supraventricular arrhythmias in follow-up. Late cardiac perforation did not occur and death in the follow-up was exceptional.

El papel del ejercicio aeróbico en la prevención y manejo de la fibrilación auricular. ¿Amigo o enemigo? / The role of aerobic exercise in the prevention and management of auricular fibrillation. Friend or foe?

La fibrilación auricular es la arritmia que presenta mayor prevalencia en la población a nivel mundial. De hecho, la bibliografía científica existente parece mostrar también una elevada prevalencia en deportistas de resistencia. Sin embargo, actualmente la relación entre la fibrilación auricular y el ejercicio aeróbico resulta controvertida. Por un lado, el ejercicio aeróbico puede considerarse una herramienta de prevención primaria para el desarrollo de enfermedades cardiovasculares, incluidas las arritmias. Por otro, realizar actividades de alta intensidad de manera regular con grandes volúmenes, ha sido identificada por algunos autores como un factor de riesgo. Actualmente, se desconoce el mecanismo exacto por el cual el ejercicio aérobico podría incrementar el riesgo de fibrilación auricular, pero podría estar relacionado con cambios anatómicos y funcionales a nivel cardíaco. Esta revisión pretende realizar una actualización del efecto que presenta el ejercicio aérobico sobre la fibrilación auricular para establecer una pauta de prescripción. Los resultados del presente trabajo, según la evidencia actual, parecen mostrar al ejercicio aérobico como una estrategia no farmacológica útil tanto para la prevención, como para el tratamiento de la fibrilación auricular. El efecto preventivo del ejercicio aeróbico en la fibrilación auricular parece estar relacionado con la disminución de factores de riesgo asociados. Aunque no existe consenso sobre la carga de ejercicio, se considera que el ejer-cicio aeróbico debería practicarse regularmente y a una intensidad moderada-vigorosa para alcanzar los mayores beneficios. Se requieren más investigaciones para determinar los mejores parámetros de ejercicio aeróbico en la fibrilación auricular

Atrial fibrillation is the arrhythmia with the highest prevalence world-wide. In fact, scientific literature seems to show a high prevalence of atrial fibrillation in endurance athletes too. However, currently the relationship between atrial fibrillation and aerobic exercise is controversial. On the one hand, aerobic exercise could be defined as a useful tool to be used as primary prevention strategy for the development of cardiovascular diseases, including arrhythmias. On the other hand, some authors identify it as a risk factor, specifically if it is performed at high intensity with large regular volumes. But the exact mechanism by which aerobic exercise might increase the risk of atrial fibrillation is unknown, although it could be related to anatomical and functional changes at the cardiac level. This review aims to update the knowledge about the effect of aerobic exercise on atrial fibrillation to establish a prescription pattern. The results of the present work, according to the current evidence, show the aerobic exercise as a non-pharmacological strategy, both for the primary and secondary prevention of atrial fibri-llation. The preventive effect of aerobic exercise on atrial fibrillation seems to be related to the reduction of associated risks. Although there is no consensus on the exercise load, it is considered that aerobic exercise should be practiced often and at a moderate-vigorous intensity to get the greatest benefits. More research is required to determine the best parameters of aerobic exercise in atrial fibrillation