Aortic balloon valvuloplasty before transcatheter valve replacement in high-risk patients with aortic stenosis. Cardiac catheterization and echocardiographic hemodynamic study.

BACKGROUND: Balloon aortic valvuloplasty (BAV) has been revived as a bridge to transcatheter aortic valve replacement (TAVR). The aim of the current prospective study was to define a safe time period from BAV to TAVR and to determine hemodynamic variables that predict event-free survival after BAV. PATIENTS AND METHODS: The present prospective study included 68 consecutive patients with severe aortic stenosis who were treated initially with BAV from 2009 to 2012. Echocardiographic and invasive hemodynamic assessments were performed before BAV. The patients were followed up at regular intervals and events were defined as cardiac hospitalization or death. RESULTS: Invasive hemodynamic evaluation yielded more favorable results than echocardiographic assessment: aortic stenosis was less severe, cardiac output was higher, and pulmonary capillary wedge pressure (PCWP) was lower. Post-BAV event-free survival was 80.4 % at 30 days, 64.5 % at 6 months, 37 % at 1 year, 22.3 % at 2 years, and 9.3 % at 3 years. After excluding pre-discharge deaths (n = 7), the 30-day event-free survival rate was 90 %. Predictors of events after BAV were atrial fibrillation, cardiogenic shock, elevated euroSCORE (European System for Cardiac Operative Risk Evaluation), elevated PCWP, and elevated pulmonary artery systolic pressure. Invasively measured PCWP was the only independent predictor of events (hazard ratio, 1.07; 95 % confidence interval, 1.03-1.11; p = 0.001). CONCLUSION: A 30-day post-BAV period may be considered a bridge to TAVR. Furthermore, invasive assessment of PCWP before BAV is an independent hemodynamic predictor of events after BAV.

Suitability of venous and arterial conduits used for coronary artery bypass grafting in conjunction with coronary disease risk factors.

UNLABELLED: BACKGROUND/STUDY OBJECTIVES: We studied patients undergoing coronary artery bypass grafting. Risk factors for coronary disease were studied in conjunction with the histopathologic findings of the grafts prior to implantation. Our aim was to correlate the histologic condition of the grafts and evaluate the morphological changes in conjunction with existing risk factors. DESIGN/PATIENTS: In 10 candidates for surgical revascularization (nine males, mean age 60.8 years), the risk factor profile was studied (smoking, dyslipidaemia, hypertension, diabetes, family history) and the Body Mass Index was calculated. Of a total of 14 grafts, 10 were saphenous vein grafts and four left internal thoracic artery grafts. Histologic samples were studied under optical and electron microscopy. We studied the intima morphology and thickness, the width of the intercellular spaces, the texture of the subendothelial layer, the endothelial status, and the condition of the basal lamina. Histopathological changes were correlated with risk factors. RESULTS: Histopathological changes were observed in the wall structure of all grafts. The most important changes were found in the venous grafts, notably: intima thickening, existence of foam cells in the intima, widening of the intercellular spaces, subendothelial oedema, degeneration and detachment of endothelial cells, and wide multilayered basal lamina. The co-existence of two or more risk factors seems to exarcerbate morphological changes. CONCLUSION: Morphological changes are present principally in the walls of venous but also arterial conduits, even prior to implantation. These changes may be attributable to preparation techniques and preservation conditions of the grafts, but they could additionally be induced by coexisting risk factors. It is conceivable that these alterations could perhaps precipitate and accelerate atherosclerotic changes, inducing lumen narrowing or even occlusion of the graft postoperatively.

Coronary vessel perforation during balloon angioplasty: a case report.

Coronary perforation can be managed with prolonged balloon inflations, covered stents, or embolization of the vessel. We report on a case of a balloon-induced perforation of the distal left anterior descending artery, that was sealed by injecting preclotted autologous blood through the balloon catheter lumen at the site of the perforation. The patency of the distal vessel was maintained.