Conductive disturbances in the transcatheter aortic valve implantation setting: An appraisal of current knowledge and unmet needs.

New-onset conduction disturbances, including left bundle branch block and permanent pacemaker implantation, remain a major issue after transcatheter aortic valve implantation. Preprocedural risk assessment in current practice is most often limited to evaluation of the baseline electrocardiogram, whereas it may benefit from a multimodal approach, including ambulatory electrocardiogram monitoring and multidetector computed tomography. Physicians may encounter equivocal situations during the hospital phase, and the management of follow-up is not fully defined, despite the publication of several expert consensuses and the inclusion of recommendations regarding the role of electrophysiology studies and postprocedural monitoring in recent guidelines. This review provides an overview of current knowledge and future perspectives regarding the management of new-onset conduction disturbances in the setting of transcatheter aortic valve implantation, from the preprocedural phase to long-term follow-up.

Determinants and Impact of Heart Failure Readmission Following Transcatheter Aortic Valve Replacement.

BACKGROUND: Heart failure (HF) readmission is common post-transcatheter aortic valve replacement (TAVR). Nonetheless, limited data are available regarding its predictors and clinical impact. This study evaluated the incidence, predictors, and impact of HF readmission within 1-year post-TAVR, and assessed the effects of the prescription of HF therapies at discharge on the risk of HF readmission and death. METHODS: Patients included in the TAVR registry of a single expert center from 2009 to 2017 were analyzed. Competing-risk and Cox regressions were performed to identify predictors of HF readmission and death. RESULTS: Among 750 patients, 102 (13.6%) were readmitted for HF within 1-year post-TAVR. Overall, 53 patients (7.1%) experienced late readmissions (>30 days post-TAVR), and 17 (2.3%) had multiple readmissions. In ≈30% of readmissions, no trigger could be identified. Predominant causes of readmissions were changes in medication/nonadherence and supraventricular arrhythmia. Independent predictors of HF readmission included diabetes mellitus, chronic lung disease, previous acute HF, grade III or IV aortic regurgitation, and pulmonary hypertension both at discharge from the index hospitalization but not HF therapies. Overall, HF readmission did not significantly impact all-cause mortality (hazard ratio [HR], 1.36 [95% CI, 0.99-1.85]). However, late (HR, 1.90 [95% CI, 1.30-2.78]) and multiple HF readmissions (HR, 2.10 [95% CI,1.17-3.76]) were significantly associated with all-cause mortality. Prescription of renin-angiotensin system inhibitors at discharge was associated with a lower rate of all-cause mortality, especially among patients receiving doses of 25% to <50% (HR, 0.67 [95% CI, 0.48-0.94]) and 75% to 100% (HR, 0.61 [95% CI, 0.37-0.98]) of the optimal daily dose. CONCLUSIONS: HF readmission is common within 1-year of TAVR. Late and multiple HF readmissions associate with an increased risk of long-term all-cause mortality. Baseline comorbidities (diabetes, chronic lung disease, previous acute HF) and echocardiographic findings at discharge (grade III or IV aortic regurgitation, pulmonary hypertension) identified patients at high risk of HF readmission.

Transfemoral Technique to Untwist a Knotted Catheter in the Brachial Artery: A Case Report.

Cardiac catheterization using the transradial access has been proven to be safe, but can be complicated in some cases by catheter kinking or knotting. This complication is often the result of excessive manipulations due to the S-shaped configuration of the right subclavian-innominate-aorta axis. When a knot occurs in the brachial artery, regular maneuvers to unknot the catheter can be unsuccessful due to the narrow diameter of the artery or to the failure of the external fixation of the distal part of the catheter. We present a case of a knotted catheter in the brachial artery, untwisted with a snare technique. This endovascular technique is simple and avoids surgical extraction.