Central-to-peripheral blood pressure amplification: role of the recording site, technology, analysis approach, and calibration scheme in invasive and non-invasive data agreement.

Background: Systolic blood pressure amplification (SBPA) and pulse pressure amplification (PPA) can independently predict cardiovascular damage and mortality. A wide range of methods are used for the non-invasive estimation of SBPA and PPA. The most accurate non-invasive method for obtaining SBPA and/or PPA remains unknown. Aim: This study aims to evaluate the agreement between the SBPA and PPA values that are invasively and non-invasively obtained using different (1) measurement sites (radial, brachial, carotid), (2) measuring techniques (tonometry, oscillometry/plethysmography, ultrasound), (3) pulse waveform analysis approaches, and (4) calibration methods [systo-diastolic vs. approaches using brachial diastolic and mean blood pressure (BP)], with the latter calculated using different equations or measured by oscillometry. Methods: Invasive aortic and brachial pressure (catheterism) and non-invasive aortic and peripheral (brachial, radial) BP were simultaneously obtained from 34 subjects using different methodologies, analysis methods, measuring sites, and calibration methods. SBPA and PPA were quantified. Concordance correlation and the Bland-Altman analysis were performed. Results: (1) In general, SBPA and PPA levels obtained with non-invasive approaches were not associated with those recorded invasively. (2) The different non-invasive approaches led to (extremely) dissimilar results. In general, non-invasive measurements underestimated SBPA and PPA; the higher the invasive SBPA (or PPA), the greater the underestimation. (3) None of the calibration schemes, which considered non-invasive brachial BP to estimate SBPA or PPA, were better than the others. (4) SBPA and PPA levels obtained from radial artery waveform analysis (tonometry) (5) and common carotid artery ultrasound recordings and brachial artery waveform analysis, respectively, minimized the mean errors. Conclusions: Overall, the findings showed that (i) SBPA and PPA indices are not "synonymous" and (ii) non-invasive approaches would fail to accurately determine invasive SBPA or PPA levels, regardless of the recording site, analysis, and calibration methods. Non-invasive measurements generally underestimated SBPA and PPA, and the higher the invasive SBPA or PPA, the higher the underestimation. There was not a calibration scheme better than the others. Consequently, our study emphasizes the strong need to be critical of measurement techniques, to have methodological transparency, and to have expert consensus for non-invasive assessment of SBPA and PPA.

Presencia de regurgitación moderada o grave luego del implante percutáneo de la válvula aórtica con la estrategia de "Cusp Overlap" / Presence of Moderate or Severe Regurgitation after Transcatheter Aortic Valve Implant with the Cusp Overlap Strategy

RESUMEN Objetivo : Analizar si la estrategia del implante alto usando superposición de las cúspides derechas e izquierdas (Cusp Overlap, COVL) en el implante percutáneo de la válvula aórtica (TAVI) se relaciona con menor incidencia de regurgitación paravalvular (RPV) moderada o grave, comparada con la estrategia convencional (CON). Material y métodos : Se analizaron 206 pacientes consecutivos que recibieron TAVI con válvulas autoexpandidles entre agosto de 2019 y mayo de 2022. Se utilizó una estrategia CON en 101 pacientes (49%) y COVL en 105 (51%). El Punto Final Primario (PFP) fue la presencia de regurgitación paravalvular moderada y grave a 30 días. Resultados : No hubo diferencia clínica entre los grupos en cuanto a la edad media, sexo ni comorbilidades; excepto una tendencia a más diabetes y angioplastia coronaria previa en el grupo COVL. El STS score fue mayor en el grupo de COVL (6,9 ± 2,2 vs. 5,8 ± 2,4 en CON, p = 0,01). A 30 días no hubo diferencia en el PFP (RPV moderada en 2% en CON, y 0,9% en COVL; ninguno presentó RPV grave). Tampoco hubo diferencia en mortalidad, infarto, oclusión coronaria, accidente cerebrovascular, sangrado mayor y complicación vascular. La necesidad de marcapasos definitivo fue menor con la estrategia de COVL (6,7% vs. 17,8%, p = 0,01) y un nuevo bloqueo de rama izquierda ocurrió en 5,7% vs. 12,9% (p = 0,07). Conclusiones : En esta serie de un solo centro, la estrategia del implante alto de la válvula aórtica percutánea usando la técnica de COVL no demostró diferencia en la presencia de regurgitaciones moderadas o graves comparada con la estrategia convencional, sin presentar diferencia en las complicaciones, y se asoció a una menor necesidad de marcapasos definitivo y a una tendencia de menos bloqueos de rama izquierda a 30 días.

ABSTRACT Objective : The aim of this study is to whether higher transcatheter aortic valve implantation (TAVI) with self-expandable valves using the right and left cusp overlap strategy (Cusp Overlap, COVL) is associated with a lower incidence of moderate or severe paravalvular regurgitation, compared with the conventional strategy (CON). Methods : A total of 206 consecutive patients undergoing TAVI with self-expandable valves between August 2019 and May 2022 were analyzed. The CON technique was used in the first 101 patients (49%) and COVL was used in 105 (51%). The primary endpoint (PEP) was the presence of moderate or severe paravalvular regurgitation at 30 days. Results : There were no clinical differences between the groups in terms of mean age, sex or comorbidities, except for a trend towards more patients with diabetes and previous percutaneous coronary intervention in the COVL group. The STS score was greater in the COVL group (6.9 ± 2.2 vs. 5.8 ± 2.4 in the CON group; p = 0.01). There was no difference in the PEP at 30 days with 2% incidence of moderate PVR in the CON group and 0.9% in the COVL group, and none of them presented severe PVR. There were no differences in mortality, myocardial infarction, coronary artery obstruction, stroke, major bleeding or vascular complications. The need for permanent pacemaker was lower with the COVL strategy (6.7% vs. 17.8%, p = 0.01) and a new left bundle branch block occurred in 5.7% vs. 12.9% (p = 0.07). Conclusions : In this single-center series, the strategy of high transcatheter aortic valve implantation using the COVL strategy showed no difference in the presence of moderate or severe regurgitation compared with the conventional strategy, with no differences in complications, and was associated with a lower need for definitive pacemaker and with a trend towards lower incidence of left bundle branch block at 30 days.

Aortic systolic and pulse pressure invasively and non-invasively obtained: Comparative analysis of recording techniques, arterial sites of measurement, waveform analysis algorithms and calibration methods.

Background: The non-invasive estimation of aortic systolic (aoSBP) and pulse pressure (aoPP) is achieved by a great variety of devices, which differ markedly in the: 1) principles of recording (applied technology), 2) arterial recording site, 3) model and mathematical analysis applied to signals, and/or 4) calibration scheme. The most reliable non-invasive procedure to obtain aoSBP and aoPP is not well established. Aim: To evaluate the agreement between aoSBP and aoPP values invasively and non-invasively obtained using different: 1) recording techniques (tonometry, oscilometry/plethysmography, ultrasound), 2) recording sites [radial, brachial (BA) and carotid artery (CCA)], 3) waveform analysis algorithms (e.g., direct analysis of the CCA pulse waveform vs. peripheral waveform analysis using general transfer functions, N-point moving average filters, etc.), 4) calibration schemes (systolic-diastolic calibration vs. methods using BA diastolic and mean blood pressure (bMBP); the latter calculated using different equations vs. measured directly by oscillometry, and 5) different equations to estimate bMBP (i.e., using a form factor of 33% ("033"), 41.2% ("0412") or 33% corrected for heart rate ("033HR"). Methods: The invasive aortic (aoBP) and brachial pressure (bBP) (catheterization), and the non-invasive aoBP and bBP were simultaneously obtained in 34 subjects. Non-invasive aoBP levels were obtained using different techniques, analysis methods, recording sites, and calibration schemes. Results: 1) Overall, non-invasive approaches yielded lower aoSBP and aoPP levels than those recorded invasively. 2) aoSBP and aoPP determinations based on CCA recordings, followed by BA recordings, were those that yielded values closest to those recorded invasively. 3) The "033HR" and "0412" calibration schemes ensured the lowest mean error, and the "033" method determined aoBP levels furthest from those recorded invasively. 4) Most of the non-invasive approaches considered overestimated and underestimated aoSBP at low (i.e., 80 mmHg) and high (i.e., 180 mmHg) invasive aoSBP values, respectively. 5) The higher the invasively measured aoPP, the higher the level of underestimation provided by the non-invasive methods. Conclusion: The recording method and site, the mathematical method/model used to quantify aoSBP and aoPP, and to calibrate waveforms, are essential when estimating aoBP. Our study strongly emphasizes the need for methodological transparency and consensus for the non-invasive aoBP assessment.

Brachial Blood Pressure Invasively and Non-Invasively Obtained Using Oscillometry and Applanation Tonometry: Impact of Mean Blood Pressure Equations and Calibration Schemes on Agreement Levels.

The use of oscillometric methods to determine brachial blood pressure (bBP) can lead to a systematic underestimation of the invasively measured systolic (bSBP) and pulse (bPP) pressure levels, together with a significant overestimation of diastolic pressure (bDBP). Similarly, the agreement between brachial mean blood pressure (bMBP), invasively and non-invasively measured, can be affected by inaccurate estimations/assumptions. Despite several methodologies that can be applied to estimate bMBP non-invasively, there is no consensus on which approach leads to the most accurate estimation. Aims: to evaluate the association and agreement between: (1) non-invasive (oscillometry) and invasive bBP; (2) invasive bMBP, and bMBP (i) measured by oscillometry and (ii) calculated using six different equations; and (3) bSBP and bPP invasively and non-invasively obtained by applanation tonometry and employing different calibration methods. To this end, invasive aortic blood pressure and bBP (catheterization), and non-invasive bBP (oscillometry [Mobil-O-Graph] and brachial artery applanation tonometry [SphygmoCor]) were simultaneously obtained (34 subjects, 193 records). bMBP was calculated using different approaches. Results: (i) the agreement between invasive bBP and their respective non-invasive measurements (oscillometry) showed dependence on bBP levels (proportional error); (ii) among the different approaches used to obtain bMBP, the equation that includes a form factor equal to 33% (bMBP = bDBP + bPP/3) showed the best association with the invasive bMBP; (iii) the best approach to estimate invasive bSBP and bPP from tonometry recordings is based on the calibration scheme that employs oscillometric bMBP. On the contrary, the worst association between invasive and applanation tonometry-derived bBP levels was observed when the brachial pulse waveform was calibrated to bMBP quantified as bMBP = bDBP + bPP/3. Our study strongly emphasizes the need for methodological transparency and consensus for non-invasive bMBP assessment.

Fractional Flow Reserve Versus Instantaneous Wave-Free Ratio in Assessment of Lesion Hemodynamic Significance and Explanation of their Discrepancies. International, Multicenter and Prospective Trial: The FiGARO Study.

Background The FiGARO (FFR versus iFR in Assessment of Hemodynamic Lesion Significance, and an Explanation of Their Discrepancies) trial is a prospective registry searching for predictors of fractional flow reserve/instantaneous wave-free ratio (FFR/iFR) discrepancy. Methods and Results FFR/iFR were analyzed using a Verrata wire, and coronary flow reserve was analyzed using a Combomap machine (both Philips-Volcano). The risk polymorphisms for endothelial nitric oxide synthase and for heme oxygenase-1 were analyzed. In total, 1884 FFR/iFR measurements from 1564 patients were included. The FFR/iFR discrepancy occurred in 393 measurements (20.9%): FFRp (positive)/iFRn (negative) type (264 lesions, 14.0%) and FFRn/iFRp (129 lesions, 6.8%) type. Coronary flow reserve was measured in 343 lesions, correlating better with iFR (R=0.56, P<0.0001) than FFR (R=0.36, P<0.0001). The coronary flow reserve value in FFRp/iFRn lesions (2.24±0.7) was significantly higher compared with both FFRp/iFRp (1.39±0.36), and FFRn/iFRn lesions (1.8±0.64, P<0.0001). Multivariable logistic regression analysis confirmed (1) sex, age, and lesion location in the right coronary artery as predictors for FFRp/iFRn discrepancy; and (2) hemoglobin level, smoking, and renal insufficiency as predictors for FFRn/iFRp discrepancy. The FFRn/iFRp type of discrepancy was significantly more frequent in patients with both risk types of polymorphisms (endothelial nitric oxide synthaser+heme oxygenase-1r): 8 patients (24.2%) compared with FFRp/iFRn type of discrepancy: 2 patients (5.9%), P=0.03. Conclusions Predictors for FFRp/iFRn discrepancy were sex, age, and location in the right coronary artery. Predictors for FFRn/iFRp were hemoglobin level, smoking, and renal insufficiency. The risk type of polymorphism in endothelial nitric oxide synthase and heme oxygenase-1 genes was more frequently found in patients with FFRn/iFRp type of discrepancy. Registration URL: https://clinicaltrials.gov; Unique identifier: NCT03033810.

Implante alto de las válvulas autoexpandibles con la técnica de "Cusp-Overlap", una estrategia para disminuir la necesidad de marcapasos en el implante percutáneo de válvula aórtica. Evolución a 30 días / High Self-expandable Valve Implantation with the Cusp-Overlap Technique, a Strategy to Reduce the Need for Pacemaker in Transcatheter Aortic Valve Implantation. 30-day Outcome

RESUMEN Objetivo: Analizar si el implante más alto en el implante percutáneo de válvula aórtica (TAVI) con válvulas auto-expandibles utilizando la superposición de las cúspides derecha e izquierda disminuye la necesidad de marcapasos definitivo. Material y Métodos: Se analizaron 164 pacientes consecutivos que recibieron TAVI con válvulas auto- expandibles; en 101(61,6%) de ellos se implantaron utilizando la vista coplanar de las tres cúspides, a la cual llamamos técnica convencional (CON) y en 63 (38,4%) utilizamos la técnica COVL, con superposición de las cúspides derecha e izquierda . El punto final primario (PFP) fue la necesidad de marcapasos definitivo (MCPD) a 30 días. Resultado: No hubo diferencias entre los grupos en la edad media, prevalencia de sexo masculino, hipertensión, cirugía de revascularización previa, antecedente de accidente cerebrovascular (ACV), función renal, o hemodiálisis. Los pacientes en el grupo COVL tuvieron más diabetes, angioplastia coronaria (ATC) e infarto previos. La ATC pre-TAVI fue similar, con mayor score STS (6,3 ± 2,1 vs. 5,8 ± 2,4; p = 0,05). La presencia de fibrilación auricular fue mayor en el grupo COVL sin diferencia en bloqueo auriculoventricular, de rama derecha o izquierda. No hubo diferencia en el área valvular aórtica, gradiente medio y fracción de eyección ventricular izquierda. A 30 días se observó una reducción significativa del PFP en la estrategia COVL, (6,3% vs 17,8%, p = 0,03). No hubo diferencia en mortalidad, ACV, sangrado mayor, infarto agudo de miocardio o regurgitación aórtica. Hubo tendencia a menor presencia de nuevo bloqueo competo de rama izquierda en el grupo COVL (4,8% vs. 12,9%, p = 0,08). Conclusiones: El uso de la técnica de COVL, que permite un implante más alto en el TAVI con válvulas autoexpandibles, demostró en esta serie ser factible y seguro, con disminución de la necesidad de MCPD sin aumento de las complicaciones.

ABSTRACT Objective: The aim of this study was to analyze whether higher transcatheter aortic valve implantation with self-expandable valves using the right and left cusp overlap strategy decreases the need for permanent pacemaker. Methods: A total of 164 consecutive patients undergoing TAVI with self-expandable valves were analyzed: 101 (61.6%) implanted with the conventional technique (CON) using the three-cusp coplanar view, and 63 (38.4%) using the right and left cusp overlap (COVL) technique. The primary endpoint (PEP) was the need for permanent pacemaker (PPM) at 30 days. Results: Mean age, prevalence of male gender, hypertension, prior coronary artery bypass graft surgery (CABG), and history of stroke, kidney function or hemodialysis was not different between groups. Patients in the COVL group had more diabetes, coronary percutaneous transluminal coronary angioplasty (PTCA) and prior infarct, and pre-TAVI PTCA was similar, with higher STS score (6.3±2.2 vs. 5.8±2.4; p=0.05). The presence of atrial fibrillation was greater in the COVL group, without differences in right or left bundle branch or atrioventricular block. There was no difference in aortic valve area, mean gradient and left ventricular ejection fraction. At 30 days, the need of PPM was significantly reduced with the COVL technique (6.3%% vs. 17.8%; p=0.03). No difference was observed in mortality, stroke, major bleeding, acute myocardial infarction or aortic regurgitation, and the presence of new-onset complete left bundle branch block was lower in the COVL group (4.8% vs. 12.9%; p=0.08). Conclusions: Use of the COVL technique, which allows higher self-expandable valve implantation during TAVI, was feasible and safe, decreasing the need for PPM without increasing complications.

Endocarditis infecciosa luego del implante de válvula aórtica por cateterismo / Infective Endocarditis after Transcatheter Aortic Valve Implantation

RESUMEN Introducción: La endocarditis infecciosa (EI) post implante percutáneo de válvula aórtica (TAVI) es poco frecuente, con una alta tasa de morbimortalidad. Métodos: Se analizaron 630 pacientes consecutivos con TAVI, de los cuales 6 (0,95%) presentaron EI. Resultados: Cuatro eran hombres, edad 81,3 ± 2,2 años, y todos sintomáticos. La fracción de eyección ventricular izquierda (FEVI) fue 56,8 ± 5,3%. Todos recibieron un implante exitoso y uno presentó regurgitación moderada. Dos requirieron marcapaso definitivo, a uno de ellos se le debió recolocar el cable a las 24 hs. La EI se presentó a los 63,5 ± 73,3 días (mediana de 35 días). El germen aislado fue un coco (+) en cuatro casos. En uno se observó una vegetación en el ecocardiograma transesofágico. Un paciente falleció dentro de los 30 días. El seguimiento fue a 23 ± 22 meses, ningún paciente presentó nuevos eventos o internaciones. En el eco Doppler la FEVI fue de 55,9 ± 4,6%, el gradiente medio 8,2 ± 1,8 mmHg y la velocidad pico de 1,8 ± 0,2 m/seg. Un paciente terminó una regurgitación moderada. Conclusiones: En esta serie de pacientes, la EI post TAVI fue poco frecuente y presentó una evolución favorable con el tratamiento antibiótico.

ABSTRACT Background: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is a rare complication with high morbidity and mortality. Methods: Of 630 consecutive patients undergoing TAVI, 6 (0.95%) presented IE. Results: Four patients were men, mean age was 81.3 ± 2.2 years and all the patients were symptomatic. Left ventricular ejection fraction (LVEF) was 56.8 ± 5.3%. The procedure was successful in all the patients and one presented moderate regurgitation. Two patients required definitive pacemaker and the lead had to be reimplanted 24 hours later in 1 patient. Time to IE was 63.5 ± 73.3 days (median 35 days). A Gram-positive coccus was isolated in four cases. One patient presented a vegetation on transesophagic echocardiography. One patient died within 30 days. During follow-up of 23 ± 22 months none of the patients presented new events or hospitalizations. On Doppler echocardiography, LVEF was 55.9 ± 4.6%, mean trans-aortic gradient was 8.2 ± 1.8 mm Hg and peak systolic velocity was 1.8 ± 0.2 m/s. One patient had moderate regurgitation. Conclusions: In this series of patients, IE after TAVI was uncommon and had a favorable course with antibiotic treatment.

Impact of Cusp-Overlap View for TAVR with Self-Expandable Valves on 30-Day Conduction Disturbances.

METHODS AND RESULTS: We retrospectively compared 257 consecutive patients undergoing TAVR with self-expandable valves using either CON (n = 101) or COVL (n = 156) in four intermediate/low volume centers. There were no significant differences in baseline characteristics between the groups. The 30-day incidence of new-onset LBBB (12.9% vs. 5.8%; p=0.05) and PPMI rate (17.8% vs. 6.4%; p=0.004) was significantly lower when using the COVL implantation view. There was no difference between the CON and COVL groups in 30-day incidence of death (4.9% vs. 2.6%), any stroke (0% vs. 0.6%), and the need for surgical aortic valve replacement (0% for both groups). CONCLUSION: Using the COVL view for implantation, we achieved a significant reduction of the LBBB and PPMI rate after TAVR in comparison with the traditional CON view, without compromising the TAVR outcomes when using self-expandable prostheses.

Intravascular ultrasound for cardiac allograft vasculopathy detection.

Cardiac allograft vasculopathy (CAV) after heart transplantation is a fibro-proliferative process affecting coronary arteries of the graft in up to 46.8% of the cases during the first 10 years post-transplantation. It is one of the main causes of graft loss and death. Due to graft denervation, CAV causing ischemia is usually clinically silent until the disease is far advanced. In this study, we compared coronary angiography with intravascular ultrasound (IVUS) for CAV detection. OUTCOMES: A total of 114 patients with HTx who underwent coronary angiography and IVUS between March 2018 and March 2019 were included. Mean follow-up was 87 ± 61 month. Lesions documented by coronary angiography were found in only 27 (24%) of the 114 patients. IVUS revealed ISHLT CAV 0 in 87 patients (76.3%); ISHLT CAV1 in 15 (13,1%) and ISHLT CAV2 and CAV3 in 6 patients (5.2%) each. Among 328 IVUS images, maximum intimal thickness (MIT) >0.5 mm was obtained in 60 vessels (52%) with 24 patients having three-vessel and 19 two-vessel involvement. CONCLUSION: As an adjunct to conventional coronary angiography to detect angiographically silent CAV in heart transplant patients, IVUS is a reliable and safe technique with a low complication rate. Large multicenter studies are necessary to confirm these findings and the potential long-term clinical impact of early detection in clinically and angiographically silent phase.

[Aortic valvular replacement by catheterism. Current state]. / Reemplazo valvular aórtico por cateterismo. Estado actual.

Severe aortic stenosis is a common disease whose prevalence is steadily growing with population ageing. Surgical aortic valve replacement (SAVR) has been the only effective alternative until the introduction of transcatheter aortic valve replacement (TAVR or TAVI). This procedure was initially used for non-surgical candidate patients where two randomized clinical trials and several registries showed superiority over conservative medical treatment. Furthermore, two additional clinical trials including high surgical risk patients proved the non-inferiority of TAVR versus surgical replacement. Similar findings regarding effectiveness were observed in other clinical trials including intermediate and low risk patients. Technical and procedural improvements, including learning curve and the current minimally invasive strategy have decreased periprocedural and mid-term complications such as those related with vascular access, stroke, the need for permanent pacemaker implantation and paravalvular leak. All things considered, durability is a pending question to establish which would be the role of TAVR in current and future practice.

La estenosis aórtica grave es una enfermedad común cuya prevalencia crece con el envejecimiento de la población. El reemplazo valvular aórtico quirúrgico (SAVR) ha sido la única alternativa efectiva hasta la aparición del reemplazo valvular aórtico por cateterismo (TAVR o TAVI). Este procedimiento se usó inicialmente para pacientes inoperables en quienes dos ensayos clínicos aleatorios y varios registros mostraron su superioridad sobre el tratamiento médico conservador. Dos ensayos clínicos adicionales en pacientes que, a pesar de ser considerados operables, tenían alto riesgo quirúrgico, demostraron la no inferioridad de TAVR versus reemplazo quirúrgico. Investigaciones posteriores probaron también su efectividad en pacientes de riesgo intermedio y bajo. Algunas complicaciones, como las relacionadas al acceso vascular, el accidente cerebro vascular, la necesidad de marcapasos definitivo y la regurgitación periprotésica, han ido disminuyendo con la mejoría de la tecnología, la curva de aprendizaje y la estrategia mínimamente invasiva actual. Queda pendiente determinar la durabilidad para establecer cuál será el papel de TAVR en la práctica clínica.

Tratamiento endovascular de aneurismas de aorta con estrategia minimalista / Endovascular Treatment of Aortic Aneurysms with Minimalistic Approach

RESUMEN Introducción: Los aneurismas de aorta siguen siendo una patología frecuente, en especial aquellos localizados en la aorta abdominal. Desde 1990, gracias al avance en los dispositivos y las técnicas endovasculares, la cirugía convencional ha dejado de ser la única opción de tratamiento. Presentamos nuestros resultados en el manejo del aneurisma de aorta con técnica endovascular mínimamente invasiva. Objetivos: Analizar los resultados a 30 días del implante de endoprótesis en la aorta torácica y abdominal con una estrategia mínimamente invasiva. Material y métodos: Entre marzo de 2012 y abril de 2019 se realizaron 395 implantes consecutivos de endoprótesis de aorta; en 264 (67%) de los cuales se utilizó una técnica mínimamente invasiva (MIN-A). De este grupo 240 procedimientos (90,9%) fueron llevados a cabo para reparar la aorta abdominal (EVAR) y 24 (9,1%) la aorta torácica (TEVAR). Resultados: De 264 pacientes se logró éxito técnico (ET) del implante en el 99,6% y éxito clínico (EC) en el 97,7%. La mortalidad a 30 días fue del 1,1% dado por neumonía, insuficiencia cardíaca y EPOC. Ningún paciente presentó IAM, ACV o necesitó de conversión a reparación quirúrgica de urgencia. El tiempo promedio del procedimiento fue de 62 minutos (SD ± 17). Algunos pacientes requirieron conversión a cierre quirúrgico del acceso [20 (7%) durante los primeros 100 casos, y 7 (3%) en los últimos 164 pacientes p = 0,05)]. El sangrado mayor que requirió transfusión fue del 1,1%. El tiempo promedio para la deambulación fue de 18 horas (SD ± 10), que luego de los primeros 100 pacientes disminuyó en forma significativa a 13 horas (SD ± 2,9 p = 0,05). La estadía hospitalaria en promedio fue de 1,4 días (SD ± 1,14) con 5 casos externados el mismo día del procedimiento. Conclusiones: Los procedimientos de reparación endovascular de aneurismas de la aorta con una estrategia miniinvasiva fueron factibles y seguros, ya que permitieron convertir estos procedimientos en abordajes percutáneos, con bajas tasas de complicaciones asociadas al acceso, menor tiempo quirúrgico, rápida deambulación y menor estadía hospitalaria, sin modificar la seguridad global del procedimiento. La curva de aprendizaje permitió bajar la tasa de conversiones a cirugía, así como los tiempos de deambulación.

ABSTRACT Background: Aortic aneurysms, particularly of the abdominal aorta, are still common. Since 1990, conventional surgery is no longer the only treatment option due to advances in endovascular devices and techniques. We present our results in the management of aortic aneurysms with a minimally invasive endovascular technique. Objectives: The aim of this study was to analyze the 30-day outcomes of endograft implantation in the thoracic aorta and abdominal aorta using a minimally invasive approach. Methods: Between March 2012 and April 2019, 395 consecutive endografts were implanted in the aorta, and 264 (67%) were performed using a minimally invasive approach (MIN-A). Among this group, 240 (90.9%) corresponded to abdominal endo-vascular aortic repair (EVAR) and 24 (9.1%) to thoracic endovascular aortic repair (TEVAR). Results: Technical success (TS) of the implant was achieved in 99.6% of the 264 patients and clinical success (CS) in 97.7%. Thirty-day mortality was 1.1% due to pneumonia, heart failure and chronic obstructive pulmonary disease. There were no cases of myocardial infarction, stroke or need for conversion to urgent surgical repair. Mean duration of the procedure was 62 minutes (SD ± 17). Some patients required conversion to surgical closure of the access site [20 (7%) during the first 100 cases and 7 (3%) in the final 164 patients, p = 0.05]. Three (1.1%) patients presented major bleeding requiring transfusion. Mean time to ambulation was 18 hours (SD ± 10) that significantly decreased to 13 hours after the first 100 patients (SD ± 2.9; p= 0.05). Mean length of hospital stay was 1.4 days (SD ± 1.14) with 5 patients discharged on the same day of the procedure. Conclusions: Endovascular aortic aneurysm repair using a minimally invasive strategy was feasible and safe, turning this procedure into a percutaneous approach, with low access site-related complications, shorter operative time, rapid ambulation and shorter length of hospital stay, without modifying overall safety of the procedure. The learning curve resulted in reduced rate of conversion to surgery and earlier ambulation.

Reemplazo valvular aórtico por cateterismo. Estado actual / Aortic valvular replacement by catheterism. Current state

Resumen La estenosis aórtica grave es una enfermedad común cuya prevalencia crece con el envejecimiento de la población. El reemplazo valvular aórtico quirúrgico (SAVR) ha sido la única alternativa efectiva hasta la aparición del reemplazo valvular aórtico por cateterismo (TAVR o TAVI). Este procedimiento se usó inicialmente para pacientes inoperables en quienes dos ensayos clínicos aleatorios y varios registros mostraron su superioridad sobre el tratamiento médico conservador. Dos ensayos clínicos adicionales en pacientes que, a pesar de ser considerados operables, tenían alto riesgo quirúrgico, demostraron la no inferioridad de TAVR versus reemplazo quirúrgico. Investigaciones posteriores probaron también su efectividad en pacientes de riesgo intermedio y bajo. Algunas complicaciones, como las relacionadas al acceso vascular, el accidente cerebro vascular, la necesidad de marcapasos definitivo y la regurgitación periprotésica, han ido disminuyendo con la mejoría de la tecnología, la curva de aprendizaje y la estrategia mínimamente invasiva actual. Queda pendiente determinar la durabilidad para establecer cuál será el papel de TAVR en la práctica clínica.

Abstract Severe aortic stenosis is a common disease whose prevalence is steadily growing with population ageing. Surgical aortic valve replacement (SAVR) has been the only effective alternative until the introduction of transcatheter aortic valve replacement (TAVR or TAVI). This procedure was initially used for non-surgical candidate patients where two randomized clinical trials and several registries showed superiority over conservative medical treatment. Furthermore, two additional clinical trials including high surgical risk patients proved the non-inferiority of TAVR versus surgical replacement. Similar findings regarding effectiveness were observed in other clinical trials including intermediate and low risk patients. Technical and procedural improvements, including learning curve and the current minimally invasive strategy have decreased periprocedural and mid-term complications such as those related with vascular access, stroke, the need for permanent pacemaker implantation and paravalvular leak. All things considered, durability is a pending question to establish which would be the role of TAVR in current and future practice.

Central Blood Pressure Waves Assessment: A Validation Study of Non-invasive Aortic Pressure Measurement in Human Beings.

INTRODUCTION: Measurement of central (aortic) systolic blood pressure has been shown to provide reliable information to evaluate target organ damage. However, non-invasive central blood pressure measurement procedures are still under analysis. AIM: To compare human pressure waveforms invasively obtained in the aorta, with the corresponding waveforms non-invasively recorded using an oscillometric device (Mobil-O-Graph). METHODS: In this research were included 20 subjects in which invasive percutaneous coronary interventions were performed. They were 10 males (68 ± 12 y. o. , BMI: 27.4 ± 4.6 kg/m2) and 10 females (77 ± 8 y. o. , BMI: 28.5 ± 5.3 kg/m2). During the invasive aortic pressure recording, a synchronized non-invasive Mobil-O-Graph acquisition beat by beat and reconstructed central pressure wave was performed. Both, invasive and non-invasive pressure waves were digitized and stored for subsequent analysis and calculations. A computerized interpolation procedure was developed in our laboratory to compare these pressure waves. RESULTS: A significant correlation between Mobil-O-Graph central blood pressure measurements and the corresponding invasive values was found in males (r < 0.81; p < 0.01) and females (r < 0.93; p < 0.01). However, in both genders, the slope of the regression lines was lesser than 1 (males: y = 0.7354x + 18.998; females: y = 0.9835x + 2.8432). In the whole population (n = 20), a significant correlation between Mobil-O-Graph central blood pressure measurements and the corresponding invasive values was found (r < 0.89; p < 0.01) and the regression line was lesser than 1 (y = 0.9774x + 1.7603). CONCLUSIONS: In this research, a high correlation between invasive central blood pressure values and those measured with the Mobil-O-Graph device was found in males, females and the whole population. However, a sub estimation of Mobil-O-Graph central blood pressure values was observed.