How accurate are manufacturers' recommendations in determining ineligibility for transfemoral transcatheter aortic valve implantation?

INTRODUCTION: Up to one-third of patients indicated for transcatheter aortic valve implantation (TAVI) may be unsuitable for transfemoral TAVI (TF-TAVI) according to manufacturers' recommendations and numerous professional societies. OBJECTIVE: This study aimed to investigate the predictive value of manufacturers' guidelines for major vascular access site complications using the Perclose ProGlide device. METHODS: Among 208 patients undergoing TF-TAVI, 144 patients (69.2%) were deemed eligible for TF-TAVI according to the manufacturer's instructions. A minimal lumen diameter (MLD) of the femoral artery below the manufacturer's specified limits and/or the presence of circumferential calcification were the reasons for ineligibility. Calcium score (CS), sheath-to-femoral artery ratio (SFAR) and MLD were estimated from computed tomography imaging. Vascular complications (VCs) (defined according to VARC-2 criteria) were retrospectively compared. RESULTS: Patients in the ineligible group had higher SFAR (1.13±0.15 vs. 0.88±0.107, p<0.001) and CS (1.66±0.99 vs. 1.24±0.73; p=0.003), and significantly lower MLD (7.72±1.03 vs. 6.31±0.96 mm; p<0.001) compared to the eligible group. Major (6.3% vs. 12.3%, p=0.13) and minor VCs (10.4% vs. 15.6%, p=0.29) were similar in the eligible and ineligible groups. The ineligible group had higher rates of rupture (0.7% vs. 6.3%; p=0.03). SFAR was the only independent predictor of major VCs (OR 469.1, 95% CI 4.95-44466.57, p=0.008). CONCLUSION: The TAVI team should not decide whether the patient is suitable for a femoral approach based solely on the manufacturer's criteria, and should incorporate additional factors that could be predictive of major VCs.

Vascular complications after transcatheter transfemoral aortic valve implantation: Modified sheath-to-femoral artery ratio as a new predictor.

OBJECTIVE: Vascular complications (VCs) contribute to increased morbidity and mortality in patients who have undergone transcatheter aortic valve implantation (TAVI); however, studies on their incidence and predictors show conflicting results. In this study, we sought to assess the incidence, impact, and predictors of VCs in transfemoral (TF) TAVI and also investigated the predictive role of manufacturer's size charts and a new predictor modified sheath-to-femoral artery ratio. METHODS: A total of 223 patients undergoing TF-TAVI were categorized into 2 groups. The patients were divided as eligible and ineligible according to the manufacturer's guidelines (MG), and the same patient cohort was dichotomized into eligible and ineligible on the basis of sheath-to-femoral artery ratio (SFAR) value of less than or greater than or equal to modified SFAR (md-SFAR). VCs (defined according to the Valve Academic Research Consortium II criteria) were retrospectively compared. RESULTS: According to the manufacturer's size charts, 65 patients were unsuitable; however, 35 patients were ineligible for TF-TAVI per the md-SFAR criteria. Although VCs occurred in 42 (18.8%) patients, 17 (27.7%) of those patients were classified as ineligible according to MG, whereas 14 (41.2%) were classified as ineligible in the md-SFAR group. In a multiple logistic regression analysis that included md-SFAR, MG, SFAR ≥1.05, peripheral artery disease, and minimum iliofemoral artery diameter, only md-SFAR was the independent predictor of VCs (odds ratio=3.71, 95% confidence interval=1.13-12.53, p=0.031). CONCLUSION: According to our results, md-SFAR might provide better patient selection to prevent VCs and improve outcomes in TF-TAVI procedures.

Value of Renal Vascular Doppler Sonography in Cardiorenal Syndrome Type 1.

OBJECTIVES: Worsening of renal function in a patient with acute decompensated heart failure is called cardiorenal syndrome (CRS) type 1. Recent studies have shown an association of persistent systemic venous congestion with renal dysfunction. This trial was set up to investigate the changes of renal Doppler parameters with diuretic therapy in patients with CRS type 1. METHODS: Cases of CRS type 1 were identified among patients hospitalized for decompensated heart failure. Serial measurements of the renal venous impedance index (VII) and arterial resistive index (ARI) were calculated by pulsed wave Doppler sonography. RESULTS: A total of 30 patients who had creatinine improvement with diuresis (group 1) and 34 patients without any improvement (group 2) were analyzed. Patients in group 1 had higher median VII and ARI (VII, 0.86 versus 0.66; P < .001; ARI, 0.78 versus 0.65; P < .001) on admission. A high ARI on admission (odds ratio, 6.25; 95% confidence interval, 1.84-14.3; P = .003) predicted the improvement of serum creatinine levels with diuretic therapy independent of confounding factors in patients with CRS type 1. CONCLUSIONS: Renal vascular Doppler parameters might offer guidance on the diagnostic and therapeutic strategies in prescribing decongestive therapy for decompensated heart failure.

Cystatin C and uncontrolled hypertension.

OBJECTIVE: Increased serum level of cystatin C, a sensitive biomarker for renal function, seems to predict adverse cardiovascular events. We investigated the predictive value of serum cystatin C for controlling hypertension in an observational study. METHODS: We screened 1037 adults residing in both rural and urban communities. They were grouped based on their diagnosis and control of hypertension. RESULTS: Serum cystatin C levels in patients with uncontrolled hypertension were higher than those in patients with controlled hypertension (0.98±0.23 mg/L vs. 0.89±0.19 mg/L, p=0.001). However, serum creatinine levels were similar between these groups (0.72±0.20 mg/dL vs. 0.70±0.18 mg/dL, p=0.89). Serum cystatin C levels increased the probability of uncontrolled hypertension independent from confounding factors (odds ratio, 1.48; 95% confidence interval, 1.09-5.64; p=0.03). CONCLUSION: Subtle kidney dysfunction may be detected using serum cystatin C concentrations among patients with poor blood pressure control and normal serum creatinine levels.

Long-term comparison of everolimus- vs. novolimus-eluting bioresorbable vascular scaffolds in real world patients.

INTRODUCTION: Elevated risk of adverse events in comparison to metallic stents resulted in withdrawal of everolimus-eluting bioresorbable scaffolds (eBVS), known as the most intensively studied BVS. There is a paucity of data comparing the two different BVS. AIM: To evaluate the long-term clinical outcomes of the novolimus-eluting bioresorbable vascular scaffold (nBVS) compared with eBVS. MATERIAL AND METHODS: Consecutive patients treated with nBVS or eBVS in our center were screened. The primary outcome was the 3-year rate of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, target vessel myocardial infarction (TV-MI), and target-lesion revascularization (TLR). RESULTS: After matching, 98 patients treated with 135 eBVS were compared with 98 patients treated with 136 nBVS. Baseline characteristics, clinical presentation, and lesion characteristics were comparable in both groups. The 3-year MACE rate was higher in the eBVS group (17.3% vs. 6.1%; p log-rank = 0.02). The occurrence of TLR (16.3% vs. 5.1%; p log-rank = 0.02) and TV-MI (8.2% vs. 0 %; p log-rank = 0.004) was also higher in the eBVS group except for cardiac deaths (1% vs. 2%; p log-rank = 0.98, eBVS vs. nBVS, respectively). Of note, definite device thrombosis rate was markedly increased in the eBVS group (5.1% vs. 0%; p log-rank = 0.03). CONCLUSIONS: The present study revealed that the 3-year event risk was lower for nBVS compared to eBVS. More evidence is needed to evaluate long-term performance of novolimus-eluting biovascular platforms.

Musculoskeletal pain and related factors in coronary artery disease: An observational cross-sectional study.

BACKGROUND AND AIM: In patients diagnosed with coronary artery disease (CAD), we aimed to determine the characteristics and risk factors of co-occurring musculoskeletal pain and examine its effects on functional capacity, psychological status and health-related quality of life. PATIENTS AND METHODS: A total of 100 patients with (n= 50) and without (n= 50) musculoskeletal pain were enrolled. All patients were assessed on sociodemographic and clinical properties. The Duke Activity Status Index (DASI), the Hospital Anxiety and Depression Scale (HADS) and the Short Form-36 (SF-36) were applied as clinical assessment scales. RESULTS: Patients with musculoskeletal pain were mostly female, and had a lower education level and annual income. The pain was mostly nociceptive, intermittent, sharp/stabbing in character, and located in the chest and spine. Having musculoskeletal pain resulted in lower levels on the DASI and all subgroups of the SF-36, and higher levels on the HADS. Female gender, lower education level and severity of emotional distress proved to be independent risk factors for the development of musculoskeletal pain. CONCLUSIONS: In CAD, the co-occurrence of musculoskeletal pain leads to a further decrease in health-related quality of life and functional status, and increased severity of anxiety and depression. This stresses the importance of the detection and optimal treatment of musculoskeletal pain in patients diagnosed with CAD.

[Ultrasound-assisted, catheter-directed thrombolysis of acute pulmonary embolism via the subclavian vein: alternative access path]. / Akut pulmoner emboli ile basvuran orta riskli bir hastada, subklavyen veni yoluyla kateter aracili ultrason ile tromboliz: Alternatif girisim yeri.

Routinely, the femoral vein is used for access in ultrasound-assisted, catheter-directed thrombolysis (USAT). Presently described is a case of bilateral femoral venous occlusion caused by chronic thrombosis, successfully treated with USAT, using subclavian vein for access.

[Interventional challenges due to venous occlusion during cardiac resynchronization therapy in patients with prior cardioverter-defibrillator implantation: Case report]. / Önceden ICD yerlestirilmis hastalarda kardiyak resenkronizasyon tedavisine geçiste venöz tikanikliga bagli girisimsel zorluklar: Olgu sunumu.

Cardiac resynchronization therapy has become a mainstay of treatment for advanced systolic heart failure refractory to medical management. However, several limitations may affect this therapy, including a non-response rate of nearly 30%, failure to implant the leads via conventional transvenous route in an optimal location, and inability to cannulate the coronary sinus branches due to difficult anatomy or presence of venous valves. Venous occlusion may also present as a potential obstacle in patients with prior implantation of cardioverter-defibrillator. Presently described are cases of 2 patients with venous occlusion.

Usefulness of Neuron-Specific Enolase to Detect Silent Neuronal Ischemia After Percutaneous Coronary Intervention.

Increased plasma levels of neuron-specific enolase (NSE) are related to damage of neurons and neuroendocrine cells. We aimed to investigate elevation of NSE after elective percutaneous coronary intervention (PCI) on the prediction of silent cerebral infarct (SCI). Study population consisted of 2 groups of patients. Group 1 included 92 consecutive patients with normal coronary angiograms, whereas group 2 consisted of 89 patients who underwent elective coronary stenting. NSE levels were studied before and 12 hours after the procedure. Elevation of >0.12 µg/L was considered as SCI. Forty-seven of 181 study patients (26%) had SCI after the procedure. NSE elevation was significantly more prevalent in patients with PCI than that of controls. Elevation of NSE was observed in 42% of patients who underwent elective PCI (n = 37) and 11% of the normal coronary artery group (n = 10) (p <0.001). The incidence of SCI was higher in active smokers and patients who had history of myocardial infarction (MI) (55% vs 10%, p <0.001 for active smokers and 40% vs 8%, p <0.001 for history of MI, respectively). Multivariate analysis demonstrated history of smoking (odds ratio [OR] 9.9; 95% confidence interval [CI] 3.7 to 26.9; p <0.001) and previous MI (OR 4.4; 95% CI 1.7 to 11.4; p = 0.01) as independent predictors of SCI. For patients who underwent elective PCI, NSE levels after procedure increases. Invasive coronary procedures have risk of SCIs, even in patients with normal coronary arteries. In conclusion, increased diagnosis of SCIs might improve understanding of their relation with invasive cardiac procedures, facilitate to prevent occurrence of silent microemboli and decrease the risk of adverse neurologic events.

Serum nitric oxide levels in patients with coronary artery ectasia.

OBJECTIVE: Serum levels of nitric oxide (NO) are decreased in patients with atherosclerosis and also are a risk factor for the development of atherosclerosis. Endothelial dysfunction and diffuse atherosclerosis have been proposed for the etiology of coronary artery ectasia (CAE). The purpose of this clinical trial was to determine the relationship between CAE and serum NO levels. METHODS: This prospective controlled study was conducted between January 2008 and March 2012. Serum levels of NO were compared in 40 patients with CAE (mean age 60.1±7.3 years) and 40 patients with normal coronary arteries (mean age 57.6±5 years) as a control group. CAE was diagnosed when a segment of coronary artery was more than 1.5 times the diameter of the adjacent healthy segment. Patients with stenotic atherosclerotic plaques, slow coronary flow, previous history of revascularization, acute coronary syndromes, left ventricular dysfunction, valvular heart disease, and systemic diseases were not included in the study. The effect of NO on the outcome was studied by constructing a receiver operating characteristic (ROC) curve with CAE as the primary variable. Effects of different variables on CAE were calculated using binary logistics regression analysis. RESULTS: Serum NO concentrations were significantly lower in patients with CAE than in the control group (42.1±20.1 µmol/L vs. 77.3±15.7 µmol/L, p<0.001). According to the results of the multivariate regression analysis, LDL and NO levels were identified as independent factors associated with CAE (OR=1.02, 95% CI 1-1.04, p=0.02 and OR=0.88, 95% CI 0.83-0.93, p=0.001, respectively). ROC analysis revealed that using a cut-off point of 63.3, NO level predicts CAE with a sensitivity of 87.5% and specificity of 90%. CONCLUSION: Our study indicates that decreased levels of NO are present in patients with CAE compared to patients with normal coronary arteries, supporting the hypothesis that decreased levels of NO might be associated with CAE development.

Prediction of recurrence after cryoballoon ablation therapy in patients with paroxysmal atrial fibrillation.

OBJECTIVE: The purpose of this study was to investigate the factors predicting the maintenance of sinus rhythm in patients with paroxysmal atrial fibrillation (PAF) who underwent cryoablation of the pulmonary veins (PVs). METHODS: Fifty-one patients (54.6±10.4 years) with paroxysmal AF who underwent the cryoablation of the PVs were to the prospective trial. The clinical risk factors and echocardiographic parameters [left atrial (LA) diameter, left ventricular ejection fraction and dimensions, left atrial spontaneous echo contrast (LASEC), mitral annulus calcification (MAC), left atrial appendage emptying peak flow velocity (LAAV), and PV flow] were assessed before the cryoablation procedure. Patients with PAF who refused to use any medication because of intolerance or presentation of resistant symptoms, despite the use of at least one antiarrhythmic drug were enrolled to the study, patients with LA/LAA thrombus on echocardiographic examination, severe valvular disease, pericardial fluid, and abnormal thyroid function tests as well as systemic disease were excluded from the study. All parameters were tested for their ability to predict the recurrence of AF during a 1-year follow-up period. RESULTS: During the period of follow-up, AF recurred in 16 of 51 patients (31.3%/year). All significant parameters associated with the recurrence of AF were evaluated in multivariate logistic regression analysis. The presence of MAC (p<0.001) as well as LA diameter (p<0.0001), LAAV of <30 cm/s (p<0.0001), PV flow systolic wave velocity (p<0.0001), and LASEC (p<0.0001) were detected as independent predictors of recurrence. In the receiver operating characteristic analysis, LAAV of >30 cm/s had a sensitivity of 85% and a specificity of 95% for predicting success after ablation (AUC=0.813; 95% CI: 0.76-0.92; p<0.0001). CONCLUSION: The presence of MAC, increased LA diameter, the existence of LASEC, low LAAV, and low peak PV systolic wave velocity are parameters that can predict the recurrence of AF after cryoablation.

Effect of Diltiazem on Coronary Artery Flow and Myocardial Perfusion in Patients With Isolated Coronary Artery Ectasia and Either Stable Angina Pectoris or Positive Myocardial Ischemic Stress Test.

Isolated coronary artery ectasia (CAE) may be associated with stable or unstable coronary events despite the absence of epicardial coronary stenosis. Impaired coronary flow dynamics and myocardial perfusion have been demonstrated in stable patients with ectatic coronary arteries. We aimed to assess whether epicardial flow and tissue-level perfusion would be improved by diltiazem in myocardial regions subtended by the ectatic coronary arteries in patients with isolated CAE. A total of 60 patients with isolated CAE were identified of 9,780 patients who underwent elective coronary angiography. Patients were randomized to 5 mg of intracoronary diltiazem or saline. Coronary blood flow of the microvascular network was assessed using myocardial blush grade (MBG) technique. The thrombolysis in myocardial infarction (TIMI) flow grade and TIMI frame count (TFC) were used to assess epicardial coronary flow. MBG (from 2.4 to 2.6, p = 0.02), TIMI flow grades (from 2.4 to 2.8, p <0.001), and TFC (from 35 to 26, p <0.001) were significantly improved after diltiazem, whereas no significant change was noticed after saline (from 2.4 to 2.4, p = 0.86 for MBG; from 2.3 to 2.3, p = 0.71 for TIMI flow grade; and from 35 to 33, p = 0.43 for TFC). Diltiazem provided amelioration of the altered coronary flow dynamics, which was suggested as the pathophysiological influence of CAE. In conclusion, the favorable effects of the diltiazem on myocardial perfusion were observed at both epicardial and tissue levels.

Comparison of a qualitative measurement of heart-type fatty acid-binding protein with other cardiac markers as an early diagnostic marker in the diagnosis of non-ST-segment elevation myocardial infarction.

OBJECTIVE: Heart-type fatty acid-binding protein (H-FABP) is a novel cardiac marker used in the early diagnosis of acute myocardial infarction (AMI), which shows myocyte injury. Our study aimed to compare bedside H-FABP measurements with routine creatine kinase-MB (CK-MB) and troponin I (TnI) tests for the early diagnosis of non-ST-elevation MI (NSTEMI), as well as for determining its exclusion capacity. METHODS: A total of 48 patients admitted to the emergency room within the first 12 hours of onset of ischaemic-type chest pain lasting more than 30 minutes and who did not have ST-segment elevation on electrocardiography (ECG) were included in the study. Definite diagnoses of NSTEMI were made in 24 patients as a result of 24-hour follow up, and the remaining 24 patients did not develop MI. RESULTS: When various subgroups were analysed according to admission times, H-FABP was found to be a better diagnostic marker compared to CK-MB and TnI (accuracy index 85%), with a high sensitivity (79%) and specificity (93%) for early diagnosis ( ≤ six hours). The respective sensitivities of bedside H-FABP and TnI tests were 89 vs 33% (p < 0.05) for patients presenting within three hours of onset of symptoms. CONCLUSION: Bedside H-FABP measurements may contribute to correct early diagnoses, as its levels are elevated soon following MI, and measurement is easy, with a rapid result.

Impact of metabolic syndrome on development of contrast-induced nephropathy after elective percutaneous coronary intervention among nondiabetic patients.

BACKGROUND: Identifying patients who are vulnerable to development of contrast-induced nephropathy (CIN) is essential because of its association with prolonged hospitalization, increased cost, and increased in-hospital and long-term mortality rates. HYPOTHESIS: Individual components of metabolic syndrome (MetS) are well-established risk factors for kidney injury. Nondiabetic patients diagnosed with MetS might be at an increased risk of developing CIN after elective percutaneous coronary intervention (PCI). METHODS: A total of 599 nondiabetic patients were enrolled, of whom 313 met the MetS criteria and 286 were included in the control group. Patients were evaluated for development of CIN after elective PCI. RESULTS: Contrast-induced nephropathy occurred in 9.3% (29 of 313) of the MetS group and 4.9% (14 of 286) of the control group (P = 0.04). The multivariable regression model revealed that baseline glomerular filtration rate < 30 mL/min, multivessel intervention, and MetS increased and use of statin decreased the probability of CIN independent from confounding factors (odds ratio [OR]: 7.84, 95% confidence interval [CI]: 3.46-24.36, P < 0.01 for baseline glomerular filtration rate < 30 mL/min; OR: 0.82, 95% CI: 0.42-0.96, P = 0.02 for statin use; OR: 2.64, 95% CI: 1.46-6.56, P < 0.01 for multivessel intervention; and OR: 1.66, 95% CI: 1.12-2.61, P = 0.03 for MetS). CONCLUSIONS: Metabolic syndrome is a risk factor for CIN in patients with stable coronary artery disease who undergo elective PCI. We suggest that clinicians recognize the patients with MetS before elective coronary interventions.

Relation of vitamin D deficiency and new-onset atrial fibrillation among hypertensive patients.

Vitamin D deficiency is associated with various cardiovascular disorders including hypertension, coronary artery disease, and heart failure. The renin-angiotensin-aldosterone system (RAS) axis is activated in vitamin D deficiency. The RAS axis also plays a role in the pathophysiology of atrial fibrillation (AF). We aimed to investigate whether vitamin D deficiency is a risk factor for the development of new-onset AF in hypertension. A total of 227 hypertensive patients were enrolled, of whom 137 had new-onset AF; 90 patients without AF were included in the control group. The age of the patient, left atrial diameter, and vitamin D deficiency increased the probability of new-onset AF independent from confounding factors (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.08; P = .03 for age; OR, 1.88; 95% CI, 1.15-3.45; P = .03 for left atrial diameter; OR, 1.68; 95% CI, 1.18-2.64; P = .03 for vitamin D deficiency). Vitamin D deficiency is associated with new-onset AF in hypertension.

Overcoming aspirin resistance with loading clopidogrel earlier in elective percutaneous coronary intervention.

We aimed to analyze the clinical effect of clopidogrel loading time on adverse cardiovascular events among patients with aspirin resistance. Recurrent adverse events may still occur despite dual antiplatelet therapy after coronary stenting. Aspirin resistance is one of the possible reasons of this trouble. Optimal antiplatelet strategy for coronary stenting is unknown among patients with aspirin resistance. A total of 980 patients scheduled for elective coronary stenting were enrolled and allocated into two groups according to the loading time of clopidogrel more or less than 6 hours before coronary intervention (early- or late-loaded groups, respectively). Aspirin resistance was determined according to the urinary levels of 11-dehydrothromboxane B2. Overall 240 patients who were allocated to early- and late-loaded groups were identified as aspirin resistant according to the urinary levels of 11-dehydrothromboxane B2. After a follow-up period of 12 months major adverse cardiac events were observed among 16 patients (13.9%) in the early-loaded group and 30 patients (25.8%) in the late-loaded group (p = 0.02). Early loading of clopidogrel was an independent predictor of lower rate of cardiac events (hazard ratio = 0.46 [0.32-0.76, 95% confidence interval], p = 0.001). The rates of bleeding events and periprocedural myocardial infarction were similar in early- and late-loaded groups. The current study demonstrated that loading of clopidogrel earlier than 6 hours before elective coronary stenting among aspirin-resistant patients was associated with increased benefits for ischemic events with similar bleeding rates.