A complex ventricular septal defect following transcatheter aortic valve implantation evaluated by 3D transthoracic echocardiography.

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of elderly patients with symptomatic severe aortic valve stenosis. Among the possible TAVI complications, a rare one is the annular/left ventricular outflow tract rupture. We report a rare case of a late complex ventricular septal defect (VSD) following TAVI with a balloon-expandable prosthesis, conservatively managed. Our case demonstrates the role of 3D transthoracic echocardiography (3DTTE) in the accurate diagnosis of this TAVI complication and suggests that, in some cases, it can be used as an alternative to other diagnostic tools, such as transesophageal echocardiography, cardiac catheterization, and computed tomography.

ICE Guided CRT: Is there Evidence of Reverse Remodeling?

Cardiac resynchronization therapy (CRT) is an accepted treatment for patients with heart failure (HF), impaired left ventricular (LV) function, and a wide QRS complex. However, more than 30% of eligible patients fail to benefit from CRT. It is clearly necessary to define the characteristics of the best candidates for this therapy. To this end, surface ECG and echocardiography have been tested. Unfortunately, however, neither of these examinations has proved sufficiently able to identify the best patients. A tailored approach based on the evaluation of both electrical and mechanical delay to guide LV lead placement seems to be the most reasonable strategy in order to increase the efficacy of CRT therapy. The good preliminary data that have been published suggest that using intracardiac echocardiography to define the mechanical delay could be an interesting option. Moreover, at present it is the only option available that can enable intraprocedural evaluation of the mechanical activation sequence. Naturally, further randomized studies with larger populations should be performed in order to ascertain the real benefit of this approach and to evaluate whether it will outweigh the additional cost of this technology.

[OBSERVANT: observational study of appropriateness, efficacy and effectiveness of AVR-TAVI procedures for the treatment of severe symptomatic aortic stenosis. Study protocol]. / OBSERVANT: studio osservazionale per la valutazione di appropriatezza, efficienza ed efficacia delle procedure AVR-TAVI nel trattamento della stenosi aortica sintomatica severa. Protocollo di studio.

RATIONALE: Severe symptomatic aortic stenosis (SSAS) is the most common acquired valvular heart disease in the western world, and its prevalence is strongly linked to the phenomenon of population ageing. After symptom onset, patients with SSAS, if untreated, show very poor prognoses, unavoidably reaching complete disability status with a significant reduction in survival. Although aortic valve replacement (AVR) is the definitive therapy for this kind of patients, a new, less-invasive alternative like transcatheter aortic valve implantation (TAVI) has been considered, at least for a large proportion of patients with very high or prohibitive operative risks. OBSERVANT represents the first observational multicenter perspective study on the comparative effectiveness of TAVI, AVR, and medical therapy in the Italian population with SSAS. MATERIALS AND METHODS: In the participating hospitals, to define the patient risk profile for each patient with SSAS, data on demographic characteristics, health status prior to intervention and presence of comorbidities will be collected. Moreover, complete information on the type of intervention will be gathered. Mortality within 30 days from intervention is the primary adverse outcome. Secondary outcomes include mortality within 12 and 24 months and the incidence of in-hospital major adverse cardiac and cerebrovascular events. Clinical monitoring procedures will allow assessment of the reliability and completeness of the database and help maintain constant quality control. To compare the effectiveness of AVR, TAVI, and medical treatment in terms of medium- and long-term outcomes, accounting for possible differences in patient case-mix among the three treatment groups, risk adjustment techniques will be applied. EXPECTED RESULTS: Short-, medium-, and long-term outcome in patients undergoing one of the three SSAS treatments; use, appropriateness, and economic and organizational impact of TAVI and AVR procedures; specific "indication criteria" to guarantee appropriate patient selection for AVR or TAVI; new pre-procedure risk score, specific for the elderly Italian population; guidelines on TAVI procedure coding and a system of administrative follow-up to be proposed to the regional health systems for managing the use of the AVR or TAVI procedures. CONCLUSIONS: The complete knowledge base derived from this study will be directly transferable to professionals and policy makers, giving them evidence-based results for use in their decision-making process.