Inferior epigastric artery as a landmark for transfemoral TAVI. Optimizing vascular access?

OBJECTIVES: This study sought to investigate whether the site of common femoral artery (CFA) cannulation in regard to the inferior epigastric artery (IEA) is associated with the incidence of vascular complications in patients undergoing transfemoral aortic valve implantation (TAVI). BACKGROUND: Vascular access complications are a main issue during TAVI and have been associated with significant increase of morbidity and mortality. The need for establishment of reliable predictors for these serious events remains important. METHODS: A total of 90 patients, who had undergone TAVI, were retrospectively studied. Vascular complications were defined as major and minor according to the Valve Academic Research Consortium (VARC) criteria. Patients were divided into high cannulation site (CS) group and low CS group depending on the common femoral artery puncture site position, in regards to the most inferior border of the IEA. RESULTS: Vascular complications were significantly more frequent in the high CS group versus the low CS group (32.3% vs. 11.9%, P = 0.039). High cannulation remained an independent predictor of vascular complications after adjustment for known risk factors (OR: 4.827, CI: 1.441-16.168; P = 0.011). CONCLUSIONS: In patients undergoing transfemoral TAVI, arterial puncture above the most inferior border of the IEA is associated with vascular complications.

A 6-month follow-up of intermittent levosimendan administration effect on systolic function, specific activity questionnaire, and arrhythmia in advanced heart failure.

BACKGROUND: Levosimendan (LS) improves cardiac contractility without increasing myocardial oxygen demand. We administrated LS on a monthly intermittent 24-hour protocol and evaluated the clinical effect after 6 months in a randomized, open, prospective study. METHODS AND RESULTS: Fifty patients (age 45-65 years) with LV systolic dysfunction and New York Heart Association (NYHA) III or IV were randomized in 2 groups. LS group (n = 25) was compared with a control group (n = 25) matched for sex, age, and NYHA class. LS was given monthly on a 24-hour intravenous protocol for 6 months. Patients were evaluated by specific activity questionnaire (SAQ) and echocardiography (ECHO) before and 3 to 5 days after last drug administration, whereas 24-hour Holter recording was performed before and during last drug administration. Patients in LS and control group had same baseline SAQ, ECHO, and Holter parameters. At the end of the study, a larger proportion of patients in the levosimendan group reported improvement in symptoms (dyspnea and fatigue) (65% versus 20% in controls, P < .01). After 6 months, the LS group had a significant increase in LV ejection fraction versus controls (28 +/- 7 versus 21 +/- 4 %, P = .003), LV shortening fraction (15 +/- 3 versus 11 +/- 3 %, P = .006) and a decrease in mitral regurgitation (1.5 +/- 0.8 versus 2.7 +/- 0.6, P = .0001). There was no increase in supraventricular or ventricular beats or supraventricular tachycardia and VT episodes in LS group, compared with controls. Two patients from the LS group died in the 6-month follow-up period, compared with 8 patients in the control group (8% versus 32%, P < .05). CONCLUSIONS: A 6-month intermittent LS treatment in patients with decompensated advanced heart failure improved symptoms and LV systolic function.

Predictive factors of vascular complications after transcatheter aortic valve implantation in patients treated with a default percutaneous strategy.

BACKGROUND: Percutaneous approach techniques with closure device after transcatheter aortic valve implantation (TAVI) have diminished vascular complications (VC). In this retrospective study, we will report incidence and angiographic factors predisposing to major VC in patients undergoing TAVI using Prostar® XL closure device as a default strategy. METHODS: Consecutive patients, who underwent TAVI transfemorally using Prostar® XL, were evaluated for the incidence of VC according to VARC criteria. Using arterial angiography, the femoral-iliac arterial tortuosity was adjusted for large arterial diameters and expressed as the ratio total tortuosity/arterial diameter (TT/AD). Arterial calcification, the combination of angulation and atheromatosis at the puncture site and ideal puncture were evaluated too. In all patients, 30 days of follow-up was available. RESULTS: Eighty-four patients (80.2 ± 5.86 years, 39 males [46.4%]), who were consecutively treated with the transfemoral approach, were evaluated. In patients with major VC (17/84 [20.23%]) comparing to those without, arterial calcification (11 [64.7%] vs. 8 [11.9%], P < 0.01) and the TT/AD (30.2 ± 11.25 vs. 22.06 ± 8.64, P < 0.01) were independent predictors. Ideal puncture was achieved more frequently among patients without VC comparing to those with major (94.1% vs. 70.6%, P = 0.01). Blood transfusions (1.48 ± 0.37 vs. 2.45 ± 0.59, P = 0.023) were more frequent among patients with major VC. Finally, minimum creatinin clearance after TAVI predicted all-cause 30-day mortality (P = 0.021). CONCLUSIONS: Major VC after TAVI with the use of Prostar closure device can be predicted by arterial calcification at the puncture site and TT/AD ratio. Minimum creatinin clearance after TAVI predicted 30-day mortality.

Predictors for very late stent thrombosis after drug-eluting stent implantation in diabetic patients.

AIMS: Despite encouraging results with drug-eluting stents (DES) reported in diabetic patients, the long-term safety is unknown because of very late stent thrombosis (VLST). We investigated the incidence, risk factors and clinical manifestations of VLST in diabetic patients treated with DES, during long-term clinical follow-up. METHODS AND RESULTS: A total of 610 consecutive diabetic patients underwent PCI with DES. Dual antiplatelet treatment (APLT) for 12 months received 93%, more than 12 months 72% and statin treatment 93% of patients. Clinical follow-up of at least 12 months post DES implantation was obtained in 597/610 (98%) patients. The incidence of VLST was 1.8%, and 1.7% of patients developed stent thrombosis (ST) up to 12 months. All patients with VLST presented with sudden cardiac death and 82% were on dual APLT at the time of the event. In a multivariate model the only predictor for VLST (HR: 20.58, 95% CI 5.17-81.90, p < 0.001) and overall ST (HR: 4.38, 95% CI 1.73-11.10, p = 0.002) was ejection fraction < 40%. CONCLUSIONS: The incidence of ST in diabetic patients undergoing PCI with DES and receiving dual APLT is low at long-term clinical follow-up. The only predictor for VLST and overall ST was depressed left ventricular systolic function.

Interleukin 8 and susceptibility to coronary artery disease: a population genetics perspective.

INTRODUCTION: Interleukin 8 is a strong chemoattractant factor for neutrophils and T lymphocytes. We investigated the potential influence of two common polymorphisms of the interleukin-8 gene, -251A/T, and 781C/T on susceptibility to coronary artery disease. MATERIALS AND METHODS: The hypothesis was tested by screening for the prevalence of the above polymorphisms in 241 angiographically diagnosed coronary artery disease patients compared to 157 selected controls with negative coronary angiography. RESULTS AND DISCUSSION: We found no significant differences between cases and controls concerning the allelic and genotypic frequencies of both the studied polymorphisms. Nevertheless, a statistically significant lower frequency of the AA containing genotypes was observed in cases presenting with acute coronary syndromes compared to asymptomatic subjects or patients with stable coronary artery disease (OR = 0.44, 95%CI: 0.2-0.98, p = 0.04). The strongest statistical significance was observed in the AA(251)TT(781) combined genotype (OR = 0.34, 95%CI: 0.14-0.85, p = 0.02). CONCLUSION: Our results suggest that the genetic diversity of the interleukin-8 gene influences the clinical manifestation of CAD.