TAVR prosthesis recoil: Unknowns and implications.

TAVR acute recoil has not been properly assessed with current generation balloon-expandable prosthesis. Acute recoil was greater during initial deployment than in postdilatation, in middle stent than inflow or outflow, and in antero-posterior than lateral axis. No predictors or clinical implications of acute valvular recoil were detected, calling for further research to better understand this phenomenon.

Retrograde approach for chronic total occlusion angioplasty: At your own risk.

The retrograde approach is needed to increase procedural success in chronic total occlusion angioplasty. This systematic review of the literature demonstrated that retrograde approach is associated with more complex anatomy, worse in-hospital and long-term outcomes. Retrograde approach needs expertise, used judiciously, and major focus in patient safety when performed.

Impella support for chronic total occlusions angioplasty: A good start.

There is limited data regarding percutaneous ventricular support in chronic total occlusion angioplasty in terms of population, procedure, and outcomes. This is the largest report to date showing promising results in terms of technical and procedural success in this highly comorbid population. This study encourages more research in the area and its use in large volume and experienced centers.

Transradial access: A case for knowledge translation.

Current transradial access (TRA) practices are unknown in the United States and the rest of the world. There is a decline in preprocedure collateral assessment, low use of ultrasound, and infrequent radial patency check after hemostasis. Significant knowledge-practice gaps exist in TRA calling for more dissemination and education.

Transcatheter aortic valve replacement hemodynamic durability: Still in question?

This study shows excellent transcatheter aortic valve replacement hemodynamic mid-term durability, aligned with prior research up to 5-years. Long-term (10+ years) data are needed before treating young low-risk people with aortic stenosis. Data so far are excellent, indicating a prosperous future for this procedure in young patients.

Percutaneous coronary interventions in diabetics: The never-ending challenge.

Diabetes mellitus (DM) is a multisystem disorder and a recognized risk factor for coronary artery disease (CAD) and DM patient are particularly challenging for revascularization. In this "real world" retrospective study post-PCI DM patients showed a high risk profile compared to the non-DM group, given by the higher prevalence of cardiovascular risk factors, multiple vessel disease, and renal dysfunction, with the highest rates seen in the ITDM. Only ITDM patients present higher 30-day mortality compared to non-DM patients in the urgent and primary PCI setting. Also ITDM, but not those NITDM patients, had an increased long-term mortality in the overall cohort and in all PCI setting.

Direct stenting versus balloon predilation: Jury is still out.

Compared to balloon predilation, direct stenting (DS) shortens procedural time and reduces radiation and contrast exposure. A meta-analysis that included 7 studies comparing these 2 strategies revealed lower adverse event rate with DS. Studies included in the present meta-analysis were mostly observational and utilized first generation drug-eluting stent. Patient and lesion selection may explain these positive results.

Double-stenting in distal left main lesions: Let's crush.

Unprotected distal left main (ULM) lesions often require double-stenting. In the MITO Registry, a mini-crush stenting technique was safer than culotte stenting. Performing mini-crush arises as the best approach in patients with distal ULM lesions requiring elective double-stenting.

Predicting Early Readmission Following PCI: A Work in Progress.

Early hospital readmissions after percutaneous coronary interventions (PCI) are common and costly. From the NCDR CathPCI Registry and the Centers for Medicare and Medicaid Services, a risk prediction model was generated using 14 clinical variables, demonstrating modest discrimination. Future research is needed to identify interventions aim to reduce early readmissions. The use of this risk model may help guide these interventions.

Overlapping bioresorbable scaffolds seems safe for now.

Overlapping permanent scaffolds carries a long-term risk of target vessel failure due to late malapposition and the development of neoatherosclerosis. Potentially, overlapping bioresorbable scaffold (BRS) may lead to lower long-term risk. The GHOST-EU registry reported similar short- and mid-term risks in patients with and without BRS overlap. Larger size studies with longer follow-up are needed to confirm the safety of BRS overlap.

Anticoagulation with heparin The art of simplicity even in patients on dialysis.

In current PCI practice, anticoagulation with either bivalirudin or unfractionated heparin in patients with ACS share comparable efficacy and safety. Nonetheless, their individual performance in patients on dialysis remains unclear. This observational PCI study reported in-hospital clinical outcome in patients on dialysis undergoing PCI according to drug regimen: bivalirudin versus heparin. Similar clinical outcome was observed with both drug regimens.

Real-world experience with BVS: Trading early sacrifices for a (possible) brighter future.

Randomized clinical trial data suggest non-inferiority of bioresorbable vascular scaffolds (BVS) compared to current drug-eluting stent. Compared to randomized data, observational studies with BVS have revealed higher rates of scaffold thrombosis. Meticulous deployment technique of the device including appropriate vessel sizing, optimal scaffold apposition, and avoidance of overexpansion may likely limit the risk of scaffold thrombosis. Large randomized studies with longer follow-up are essential to define the role of this novel technology during routine clinical practice.

Aorto-Ostial Lesions: Battling an Old Foe.

Aorto-ostial lesions (AOLs) entail several diagnostic and treatment challenges. The Flash Ostial System enables flaring of the overhanging stent, optimizing stent deployment in AOLs. Careful planning is essential to achieve optimal stent implantation and avoid early and late complications during the treatment of AOLs.

Ischemic Postconditioning: Not Giving Up Yet.

Ischemic postconditioning protects against reperfusion injury. Adjunctive use of manual thrombus aspiration improves reperfusion results in patients undergoing primary angioplasty. Combining both strategies (ischemic postconditioning and thrombus aspiration) may have additive effects in terms of myocardial salvage. The PORT trial will study the role of ischemic postconditioning in patients undergoing primary angioplasty with thrombus aspiration.

To achieve, or not to achieve complete revascularization.

Prior to minimally invasive valve surgery, a strategy of complete revascularization did not impact overall survival. Angiographically guided revascularization may have resulted in unnecessary procedures. A larger sample size and greater atherosclerotic burden may be needed to observe an impact with complete revascularization.

Optimal anticoagulation prior to cath: Bivalirudin vs. Heparin the saga continues .

During the pre-procedural (medication) phase, the use of bivalirudin monotherapy is associated with the lowest rate of bleeding in patients with Non-ST elevation myocardial infarction (Non-STEMI) undergoing an early invasive strategy. Monotherapy with either bivalirudin or unfractionated heparin (UFH) appear interchangeable in this setting. The use of GPI upstream with either drug should be discouraged due to an increased risk of bleeding and net adverse events. The use of low dose aspirin plus potent P2Y12 inhibitors followed by a transradial approach with implantation of drug-eluting coronary stents with fluorinated polymers represents an strategy that may help limit perioperative ischemic and hemorrhagic complications in these individuals.

Acute kidney injury after TAVI: Predict, detect, and prevent.

Acute kidney injury (AKI) is frequently observed immediately after transcatheter aortic valve implantation (TAVI). Both classifications, the RIFLE (the Risk, Injury, Failure, Loss, and End-stage Kidney) and the KDIGO (Kidney Disease: Improving Global Outcomes) from the VARC-2 (Valve Academic Research Consortium-2) are fairly interchangeable and performed well as clinical predictors of all-cause mortality. Patients with baseline reduced glomerular filtration rate (GFR) or known atherosclerotic arterial disease are at increased risk of AKI.