Transfemoral transcatheter ACURATE-neo™ aortic valve replacement in a patient with a previous mechanical mitral valve.

Transcatheter aortic valve replacement (TAVR) in the presence of a mechanical mitral valve (MMV) prosthesis is challenging due to the stiff mitral cage in the boundaries of the aorto-mitral curtain. We describe the technique for TAVR using the ACURATE-neo™ aortic bioprosthesis in a patient with a MMV prosthesis.

The hemodynamic performance of balloon-expandable aortic bioprostheses in the elderly: a comparison between rapid deployment and transcatheter implantation.

BACKGROUND: Surgical aortic valve replacement with a rapid deployment valve (RDV) is a relatively recent treatment option. The aim of this study was to compare the hemodynamic performance of balloon-expandable (BE)-RDVs and BE-transcatheter heart valves (THVs) in a high surgical risk and frail-elderly population. METHODS: BE-THVs and BE-RDVs were implanted in 138 and 47 patients, respectively, all older than 75 years and with a Canadian Study of Health and Aging category of 5 or above. Echocardiographic assessment was performed at discharge and six months later. RESULTS: At discharge, transprosthetic pressure gradients and indexed effective orifice area (iEOA) were similar in both cohorts. At six-month follow-up, BE-RDVs showed lower peak (14.69 vs. 20.86 mmHg; p < 0.001) and mean (7.82 vs. 11.83 mmHg; p < 0.001) gradients, and larger iEOA (1.05 vs. 0.84 cm2/m2; p < 0.001). Similar findings were also shown considering only small-sized valves. Moderate-to-severe paravalvular leakage was more prevalent in BE-THVs at discharge (14.49 vs. 0.00%; p = 0.032) and, considering exclusively small prostheses, at six months too (57.69 vs. 15.00%; p = 0.014). Nevertheless, BE-THVs determined amelioration in left ventricular ejection fraction (53.79 vs. 60.14%; p < 0.001), pulmonary artery systolic pressure (35.81 vs. 33.15 mmHg; p = 0.042), and tricuspid regurgitation severity (40.58 vs. 19.57%; p = 0.031), from discharge to mid-term follow-up. CONCLUSIONS: BE-RDVs showed better hemodynamic performance, especially when implanted in small annuli. Despite their worse baseline conditions, transcatheter patients still exhibited a greater improvement of their echocardiographic profile at mid-term follow-up.

Impaired flow-mediated dilation and risk of restenosis in patients undergoing coronary stent implantation.

BACKGROUND: Impaired endothelial function is a key event in the atherosclerosis process and predicts future cardiovascular events in subjects with and without coronary artery disease (CAD). We performed the first prospective study evaluating whether early measurement of brachial artery endothelium-dependent dilation (flow-mediated dilation [FMD]) after coronary stenting could predict occurrence of in-stent-restenosis. METHODS AND RESULTS: The study population included 136 patients with single-vessel CAD undergoing percutaneous coronary intervention (PCI) with stenting and at least 6 months of follow-up. All patients underwent ultrasound detection of brachial artery reactivity 30 days after PCI; FMD was investigated before and after 5 minutes of occlusion of the brachial artery, and nitroglycerin-mediated dilation was investigated before and after administration of sublingual nitrates. Clinical in-stent restenosis was demonstrated in 20 patients (15%), whereas 116 patients (85%) remained free of signs or symptoms of recurrent ischemia. FMD was significantly impaired in patients with restenosis versus those without restenosis (percent diameter variation 4.6+/-5.8% versus 9.5+/-6.6%, P=0.002); moreover, 4% of patients with FMD > or =7% (median value) developed in-stent restenosis versus 28% of those with FMD <7% (P=0.0001). On multivariate analysis, FMD was the strongest predictor of restenosis (OR 4.5, 95% CI 2.4 to 12.0); conversely, nitroglycerin-mediated dilation did not independently predict the risk of restenosis (OR 2.4, 95% CI 0.8 to 6.3). CONCLUSIONS: This is the first prospective study indicating that impaired FMD independently predicts occurrence of in-stent restenosis in patients undergoing PCI. Early evaluation of endothelial function after stenting may represent a useful screening tool to stratify patients according to future risk of restenosis.

Transcatheter Simultaneous Double-Transapical Access for Paravalvular Mitral Leak Closure Using the Occlutech PLD.

A 67-year-old patient with rheumatic heart valve disease had undergone two cardiac surgeries at the age of 30 years, then re-do with mitral valve replacement at 50 years. She presented with congestive heart failure and hemolytic anemia. Doppler echocardiography showed moderate-severe mitral regurgitation due to paravalvular mitral valve leak (PVML) and severe pulmonary hypertension. Transesophageal echocardiography demonstrated severe PVML secondary to a large 20 mm-long PVML defect. Due to comorbidities, the heart team deemed a third reoperation at very high surgical risk; therefore, the patient was considered most suitable for a transcatheter approach to PVML closure. Two Occlutech paravalvular leak devices were successfully delivered using a simultaneous double-transapical access with double-wire technique.