Degenerative aortic stenosis is an atherosclerotic-like process associated with impaired endothelial and autonomic function. Transcatheter aortic valve implantation (TAVI) has become a treatment of ...choice for patient with severe degenerative aortic stenosis at high surgical risk. The effect of this procedure on endothelial function measured with flow mediated dilatation (FMD) and autonomic function measured with heart rate variability (HRV) at different time-points of disease management (early and late follow-up) remains unknown.BackgroundDegenerative aortic stenosis is an atherosclerotic-like process associated with impaired endothelial and autonomic function. Transcatheter aortic valve implantation (TAVI) has become a treatment of choice for patient with severe degenerative aortic stenosis at high surgical risk. The effect of this procedure on endothelial function measured with flow mediated dilatation (FMD) and autonomic function measured with heart rate variability (HRV) at different time-points of disease management (early and late follow-up) remains unknown.We prospectively included 50 patients with severe aortic stenosis who were deemed suitable for TAVI by the Heart Team. FMD and HRV parameters were collected at baseline ( < 24 h pre-TAVI), at early follow-up (up to 48 h post-TAVI) and at late follow-up (3-6 months post-TAVI).MethodsWe prospectively included 50 patients with severe aortic stenosis who were deemed suitable for TAVI by the Heart Team. FMD and HRV parameters were collected at baseline ( < 24 h pre-TAVI), at early follow-up (up to 48 h post-TAVI) and at late follow-up (3-6 months post-TAVI).43 patients (mean age 81 (75-85); 60% women) completed the study. FMD significantly improved from 2.8 ± 1.5% before TAVI to 4.7 ± 2.7% early after TAVI (p < 0.001) and was later maintained on late follow-up (4.8 ± 2.7%, p = 0.936). Conversely, high-resolution ECG parameters remained preserved at early and improved at late follow-up after TAVI. Significant improvement was detected in a high frequency-domain parameter-HF (from 5231 ± 1783 to 6507 ± 1789 ms 2 ; p = 0.029) and in two Poincare plot parameters: ratio of the short- and long-term R-R variability in the Poincare plot-SD1/SD2 (from 0.682 to 0.884 ms 2 ; p = 0.003) and short-term R-R variability in the Poincare plot-SDRR (from 9.6 to 23.9 ms; p = 0.001). Echocardiographic parameters comprising baseline maximal aortic valve velocity (R = 0.415; p = 0.011), mean aortic gradient (R = 0.373; p = 0.018), indexed stroke volume (R = 0.503; p = 0.006), change in aortic valve maximal velocity (R = 0.365; p = 0.031), change in mean aortic gradient (R = 0.394; p = 0.019) and NT-proBNP (R = 0.491; p = 0.001) were found as significant predictors of change in FMD.Results43 patients (mean age 81 (75-85); 60% women) completed the study. FMD significantly improved from 2.8 ± 1.5% before TAVI to 4.7 ± 2.7% early after TAVI (p < 0.001) and was later maintained on late follow-up (4.8 ± 2.7%, p = 0.936). Conversely, high-resolution ECG parameters remained preserved at early and improved at late follow-up after TAVI. Significant improvement was detected in a high frequency-domain parameter-HF (from 5231 ± 1783 to 6507 ± 1789 ms 2 ; p = 0.029) and in two Poincare plot parameters: ratio of the short- and long-term R-R variability in the Poincare plot-SD1/SD2 (from 0.682 to 0.884 ms 2 ; p = 0.003) and short-term R-R variability in the Poincare plot-SDRR (from 9.6 to 23.9 ms; p = 0.001). Echocardiographic parameters comprising baseline maximal aortic valve velocity (R = 0.415; p = 0.011), mean aortic gradient (R = 0.373; p = 0.018), indexed stroke volume (R = 0.503; p = 0.006), change in aortic valve maximal velocity (R = 0.365; p = 0.031), change in mean aortic gradient (R = 0.394; p = 0.019) and NT-proBNP (R = 0.491; p = 0.001) were found as significant predictors of change in FMD.Endothelial function measured with FMD and autonomic function obtained with HRV parameters significantly improve after TAVI. While endothelial function improves early and is maintained later after TAVI, autonomic function remains stable and improves on late follow-up. This is most likely caused by early hemodynamic changes after resolution of aortic valve obstruction and gradual left ventricular remodeling.ConclusionsEndothelial function measured with FMD and autonomic function obtained with HRV parameters significantly improve after TAVI. While endothelial function improves early and is maintained later after TAVI, autonomic function remains stable and improves on late follow-up. This is most likely caused by early hemodynamic changes after resolution of aortic valve obstruction and gradual left ventricular remodeling.www.clinicaltrials.gov, identifier NCT04286893.Clinical Trial Registrationwww.clinicaltrials.gov, identifier NCT04286893.
Transcatheter aortic valve implantation (TAVI) improves event-free survival in patients with severe aortic stenosis, but patients’ exercise capacity remains poor after the procedure. Therefore, we ...sought to compare the effects of a supervised center-based exercise training program and unsupervised exercise routine on exercise capacity and vascular function in patients after TAVI. Patients were randomized to either center-based exercise training (12–24 sessions of combined aerobic and low-weight resistance training twice weekly for 8–12 weeks) or an unsupervised home-based exercise routine (initial appraisal with detailed recommendations and monthly follow-up). Exercise capacity (cardiopulmonary testing) and vascular function (ultrasonographic measurement of flow-mediated vasodilation (FMD) and arterial stiffness) were assessed at the baseline and after the study period. We included 23 patients (mean age of 81 years, 61% women), with higher-than-expected drop-out rates (41%) because of the coronavirus-19 pandemic outbreak. Exercise capacity improved over time, irrespective of the intervention group: 0.09 mL/min/kg increase in peak oxygen uptake (95% CI 0.01–0.16; p = 0.02), 8.2 Watts increase in workload (95% CI 0.6–15.8; p = 0.034), and 47 s increase in cumulative exercise time (95% CI 5.0–89.6; p = 0.029). A between-group difference in change over time (treatment effect) was detected only for FMD (4.49%; 95% CI 2.35; 6.63, p < 0.001), but not for other outcome variables. Both supervised and unsupervised exercise training improve exercise capacity and vascular function in patients after TAVI, with supervised exercise training possibly yielding larger improvements in vascular function, as determined by FMD.
An ascending aortic pseudoaneurysm is a potentially lethal complication in aortic procedures. We present a hybrid approach using surgical innominate artery access and the endovascular insertion of an ...abdominal stent-graft extension to successfully treat a zone 0 ascending aortic pseudoaneurysm in a patient with a prior valve-in-valve transcatheter aortic valve implantation.
Treatment with a coronary sinus reducer (CSR) is a new therapeutic option for refractory angina patients. Preclinical studies have shown antiarrhythmic properties of coronary sinus narrowing. The ...possible antiarrhythmic effect of CSR implantation is unknown. This study aimed to determine the possible antiarrhythmic effects of CSR implantation as assessed by high-resolution electrocardiogram (hrECG) parameters.BackgroundTreatment with a coronary sinus reducer (CSR) is a new therapeutic option for refractory angina patients. Preclinical studies have shown antiarrhythmic properties of coronary sinus narrowing. The possible antiarrhythmic effect of CSR implantation is unknown. This study aimed to determine the possible antiarrhythmic effects of CSR implantation as assessed by high-resolution electrocardiogram (hrECG) parameters.24 patients from the Crossroad study randomized to either CSR treatment (n = 12) or a sham procedure (n = 12) had hrECG recorded at baseline and after 6 months. T-peak and T-end interval (TpTe) defined as the time difference between the peak amplitude of the T wave and the global end of the T wave, spatial angle between QRS complex and T axis defined as the angle between the ventricular depolarization and repolarization vectors using maximal (QRSTP) and mean (QRSTM) vector amplitudes and spatial ventricular gradient (SVG) calculated as integral of ECG voltages over the entire QRST complex were analyzed. Additionally, we analyzed parameters of QT and heart rate variability using time and frequency domain.Methods24 patients from the Crossroad study randomized to either CSR treatment (n = 12) or a sham procedure (n = 12) had hrECG recorded at baseline and after 6 months. T-peak and T-end interval (TpTe) defined as the time difference between the peak amplitude of the T wave and the global end of the T wave, spatial angle between QRS complex and T axis defined as the angle between the ventricular depolarization and repolarization vectors using maximal (QRSTP) and mean (QRSTM) vector amplitudes and spatial ventricular gradient (SVG) calculated as integral of ECG voltages over the entire QRST complex were analyzed. Additionally, we analyzed parameters of QT and heart rate variability using time and frequency domain.At baseline, all analyzed parameters were comparable between both groups and heart rate remained constant. The intragroup analysis did not show any significant change in TpTe, QRSTP, QRSTM, SVG, QT, and heart rate variability at follow-up. Furthermore, intergroup comparison between CSR implantation and sham procedure also did not show any significant difference in the change of analyzed parameters.ResultsAt baseline, all analyzed parameters were comparable between both groups and heart rate remained constant. The intragroup analysis did not show any significant change in TpTe, QRSTP, QRSTM, SVG, QT, and heart rate variability at follow-up. Furthermore, intergroup comparison between CSR implantation and sham procedure also did not show any significant difference in the change of analyzed parameters.Compared to the sham procedure, CSR implantation did not demonstrate a significant impact on the arrhythmogenic substrate assessed with hrECG.ConclusionsCompared to the sham procedure, CSR implantation did not demonstrate a significant impact on the arrhythmogenic substrate assessed with hrECG.Unique Identifier: NCT04121845, https://classic.clinicaltrials.gov/ct2/show/NCT04121845.Clinical Trial RegistrationUnique Identifier: NCT04121845, https://classic.clinicaltrials.gov/ct2/show/NCT04121845.
Summary
Background
The aim of this study was to compare short-term and mid-term outcomes in low-risk octogenarian population treated with transfemoral transcatheter aortic valve implantation ...(tf-TAVI) or minimally invasive aortic valve replacement (mini-AVR) for severe aortic stenosis.
Methods
In this single-center, retrospective cohort study we gathered data on low-risk (Society of Thoracic Surgeons STS score < 4%) octogenarians before and after tf-TAVI and mini-AVR performed between January 2013 and May 2019; follow-up was completed in May 2022. Short-term outcomes were hospital length of stay, in-hospital all-cause mortality and other major postoperative outcomes. Mid-term clinical outcomes were 1‑year and 3‑year all-cause mortality. Propensity score-based matching was performed.
Results
In total 106 patients were matched, resulting in 53 pairs. In-hospital complications were similar between the matched groups of patients with the exception of mild and moderate paravalvular leak (mini-AVR vs. tf-TAVI: mild PVL: 3.8% vs. 45.3%,
p
< 0.001; moderate PVL: 0% vs. 3.8%,
p
= 0.4952) and of postprocedural acute kidney injury that was more frequent in mini-AVR group (mini-AVR vs. tf-TAVI: 22.6% vs. 5.7%;
p
= 0.023). Hospital length of stay (
p
= 0.239) and in-hospital mortality (
p
= 0.495) did not differ between groups. The 1-year and 3‑year all-cause mortality Kaplan-Meier estimates were similar between mini-AVR and tf-TAVI.
Conclusion
In the present study on low-risk octogenarians, transfemoral TAVI and minimally invasive AVR showed comparable short-term and mid-term results. Both procedures are deemed safe and effective. Larger RCTs will be required to determine which low-risk patients will benefit most from TAVI.
Coronary sinus reducer (CSR) implantation is a new treatment option for patients with refractory angina pectoris. However, there is no evidence from a randomized trial that would show an improvement ...in exercise capacity after this treatment. The aim of this study was to evaluate the influence of CSR treatment on maximal oxygen consumption and compare it to a sham procedure. Twenty-five patients with refractory angina pectoris (Canadian Cardiovascular Society (CCS) class II-IV) were randomized to a CSR implantation (
= 13) or a sham procedure (
= 12). At baseline and after 6 months of follow-up, the patients underwent symptom-limited cardiopulmonary exercise testing with an adjusted ramp protocol and assessment of angina pectoris using the CCS scale and Seattle angina pectoris questionnaire (SAQ). In the CSR group, maximal oxygen consumption increased from 15.56 ± 4.05 to 18.4 ± 5.2 mL/kg/min (
= 0.03) but did not change in the sham group (
= 0.53);
for intergroup comparison was 0.03. In contrast, there was no difference in the improvement of the CCS class or SAQ domains. To conclude, in patients with refractory angina and optimized medical therapy, CSR implantation may improve oxygen consumption beyond that of optimal medical therapy.
Background
Aortic regurgitation is a major concern following transcatheter aortic valve implantation (TAVI), as even low-grade regurgitation is associated with increased mortality. This is of ...particular concern to patients with pre-existing aortic disease who are at increased risk of TAVI valve slippage. Furthermore, conduction system disturbances after TAVI, namely left bundle branch block (LBBB), may have an additional detrimental effect on cardiac function.
Case presentation
This report documents a successful treatment strategy in a frail patient with a bicuspid aortic valve and aortic disease after valve-sparing surgical repair in 1998, who subsequently developed aortic stenosis and underwent TAVI with an Evolut R self-expanding aortic valve. The progression of aortic disease, aortic root dilatation, and leaflet degeneration over the following years caused aortic regurgitation of the self-expanding aortic valve, resulting in left ventricular dilatation and heart failure along with LBBB and left ventricular (LV) mechanical dyssynchrony. Diagnostic workup of the patient showed persistence of the aneurysm distal to the graft with a dissection spanning the ascending aorta, arch, and terminating proximal to the aortic isthmus. After consideration by the cardiac team, a balloon-expandable valve was chosen for a valve-in-valve (ViV) procedure to provide sufficient radial force to expand the existing valve and correct the regurgitation. Due to the anatomy, a J-wire and pigtail catheter were successfully used for a safe approach and placement of the valve. Following the procedure, intermittent complete atrioventricular block was observed in addition to the pre-existing left bundle branch block, necessitating resynchronization pacing. Due to anatomical considerations, ease of placement, and the expected good level of resynchronization due to the proximal block, we opted for left bundle branch pacing, which showed improvement in left ventricular dyssynchrony and LV function at follow-up.
Conclusion
Valve-in-valve implantation of a balloon-expandable Myval TAVI device to treat aortic regurgitation caused by slippage and right leaflet disfunction of slef valve is feasible in challenging anatomical scenarios. Left bundle branch pacing is a viable alternative to correct mechanical dyssynchrony in complex patients with LBBB and anatomical challenges necessitating resynchronization.
Od prve koronarne angioplastike leta 1977 preko femoralnega pristopa je intervencijska kardiologija drastično spremenila zdravljenje ishemične bolezni srca. Prvotna perkutana transluminalna ...angioplastika z uporabo navadnih balonskih katetrov je sčasoma postala le pomožna tehnika za pripravo žilne spremembe in optimiziranje vstavljene žilne opornice. S pojavom navadnih žilnih opornic smo izboljšali rezultate na račun zmanjšanega elastičnega odsunka, poškodbe in konstriktivnega remodeliranja koronarnih arterij, z razvojem antiagregacijske terapije pa dosegli manjše število tromboz v žilnih opornicah. Ob nadaljnjih raziskavah neointimalne hiperplazije so se pojavile metode za lokalno apliciranje antiproliferacijskih zdravil. Razvile so se z zdravili prevlečene opornice, ki so leta 2019 postale novi zlati standard. Ob uporabi modernejših materialov so poskrbele za izboljšanje rezultatov na račun zmanjšanja neointimalne hiperplazije in števila zapletov. A kljub temu so še vedno tujek v žilni steni, ki spodbuja kronično vnetje, neoaterosklerozo, s tem pa restenozo ter zelo pozne pojave tromboze. To spoznanje zadnja leta vodi v razvijanje tehnik, ki bi za sabo pustile čim manj tujega materiala oziroma bi bil le-ta čimbolj biološko kompatibilen. Ob razvoju razgradljivih žilnih opornic so ena obetajočih terapevtskih možnosti z zdravili prevlečeni balonski katetri, ki razširijo žilno svetlino in lokalno aplicirajo antiproliferativno zdravilo na samo mesto spremembe brez uporabe opornice, ki bi ostala v žilni steni in spodbujala vnetje.
This study presents a case of a successful severed femoral sheath recapture during transfemoral transcatheter aortic valve replacement (TAVR). During skin tunneling with a scalpel, the discontinuity ...of the femoral sheath occurred. Grasping of the distal sheath with the surgical hemostat was attempted unsuccessfully. A proximal part of the severed sheath was removed and Medtronic Sentrant introducer sheath (14 French) was then placed over the existing Confida wire which permanently remained in position, followed by the introduction of the Amplatz Left 2 (AL2) catheter which pushed the severed sheath in the ascending aorta over the Confida wire. The crucial maneuver was the entanglement of the severed sheath in the aortic non-coronary cusp which allowed for its entrapment by the AL2 catheter. This allowed for the coronary guidewire BMW Universal (0.014″) placement and a slow balloon retrieval (SeQuent NEO 2.5 × 25 mm2) of the severed sheath into the introducer sheath. The guidewire/balloon catheter was then exchanged for the support wire (0.035″) followed by the removal of the introducer sheath, AL2 catheter and the severed sheath. In conclusion, sheath severing is a complex accidental event during TAVR, which can be solved by intra-aortic recapture and retraction.
Background
Transcatheter aortic valve implantation (TAVI) is the preferred treatment option for severe aortic stenosis in the elderly and in patients with comorbidities. We sought to compare outcomes ...after TAVI and surgical aortic valve replacement (SAVR) in octogenarians.
Methods
In this retrospective cohort study conducted at our tertiary center, clinical data were gathered before and after TAVI and SAVR procedures performed from January 2013 to May 2019; follow-up completed in March 2021. The primary outcome was 1-year mortality. Patients were stratified according to Society of Thoracic Surgeons (STS) score and procedure type. Propensity score-based matching was also performed.
Results
Of 542 patients who matched the inclusion criteria, 273 underwent TAVI and 269 SAVR. TAVI patients were older (85.8 ± 3.0 vs. 82.2 ± 2.2 years;
P
< 0.001) and had a higher mean STS score (5.0 ± 4.0 vs. 2.8 ± 1.3;
P
< 0.001) and EuroSCORE II (5.3 ± 4.1 vs. 2.8 ± 6.0;
P
< 0.001). Rates of postoperative permanent pacemaker insertion (15.0% vs. 9.3%;
P
= 0.040) and paravalvular leak (9.9% vs. 0.8%;
P
< 0.001) were higher and acute kidney injury lower (8.8% vs. 32.7%;
P
< 0.001) after TAVI, with no difference between treatment groups for major bleeding (11.0% vs. 6.7%;
P
= 0.130) or 30-day mortality (5.5% vs. 3.7%;
P
= 0.315). A statistically significant difference was found between TAVI and SAVR in low- and intermediate-risk groups when it came to occurrence of paravalvular leak, acute kidney injury, and new onset AF (all
P
< 0.001).
Conclusion
This analysis of an octogenarian “real-life” population undergoing TAVI or SAVR (with a biological valve) showed similar outcomes regarding clinical endpoints in low- and medium-risk (STS score) groups.
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