Smoking cessation is the most effective intervention to reduce mortality in patients with established atherosclerotic cardiovascular disease (ASCVD), with ‘e-cigarettes’ becoming an increasingly used ...intervention to achieve smoking cessation. The current review aims to summarise the current evidence base for their efficacy and safety in the ASCVD cohort. A search of the PUBMED and MEDLINE databases using the terms ‘e-cigarette’, ‘cessation’, ‘safety’ and ‘efficacy’ since 2012 yielded 706 results. Both observational and experimental studies were included, while those with an unavailable full text, non-English or duplicates were excluded, yielding 78 relevant articles, with 13 subsequent additional articles included from a search of reference lists, for a total of 91 included papers. E-cigarette vapour contains many known pro-atherosclerotic substances and has been demonstrated to potentiate traditional atherosclerotic mechanisms. While e-cigarettes may be more effective in promoting smoking cessation in the general population over a medium term (>6 months), when compared with nicotine replacement therapy (NRT), few studies specifically examined those with ASCVD, despite the latter having a higher baseline quit rate (52% vs 2%). Most studies compare e-cigarettes with NRT alone and do not include pharmacotherapy, which may be more effective in the ASCVD cohort. The single randomised controlled trial addressing the research question favoured traditional methods. Those that successfully quit smoking using e-cigarettes are more likely to continue to use the intervention at 1 year (90% vs 9%). Conflicting advice exists regarding the utilisation of e-cigarettes for smoking cessation. E-cigarettes may be inferior to standard care for smoking cessation in those with ASCVD, and their use is likely to promote the key drivers of the atherosclerotic process already active in this cohort.
Deformation imaging represents a method of measuring myocardial function, including global longitudinal strain (GLS), peak atrial longitudinal strain (PALS) and radial strain. This study aimed to ...assess subclinical improvements in left ventricular function in patients undergoing transcatheter aortic valve implantation (TAVI) by comparing GLS, PALS and radial strain pre and post procedure.
We conducted a single site prospective observational study of 25 patients undergoing TAVI, comparing baseline and post-TAVI echocardiograms. Individual participants were assessed for differences in GLS, PALS and radial strain in addition to changes in left ventricular ejection fraction (LVEF) (%).
Our results revealed a significant improvement in GLS (mean change pre-post of 2.14% 95% CI 1.08, 3.20 p = 0.0003) with no significant change in LVEF (0.96% 95% CI - 2.30, 4.22, p = 0.55). There was a statistically significant improvement in radial strain pre and post TAVI (mean 9.68% 95% CI 3.10, 16.25 p = 0.0058). There was positive trend towards improvements in PALS pre and post TAVI (mean change of 2.30% 95% CI - 0.19, 4.80 p = 0.068).
In patients undergoing TAVI, measuring GLS and radial strain provided statistically significant information regarding subclinical improvements in LV function, which may have prognostic implications. The incorporation of deformation imaging in addition to standard echocardiographic measurements may have an important role in guiding future management in patients undergoing TAVI and assessing response.
This study assessed the effect of overexpansion beyond labeled size (diameter) of transcatheter heart valves through an ex vivo bench study.
Transcatheter heart valves function optimally when ...expanded to specific dimensions. However, clinicians may sometimes wish to overexpand balloon-expandable valves to address specific clinical challenges. The implications of overexpansion have assumed considerable importance, and objective information to guide practice is limited.
We evaluated SAPIEN 3 transcatheter heart valves (Edwards Lifesciences, Irvine, California). Valves (diameters of 23, 26, and 29 mm) were expanded to nominal dimensions, and then incrementally overexpanded with balloons sized 1-, 2-, and 3-mm larger than the recommended diameter. Valves underwent visual, microcomputed tomography, and hydrodynamic evaluation at various degrees of overexpansion.
SAPIEN 3 valves with labeled diameters of 23, 26, and 29 mm could be incrementally overexpanded to midvalve diameters of 26.4, 28.4, and 31.2 mm, respectively. With overexpansion, there was visible restriction of the valve leaflets, which was particularly evident with the smaller valves. After maximal overexpansion of a 26-mm valve a leaflet tear was observed. High-speed video demonstrated impaired leaflet motion of both the 23- and 26-mm valves and hydrodynamic testing documented a regurgitant fraction for the 23- and 26-mm valves above accepted international standards. The maximally overexpanded 29-mm SAPIEN 3 still had relatively normal leaflet motion and excellent hydrodynamic function. Durability was not specifically evaluated.
Overexpansion of balloon-expandable valves is possible. However, excessive overexpansion may be associated with impaired hydrodynamic function, acute leaflet failure, and reduced durability. Smaller valves may be at greater risk with overexpansion than larger valves. Overexpansion is best avoided unless clinical circumstances are compelling.
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Growing clinical data support the use of transcatheter therapies for significant mitral valve disease. Currently, edge-to-edge repair is the transcatheter treatment of choice, but many anatomies are ...not suitable. Transcatheter mitral valve replacement offers several potential advantages over transcatheter repair, most notably a greater and more sustained reduction in mitral regurgitation post-implantation, but also potential disadvantages. To enable the successful treatment of mitral valve disease in a wide range of patients and anatomies, we require an armory of transcatheter devices, including transcatheter mitral valve replacement systems.
Severe mitral regurgitation (MR) conveys significant morbidity and mortality, and surgical repair or replacement may not be a desirable option.
The purpose of this study was to evaluate the ...feasibility of a percutaneous transseptal transcatheter mitral valve replacement (TMVR) system.
This first-in-human study was conducted between August 2017 and August 2018. The system comprises a nitinol dock, which encircles the chordae tendineae, and a balloon-expandable transcatheter heart valve. The dock and transcatheter heart valve form an ensemble, with the native mitral valve leaflets secured in between, thereby abolishing MR. Key inclusion criteria were severe symptomatic MR and high surgical risk; exclusion criteria included left ventricular ejection fraction <30% or screening suggesting unfavorable anatomy. The primary endpoint was technical success as defined by Mitral Valve Academic Research Consortium (MVARC) criteria at completion of the index procedure. The secondary endpoint was freedom from mortality, stroke, and device dysfunction (MR grade >1, mitral gradient >6 mm Hg, left ventricular outflow tract gradient >20 mm Hg) at 30 days.
Ten patients with severe MR of various etiologies (4 degenerative, 4 functional, and 2 mixed) were treated. The device was successfully implanted and the primary endpoint was achieved in 9 of 10 patients (90%). By transesophageal echocardiography, total MR was reduced to ≤ trivial in all implanted patients, and mean transmitral gradient was 2.3 ± 1.4 mm Hg. A pericardial effusion occurred in 1 patient: pericardiocentesis was performed, and the device was not implanted. Median length of hospital stay was 1.5 days. At 30 days, there was no stroke, myocardial infarction, rehospitalization, left ventricular outflow tract obstruction, device migration, embolization, or conversion to mitral surgery. One patient had recurrent regurgitation due to a paravalvular leak, treated with a closure device. All other treated patients had ≤1+ MR. No patients died.
Percutaneous transvenous transseptal TMVR is feasible and safe in patients with severe MR who are at high risk for mitral valve surgery. Further evaluation is warranted.
Key Points
In patients with end stage renal disease on hemodialysis, TAVR resulted in reduced length of stay, hospitalization cost, complication rate and higher rates of home discharge compared to ...SAVR.
In‐hospital mortality and complication rates were high in both groups.
Careful patient selection and further research is required to identify patients with end‐stage renal disease who might, or might not, benefit from intervention.
Transcatheter aortic valve implantation and implantation of other transcatheter heart valves, generally requires insertion of a temporary venous pacemaker. Implantation of a temporary venous ...pacemaker adds complexity, time and risk to the procedure. Guidewire modification to allow pacing is increasingly popular, however it requires technical expertise and provides unipolar pacing resulting in high thresholds and potential capture loss. The Wattson temporary pacing guidewire is a novel device which offers guidewire support for valve delivery and concomitant bipolar pacing. It may offer a safe and effective solution to guidewire pacing for transcatheter aortic valve implantation and other transcatheter heart valve implantations. Herein, we review the literature surrounding left ventricular guidewire pacing along with the features and clinical data of the Wattson wire.
Abstract Background The transradial route has become the primary approach for coronary angiography with the presence of radial artery anomalies found to be 10–20%. There has been limited study on the ...influence of these anomalies on procedural pain. Our aims were to determine local prevalence of the high radial origin (HRO) anatomical variant; to investigate factors influencing transradial procedural pain; and to determine if HRO specifically was associated with increased pain. Methods Radial artery anatomy was characterized by arteriography in sequential patients undergoing angiography. Patients were asked to mark their perceived procedural pain on a visual analogue scale, which was converted to a pain score. Results 382 patients were enrolled, 5 were excluded. There were 259 males (68.7%) and 118 females (31.3%). HRO was present in 51 patients (13.5%). Overall mean pain score was 2.6 (SD 2.5). HRO was associated with a higher mean pain score than normal anatomy (3.3 (SD 2.9) vs. 2.4 (SD 2.4) p = 0.027). HRO was not associated with increased procedural failure, screening time or procedure time. When pain score was dichotomized into mild pain (< 4.0) and moderate-to-severe pain (≥ 4.0), HRO was associated with almost double the frequency of moderate-to-severe pain (37.2% vs. 21.1%, p = 0.012). Using a logistic regression model, only female gender, younger age and HRO remained significant predictors of moderate-to-severe pain. Conclusions There was significantly increased pain in patients with HRO without increased procedure/screening time or procedural failure. Female gender and younger age were also found to be significant predictors of increased pain.
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