Objective
To demonstrate the feasibility of achieving good hemodynamic results with valve‐in‐valve transcatheter aortic valve replacement (ViV TAVR) for degenerated 19 mm surgical bioprosthetic ...valves.
Background
Considerable controversy exists regarding ViV TAVR within 19mm surgical prostheses due to concerns of elevated valve gradients and mortality.
Methods
Among all patient undergoing ViV TAVR between 7/2016 and 4/2017 for symptomatic severe bioprosthetic aortic stenosis (AS), five had a 19 mm surgical valve in place and were included in this publication. None of the patients had patient‐prosthesis mismatch. Aggressive post‐dilation was performed in four out of five cases using a special technique we describe below.
Results
In all cases, mean aortic valve (AV) gradients significantly improved post‐ViV TAVR, particularly after post‐dilation. Interestingly, high pressure post‐dilation of the ViV resulted in an increase in the diameter of surgical valve stent frame dimensions in nearly all patients who underwent post‐dilation.
Conclusions
Good hemodynamic outcome is possible with aggressive post‐dilation in patients with 19 mm failed surgical bioprostheses. High‐risk patients with 19 mm failed surgical prostheses who do not otherwise have viable surgical options should be considered for ViV TAVR.
Mitral valve regurgitation (MR) is the most prevalent valvular disorder among the growing elderly population, occurring in over 6% of those aged >65. Unfortunately, many individuals with severe MR ...(particularly those with systolic dysfunction or secondary MR) will not be candidates for surgical valve repair or replacement due to high or prohibitive operative risk. For such patients, transcatheter mitral valve replacement represents a viable option. The Tendyne
valve (Abbott Vascular, CA, USA) is one of the most well-studied system to date, with a good safety and efficacy profile.
In the current era, 10–15 % of transcatheter aortic valve replacement (TAVR)-eligible high and prohibitive risk patients with severe symptomatic aortic stenosis are not candidates for transfemoral ...arterial access. Knowledge of the various alternative access options can enable TAVR teams to provide improved quality of life and potentially life-saving treatment for a group of patients who otherwise have no viable options. In this article, we review approach to patients with unfavorable femoral arterial anatomy and provide an in-depth discussion on the various alternative routes for TAVR.
Current evidence supports deferral of revascularization for lesions with fractional flow reserve (FFR) values >0.80. The natural history after deferral of revascularization of lesions with borderline ...FFR values is unknown. This study evaluated the outcomes of patients after deferred revascularization of coronary stenoses based on a borderline FFR value. We retrospectively studied 720 patients with 881 intermediate-severity coronary stenoses who underwent FFR assessment from October 2002 to July 2010 and were deferred revascularization. Patients were divided into gray zone (0.75 to 0.80), borderline (0.81 to 0.85), and nonborderline (>0.85) FFR groups. Any subsequent percutaneous coronary intervention or coronary artery bypass grafting of a deferred stenosis during follow-up was classified as a deferred lesion intervention (DLI). Patient and/or lesion characteristics and clinical outcomes were compared between the FFR groups using univariate and propensity score–adjusted inverse probability of weighting Cox proportional hazards analyses. During a mean follow-up of 4.5 ± 2.1 years, 157 deferred lesions (18%) underwent DLI by percutaneous coronary intervention (n = 117) or coronary artery bypass grafting (n = 40). No statistically significant differences were observed in clinical outcomes between the gray zone and borderline FFR groups. Lesions with a borderline FFR were associated with a significantly higher risk of DLI compared with lesions with nonborderline FFR values (hazard ratio 1.63, 95% confidence interval 1.14 to 2.33, p = 0.007). Lesions deferred revascularization because of a borderline FFR (0.81 to 0.85) were associated with a higher risk of DLI compared with lesions with a nonborderline FFR (>0.85). Further study is needed to determine the optimal management of coronary stenoses with a borderline FFR value.
Although lesions deferred revascularization following fractional flow reserve (FFR) assessment have a low risk of adverse cardiac events, variability in risk for deferred lesion intervention (DLI) ...has not been previously evaluated. The aim of this study was to develop a prediction model to estimate 1-year risk of DLI for coronary lesions where revascularization was not performed following FFR assessment.
A prediction model for DLI was developed from a cohort of 721 patients with 882 coronary lesions where revascularization was deferred based on FFR between 10/2002 and 7/2010. Deferred lesion intervention was defined as any revascularization of a lesion previously deferred following FFR. The final DLI model was developed using stepwise Cox regression and validated using bootstrapping techniques. An algorithm was constructed to predict the 1-year risk of DLI. During a mean (±SD) follow-up period of 4.0 ± 2.3 years, 18% of lesions deferred after FFR underwent DLI; the 1-year incidence of DLI was 5.3%, while the predicted risk of DLI varied from 1 to 40%. The final Cox model included the FFR value, age, current or former smoking, history of coronary artery disease (CAD) or prior percutaneous coronary intervention, multi-vessel CAD, and serum creatinine. The c statistic for the DLI prediction model was 0.66 (95% confidence interval, CI: 0.61-0.70).
Patients deferred revascularization based on FFR have variation in their risk for DLI. A clinical prediction model consisting of five clinical variables and the FFR value can help predict the risk of DLI in the first year following FFR assessment.
The safety of deferring revascularization based on fractional flow reserve (FFR) during acute coronary syndrome (ACS) is unclear. We evaluated the association of FFR and adverse cardiac events among ...patients with coronary lesions deferred revascularization based on FFR in the setting of ACS versus non-ACS.
The study population (674 patients; 816 lesions) was divided into ACS (n=334) and non-ACS (n=340) groups based on the diagnosis when revascularization was deferred based on FFR values >0.80 between October 2002 and July 2010. The association and interaction between FFR and clinical outcomes was evaluated using Cox proportional hazards models within each group (mean follow-up of 4.5±2.1 years). Subsequent revascularization of a deferred lesion was classified as a deferred lesion intervention (DLI), whereas the composite of DLI or myocardial infarction (MI) attributed to a deferred lesion was designated as deferred lesion failure (DLF). In the non-ACS group, lower FFR values were not associated with any increase in adverse cardiac events. In the ACS group, every 0.01 decrease in FFR was associated with a significantly higher rate of cardiovascular death, MI, or DLI (hazard ratio HR, 1.08; 95% confidence interval CI, 1.03 to 1.12), MI or DLI (HR, 1.09; 95% CI: 1.04 to 1.14), DLF (HR, 1.12; 95% CI, 1.06 to 1.18), MI (HR, 1.07; 95% CI, 1.00 to 1.14), and DLI (HR, 1.12; 95% CI, 1.06 to 1.18).
Lower FFR values among ACS patients with coronary lesions deferred revascularization based on FFR are associated with a significantly higher rate of adverse cardiac events. This association was not observed in non-ACS patients.
Abstract Objectives This study evaluated clinical outcomes associated with erythropoiesis stimulating agent (ESA) use in left ventricular assist devices (LVAD)–supported patients. Background Use of ...ESAs in patients with LVADs may minimize blood transfusions and decrease allosensitization. ESAs increase thrombotic events, which is concerning because LVADs are sensitive to pump thrombosis (PT). Methods We retrospectively reviewed 221 patients at our center who received a HeartMate II (Thoratec Corp., Pleasanton, California) LVAD between January 1, 2009 and June 6, 2013. Patients were divided into those who received ESAs during index admission (n = 121) and those who did not (n = 100). Suspected PT was defined as evidence of thrombus in the LVAD or severe hemolysis (lactate dehydrogenase >1,000 mg/dl or plasma-free hemoglobin >40 mg/dl). Outcomes were compared between cohorts using inverse probability-weighted analyses. Results During a mean follow-up of 14.2 ± 11.9 months, suspected PT occurred in 37 patients (ESA 23%, no ESA 12%; p =0.03). The ESA cohort received ESAs 13.9 ± 60.9 days after LVAD implantation. At 180 days, event-free rates for suspected PT were ESA 78.6% versus no ESA 94.5% (p < 0.001). ESA use had higher rates of suspected PT (hazard ratio HR: 2.35; 95% confidence interval CI: 1.38 to 4.00; p = 0.002). For every 100-unit increase in cumulative ESA dosage, the hazard of suspected PT increased by 10% (HR: 1.10; 95% CI: 1.04 to 1.16; p < 0.001). After inverse probability weighting, ESA use was associated with a significantly higher rate of all-cause mortality (HR: 1.62; 95% CI: 1.12 to 2.33; p = 0.01). Conclusions ESA use in LVAD patients is associated with higher rates of suspected PT.
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