Objectives
To evaluate the impact of coronary artery disease (CAD) with or without recent (≤ 30 days) percutaneous coronary intervention (PCI) in women undergoing transcatheter aortic valve ...replacement (TAVR).
Background
Although women display a specific risk‐profile for both PCI and TAVR, the impact of CAD and PCI in the setting of TAVR in women is unclear.
Methods
The multinational Women's International Transcatheter Aortic Valve implantation registry enrolled consecutive female patients undergoing contemporary TAVR in 19 centers between 2013 and 2015. Patients with available coronary angiography or CT scan in the pre‐operative assessment of TAVR were categorized as without CAD, with CAD but no recent PCI and CAD and recent PCI (≤30 days). All events were adjudicated according to the VARC‐2 criteria.
Results
A total of 787 patients were included in this analysis, among whom 459 (58.3%) had no CAD, 247 (31.4%) had CAD without recent PCI and 81 (10.3%) underwent recent PCI (≤ 30 days before TAVR). After multivariable adjustment, both groups of CAD patients, without and with recent PCI, presented with higher risk of death, myocardial infarction or stroke, compared with patients without CAD (adjHR 1.56, 95%CI 1.03–2.39, P = 0.038 and adjHR 1.96, 95% CI 1.1–3.5, P = .021, respectively). Patients with recent PCI had increased risk of all‐cause death (adjHR 1.89, 95% CI 1.0–3.5, P = 0.04) and stroke (adjHR 3.7, 95% CI 1.0–13.5, P = 0.046) compared with patients without CAD.
Conclusion
The presence of CAD in women undergoing TAVR, with or without recent PCI, was associated with long‐term poorer outcomes.
Valvuloarterial impedance (Z(va)) can estimate the global hemodynamic load on the left ventricle in patients with severe aortic stenosis better than the standard indexes, as shown in previous ...studies. In fact, Z(va) can estimate global left ventricular hemodynamic load as the sum of valvular and vascular loads. The aim of this study was to evaluate the acute improvement of left ventricular performance in patients with symptomatic aortic stenosis after transcatheter aortic valve implantation (TAVI) using Z(va).
One hundred two consecutive patients who underwent TAVI were submitted to transthoracic echocardiography immediately before and after aortic valve implantation, together with invasive hemodynamic measurements.
After TAVI, immediate reductions in the transaortic peak pressure gradient (P < .0001) and mean pressure gradient (P < .0001) and a concomitant increase in aortic valve area (P < .0001) were seen on echocardiography. Left ventricular ejection fraction significantly increased immediately after TAVI in all patients (from 48.9 ± 10.3% to 52.1 ± 11.1%, P < .0001). Regarding global left ventricular hemodynamic load, acute and significant reductions in end-systolic meridional wall stress (from 82.7 ± 42.6 to 57.8 ± 30.1 kdyne · cm(-2), P < .0001) and in Z(va) (from 6.81 ± 2.51 to 5.38 ± 2.13 mm Hg · mL(-1) · m(-2), P < .0001) were observed. Furthermore, patients who died at 6-month follow-up had higher baseline Z(va) values compared with those who were alive at 6-month follow-up (8.13 ± 3.08 vs 6.41 ± 2.12 mm Hg · mL(-1) · m(-2), P < .004).
TAVI is characterized by an immediate enhancement of global left ventricular hemodynamic performance, as demonstrated by an acute Z(va) improvement, even in patients with low baseline ejection fractions.
Surgical aortic valve replacement (SAVR) is the definitive proven therapy for patients with severe aortic stenosis who have symptoms or decreased left ventricular (LV) function. The development of ...transcatheter aortic valve implantation (TAVI) offers a viable and "less invasive" option for the treatment of patients with critical aortic stenosis at high risk with conventional approaches. The main objective of this study was the comparison of LV hemodynamic and structural modifications (reverse remodeling) between percutaneous and surgical approaches in the treatment of severe aortic stenosis.
Fifty-eight patients who underwent TAVI with the CoreValve bioprosthetic valve were compared with 58 patients with similar characteristics who underwent SAVR. Doppler echocardiographic data were obtained before the intervention, at discharge, and after 6-month to 12-month follow-up.
Mean transprosthetic gradient at discharge was lower (P<.003) in the TAVI group (10±5 mm Hg) compared with the SAVR group (14±5 mm Hg) and was confirmed at follow-up (10±4 vs 13±4 mm Hg, respectively, P<.001). Paravalvular leaks were more frequent in the TAVI group (trivial to mild, 69%; moderate, 14%) than in the SAVR group (trivial to mild, 30%; moderate, 0%) (P<.0001). The incidence of severe prosthesis-patient mismatch (PPM) was significantly lower (P<.004) in the TAVI group (12%) compared with the SAVR group (36%). At follow-up, LV mass and LV mass indexed to height and to body surface area improved in both groups, with no significant difference. In patients with severe PPM, only the TAVI subgroup showed significant reductions in LV mass. LV ejection fraction improved at follow-up significantly only in TAVI patients compared with baseline values (from 50.2±9.6% to 54.8±7.3%, P<.0001).
Hemodynamic performance after TAVI was shown to be superior to that after SAVR in terms of transprosthetic gradient, LV ejection fraction, and the prevention of severe PPM, but with a higher incidence of aortic regurgitation. Furthermore, LV reverse remodeling was observed in all patients in the absence of PPM, while the same remodeling occurred only in the TAVI subgroup when severe PPM was present.
It remains unclear whether radial access (RA), compared with femoral access (FA), mitigates the risk of acute kidney injury (AKI).
The authors assessed the incidence of AKI in patients with acute ...coronary syndrome (ACS) enrolled in the MATRIX-Access (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trial.
Among 8,404 patients, 194 (2.3%) were excluded due to missing creatinine values, no or an incomplete coronary angiogram, or previous dialysis. The primary AKI-MATRIX endpoint was AKI, defined as an absolute (>0.5 mg/dl) or a relative (>25%) increase in serum creatinine (sCr).
AKI occurred in 634 patients (15.4%) with RA and 712 patients (17.4%) with FA (odds ratio OR: 0.87; 95% confidence interval CI: 0.77 to 0.98; p = 0.0181). A >25% sCr increase was noted in 633 patients (15.4%) with RA and 710 patients (17.3%) with FA (OR: 0.87; 95% CI: 0.77 to 0.98; p = 0.0195), whereas a >0.5 mg/dl absolute sCr increase occurred in 175 patients (4.3%) with RA versus 223 patients (5.4%) with FA (OR: 0.77; 95% CI: 0.63 to 0.95; p = 0.0131). By implementing the Kidney Disease Improving Global Outcomes criteria, AKI was 3-fold less prevalent and trended lower with RA (OR: 0.85; 95% CI: 0.70 to 1.03; p = 0.090), with stage 3 AKI occurring in 28 patients (0.68%) with RA versus 46 patients (1.12%) with FA (p = 0.0367). Post-intervention dialysis was needed in 6 patients (0.15%) with RA and 14 patients (0.34%) with FA (p = 0.0814). Stratified analyses suggested greater benefit with RA than FA in patients at greater risk for AKI.
In ACS patients who underwent invasive management, RA was associated with a reduced risk of AKI compared with FA. (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX MATRIX; NCT01433627).
The recent development of transcatheter aortic valve implantation (TAVI) to treat severe aortic stenosis (AS) offers a viable option for high-risk patients categories. Our aim is to evaluate the ...early effects of implantation of CoreValve aortic valve prosthesis on arterial-ventricular coupling by two dimensional echocardiography. Sixty five patients with severe AS performed 2D conventional echocardiography before, immediately after TAVI, at discharge (mean age: 82.6 ± 5.9 years; female: 60%). The current third generation (18-F) CoreValve Revalving system (Medtronic, Minneapolis, MN) was used in all cases. Vascular access was obtained by percutaneous approach through the common femoral artery; the procedure was performed with the patient under local anesthesia. We calculated, apart the conventional parameters regarding left ventricular geometry and the Doppler parameters of aortic flow (valvular load), the vascular load and the global left ventricular hemodynamic load. After TAVI we showed, by echocardiography, an improvement of valvular load. In particular we observed an immediate reduction of transaortic peak pressure gradient (
P
< 0.0001), of mean pressure gradient (
P
< 0.0001) and a concomitant increase in aortic valve area (AVA) (0.97 ± 0.3 cm
2
). Left ventricular ejection fraction improved early after TAVI (before: 47 ± 11, after: 54 ± 11;
P
< .0001). Vascular load, expressed by systemic arterial compliance, showed a low but significant improvement after procedure (
P
< 0.01), while systemic vascular resistances showed a significant reduction after procedure (
P
< 0.001). As a global effect of the integrated changes of these hemodynamic parameters, we observed a significant improvement of global left ventricular hemodynamic load, in particular through a significant reduction of end-systolic meridional stress (before: 80 ± 34 and after: 55 ± 29,
P
< 0.0001). The arterial-valvular impedance showed a significant reduction (before: 7.6 ± 2 vs after: 5.8 ± 2;
P
< 0.0001. Furthermore we observed a significant reduction with a normalization of arterial-ventricular coupling (
P
< 0.005). With regard to left ventricular (LV) efficiency, we observed, after the procedure, a significant reduction of stroke work (
P
< 0.001) and potential energy (
P
< 0.001), with a significant increase of work efficiency early after the procedure (
P
< 0.001). Our results showed that the TAVI procedure was able to determine an early improvement of the global left ventricular hemodynamic load, allowing a better global LV performance. Further follow-up investigations are needed to evaluate these results in a more prolonged time observation.
Background Few data are available concerning the effects on clinical outcome and left ventricular function of abciximab administration in patients undergoing rescue percutaneous transluminal coronary ...angioplasty (PTCA) after failed thrombolysis for acute myocardial infarction. The aim of the study was to investigate such effects. Methods Eighty-nine consecutive patients referred to our laboratory from other hospitals for rescue PTCA within 24 hours from the onset of chest pain were prospectively randomized before the procedure to abciximab treatment (44 patients) or placebo (45 patients). No significant differences in baseline characteristics were observed between the 2 groups. Study end points were the occurrence of major adverse cardiac events (MACE) such as death, reinfarction, congestive heart failure, target lesion revascularization, or recurrent ischemia at 30-day and 6-month follow-up and the occurrence of periprocedural bleeding. Results Mean time from symptom onset to reperfusion was 8.5 ± 5.4 hours; rescue PTCA was successful in 96% of patients. The incidence of major, moderate, and minor bleeding was similar in the 2 groups. At 30-day follow-up, the echocardiographic left ventricular wall motion score index showed a significantly higher improvement in the abciximab group versus the placebo group (P <.001). At 6-month follow-up, the incidence of MACE was 11% in the abciximab group versus 38% in the placebo group (P =.004). Abciximab administration (P =.003) and cardiogenic shock (P =.005) were the only independent predictors of the occurrence of MACE at multivariable analysis. Conclusion Treatment with abciximab during rescue PTCA positively affects clinical outcome at 6-month follow-up without increasing periprocedural bleeding. (Am Heart J 2002;143:334-41.)
Serious flaws in the scientific evaluation in the RAR incorrectly characterise the potential for a carcinogenic hazard from exposure to glyphosate. Since the RAR is the basis for the European Food ...Safety Agency (EFSA) conclusion, 4 it is critical that these shortcomings are corrected. ...the WG also saw a significant increase in the incidence of pancreatic islet cell adenomas in two studies in male Sprague-Dawley rats. 14-16 In one of these rat studies, thyroid gland adenomas in females and liver adenomas in males were also increased.
The recent development of transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) treatment offers a viable option for high-risk patient categories. Our aim is to evaluate ...whether 2D strain and strain rate can detect subtle improvement in global and regional LV systolic function immediately after TAVI. 2D conventional and 2D strain (speckle analysis) echocardiography was performed before, at discharge and after three months in thirty three patients with severe AS. After TAVI, we assessed by conventional echocardiography an immediate reduction of transaortic peak pressure gradient (p<0.0001), of mean pressure gradient (p<0.0001) and a concomitant increase in aortic valve area (AVA: 1.08±0.31 cm(2)/m(2); p<0.0001). 2D longitudinal systolic strain showed a significant improvement in all patients, both at septal and lateral level, as early as 72 h after procedure (septal: -14.2±5.1 vs -16.7±3.7%, p<0.001; lateral: -9.4±3.9 vs -13.1±4.5%, p<0.001; respectively) and continued at 3 months follow-up (septal: -18.1±4.6%, p<0.0001; lateral: -14.8±4.4%, p<0.0001; respectively). Conventional echocardiography after TAVI proved a significant reduction of LV end-systolic volume and of LV mass with a mild improvement of LV ejection fraction (EF) (51.2±11.8 vs 52.9±6.4%; p<0.02) only after three months. 2D strain seems to be able to detect subtle changes in LV systolic function occurring early and late after TAVI in severe AS, while all conventional echo parameters seem to be less effective for this purpose. Further investigations are needed to prove the real prognostic impact of these echocardiographic findings.
Abstract
Aims
Permanent pacemaker implantation (PPM-I) remains nowadays the most important drawback of transcatheter aortic valve replacement (TAVR) procedure and the optimal strategy of delayed ...conduction disturbances (CDs) in these patients is unclear. The study aimed to validate an ambulatory electrocardiogram (ECG) monitoring through a 30 s spot ambulatory digital mobile ECG (AeECG), by using KardiaMobile-6L device in a 30-day period after TAVR procedure.
Methods and results
Between March 2021 and February 2022, we consecutively enrolled all patients undergoing TAVR procedure, except pacemaker (PM) carriers. At discharge, all patients were provided of a KardiaMobile-6L device and a spot digital ECG (eECG) recording 1 month schedule. Clinical and follow-up data were collected, and eECG schedule compliance and recording quality were explored. Among 151 patients without pre-existing PM, 23 were excluded for pre-discharge PPM-I, 18 failed the KardiaMobile-6L training phase, and 10 refused the device. Delayed CDs with a Class I/IIa indication for PPM-I occurred in eight patients (median 6 days). Delayed PPM-I vs. non-delayed PPM-I patients were more likely to have longer PR and QRS intervals at discharge. PR interval at discharge was the only independent predictor for delayed PPM-I at multivariate analysis. The overall eECG schedule compliance was 96.5%. None clinical adverse events CDs related were documented using this new AeECG monitoring modality.
Conclusion
A strategy of 30 s spot AeECG is safe and efficacious in delayed CDs monitoring after TAVR procedure with a very high eECG schedule level of compliance.
Graphical Abstract
Graphical Abstract
(A) Flow chart programme for patient access to the device training phase and its rules. (B) eECG 1 month schedule. (C ) Histogram illustrating the number of cases and associated time to development of delayed CDs requiring PPM-I. CD, conduction disturbance; eECG, digital electrocardiogram; PPM-I, permanent pacemaker implantation.
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