The aim of this study was to determine the utility of rapid atrial pacing immediately after transcatheter aortic valve replacement (TAVR) to predict the need for permanent pacemaker implantation ...(PPI).
Risk stratification for patients without high-grade atrioventricular block (AVB) after TAVR is imprecise and based on anatomic considerations, electrocardiographic characteristics, and clinical suspicion. A more reliable assessment is necessary to minimize inpatient rhythm monitoring and/or reduce unnecessary PPI.
Consecutive patients undergoing TAVR at 2 centers were included. After valve implantation in patients without pacemakers who did not have complete heart block or atrial fibrillation, the temporary pacemaker was withdrawn from the right ventricle and placed in the right atrium. Rapid atrial pacing was performed from 70 to 120 beats/min, and patients were assessed for the development of Wenckebach AVB. Patients were then followed for clinical outcomes, including PPI.
A total of 284 patients were included. Of these, 130 (45.8%) developed Wenckebach AVB. There was a higher rate of PPI within 30 days of TAVR among the patients who developed Wenckebach AVB (13.1% vs. 1.3%; p < 0.001), with a negative predictive value for PPI in the group without Wenckebach AVB of 98.7%. A greater percentage of patients receiving self-expanding valves required PPI than those receiving a balloon-expandable valves (15.9% vs. 3.7%; p = 0.001), though these rates were still relatively low among patients who did not develop Wenckebach AVB (2.9% and 0.8%).
Atrial pacing post-TAVR is easily performed and can help identify patients who may benefit from extended rhythm monitoring. Patients who did not develop pacing-induced Wenckebach AVB demonstrated an extremely low likelihood of PPI.
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Antiplatelet therapy, the cornerstone of post coronary stenting antithrombotic therapy, reduces the rate of hard clinical endpoints in patients treated both conservatively and invasively following an ...acute coronary syndrome, as well as in those patients with chronic stable coronary disease who receive a coronary stent. The development of newer antiplatelet and direct anticoagulant agents provides new options in the antithrombotic management of patients with coronary artery disease, enabling different therapeutic combinations to be tailored to an individual patient’s bleeding and ischemic risk profile. In this review, we will summarize the history of dual antiplatelet therapy, discuss the latest evidence and future perspectives in treating patients with coronary artery disease.
Complex percutaneous coronary intervention (PCI) is associated with increased procedural challenges and high contrast load. We aimed to evaluate the association between complex PCI and ...contrast-induced nephropathy (CIN).
This single-center retrospective study included all-comers undergoing PCI between January 2012 and December 2016. Complex PCI was defined as a procedure with ≥1 of the following characteristics: 3 vessels treated, ≥3 stents implanted, two-stent bifurcation intervention, total stent length >60 mm, PCI on a chronic total occlusion, saphenous vein graft, or left main, protected PCI, use of rotational/laser atherectomy. CIN was defined as an increase in post-PCI creatinine of ≥0.3 mg/dl or ≥50% from baseline.
We included 2660 patients (n = 1128 complex PCI, n = 1532 non-complex PCI). Complex PCI patients tended to be older, and had higher cardiovascular comorbidity and Mehran CIN risk score. They also had a higher prevalence of type B2/C lesions and need for mechanical circulatory support, and received a higher mean contrast volume (284 ± 137 vs. 189 ± 90 ml, p < 0.001). CIN incidence was similar in complex vs. non-complex PCI patients (12.1% vs. 11.5%, p = 0.63), as was the need for in-hospital dialysis (0.5% vs. 0.2%, p = 0.25). Upon multivariable adjustment, age, female sex, diabetes, ejection fraction, periprocedural hypotension, presentation with acute coronary syndrome, and contrast volume were independently associated with CIN, while complex PCI was not.
Complex PCI is not associated with an increased risk of CIN in all-comers. Further studies should confirm our findings and investigate novel effective strategies to decrease the risk of this serious complication.
•Complex PCI is associated with procedural challenges and higher contrast volumes.•Complex PCI might be linked to a higher risk for contrast-induced nephropathy.•CIN incidence was similar in complex vs. non-complex PCI (12.1% vs. 11.5%, p = 0.63).•Upon multivariable adjustment complex PCI was not independently associated with CIN.
Renin-angiotensin-aldosterone (RAAS) is a hormone system which acts on multiple physiologic pathways primarily by regulating blood pressure and fluid balance, but also by local autocrine and ...paracrine actions. In pathophysiologic conditions RAAS also contributes to the development of atherosclerosis and its various manifestations, both directly and indirectly through the actions on other systems. RAAS mainly acts as a promoter of atherosclerosis by its action on vessels, and by promoting the development of hypertension, insulin resistance and diabetes, obesity, vascular and systemic inflammation. As RAAS plays a key role in the pathogenesis of cardiovascular diseases, RAAS genes have been extensively studied as candidate genes for atherosclerosis and coronary artery disease. Several polymorphisms of its genes have been found to be in relationship with atherosclerosis and cardiovascular diseases. In this review we will discuss these issues and present the most recent advances about this topic.
Contrast‐induced acute kidney injury (CI‐AKI) represents a common but serious complication of percutaneous coronary interventions (PCI)—and in general of all those examinations requiring iodinated ...contrast injection—which affects not only renal function but also long‐term prognosis. While several prophylactic approaches were designed in order to prevent CI‐AKI, most failed to demonstrate clear benefits in randomized trials, and their implementation is therefore discouraged in clinical practice. The most notorious examples include pre‐procedural bicarbonate or N‐acetylcysteine, and preprocedural withdrawal of ACE inhibitors/Angiotensin receptor blockers. Those strategies that were instead demonstrated effective include the appropriate use of preprocedural hydration, reduction in contrast volume utilization, adoption of techniques for zero‐ or ultra‐low‐contrast procedures, and pharmacological treatments with statins. In this brief review, we summarize the main preventive strategies into brief and pragmatic recommendations designed to improve everyday clinical practice.
Despite advancements in the safety of transcatheter aortic valve replacement (TAVR) resulting in progressively wider indications, adverse periprocedural outcomes still raise concern. Real-world ...outcome data are thus of primary importance to evaluate the procedural risk-benefit trade-off in the continuously changing populations undergoing TAVR.
We retrospectively assessed 1348 consecutive patients undergoing TAVR between 2007 and 2017. The primary endpoint was a composite of procedural mortality and need for conversion to emergent surgery, as defined by the Valve Academic Research Consortium-2 criteria. Temporal trends in baseline characteristics and outcomes were evaluated. The independent outcomes predictors were assessed through multivariate regression analysis.
A total of 56 (4.1%) patients experienced the primary endpoint. 47 (3.5%) patients died during hospital stay, 19 (1.4%) within 72 h from the procedure. 17 patients (1.2%) needed an emergent conversion to open surgery, of whom 7 (41.2%) did not survive.
Significant temporal trends of increasing mean age (from 79.4 ± 7.4 to 81 ± 7.5, p = 0.007) and decreasing surgical risk (mean STS: from 9 ± 9.5 to 7.1 ± 9.8, p = 0.010) were observed. When dichotomized at the median procedural date (year 2014), a significant reduction in the occurrence of the primary endpoint in more recent years was observed (3.0% vs 5.2%, p = 0.041). This was the single primary endpoint independent predictor at multivariate analysis.
The high-volume 10-year experience in TAVR procedures at our center shows encouraging trends in procedural mortality reduction, which anyhow still occurs at a non-negligible rate, calling for further research to detect and to blunt the determinant of early procedural events.
•Characteristics of patients undergoing transcatheter aortic valve replacement changed across the years.•A temporal trend of reduced procedural mortality is apparent following transcatheter aortic valve replacement.•Non-negligible procedural death occurrence calls for research to further reduce early procedural events.
A relationship between malignancy and impaired hemostasis has been proven, and balancing clotting and bleeding risks can be challenging. Half of cancer patients with atrial fibrillation (AF) do not ...receive any oral anticoagulation (OAC). Using PubMed on the relationship between cancer and AF and their association with hemostasis, targeting studies comparing vitamin K antagonists (VKAs) and direct OAC (DOAC) strategies in AF cancer patients, three RCTs (>3000 patients) and eight observational studies (>250,000 patients) comparing different OACs were retrieved. The VKA prescribed was always warfarin. Dabigatran was the only DOAC not analyzed in the RCTs but the most used in non-randomized studies, whereas edoxaban-treated patients were the majority in the RCTs. Overall, the DOAC patients showed similar or lower rates of efficacy (thromboembolic) and safety (bleeding) outcomes compared to the VKA patients. DOACs are subject to fewer interactions with antineoplastic agents. DOACs may be preferable to VKAs as a thromboembolic prophylaxis in cancer patients with non-valvular AF.
(1) Introduction: Cancer and atrial fibrillation (AF) are increasingly coexisting medical challenges. These two conditions share an increased thrombotic and bleeding risk. Although optimal regimens ...of the most suitable anti-thrombotic therapy are now affirmed in the general population, cancer patients are still particularly understudied on the matter; (2) Aims And Methodology: This metanalysis (11 studies (incl. 266,865 patients)) aims at evaluating the ischemic-hemorrhagic risk profile of oncologic patients with AF treated with oral anticoagulants (vitamin K antagonists vs. direct oral anticoagulants); (3) Results: In the oncological population, DOACs confer a benefit in terms of the reduction in ischemic, hemorrhagic and venous thromboembolic events. However, ischemic prevention has a non-insignificant bleeding risk, lower than Warfarin but significant and higher than the non-oncological patients; (4) Conclusions: Anticoagulation with DOACs provides a higher safety profile with respect to VKAs in terms of stroke reduction and a relative bleeding reduction risk. Further studies are needed to better assess the optimal anticoagulation strategy in cancer patients with AF.
The tricuspid valve has been neglected for a long time and severe tricuspid regurgitation (TR) was largely undertreated in the past due to a high operative risk. In the last years we observed the ...development of different less invasive percutaneous options to treat TR. Currently, percutaneous treatments are reserved for high-risk patients presenting with advanced stage disease by which time they are likely to derive a partial benefit at best. There is a limited evidence base, including no randomized trials, to guide the management strategy for severe TR. In the interim we feel that choosing the best device for the most appropriate clinical candidate and with an adequate timing (most probably an "earlier" timing) will be the key combination to improve early and late outcomes of percutaneous treatments.
Stent implantation represents the standard of care in coronary intervention. While a short stent implanted on a focal lesion located on the left anterior descending artery (LAD) seems a reasonable ...alternative to an internal mammary implant, the same for long stents is still debated.
We reported the long-term data of 531 consecutive patients who underwent Percutaneous Coronary Intervention (PCI) with long stents in two highly specialized centres. The main inclusion criteria were the implantation of stents longer than 30 mm on the LAD and a minimum follow-up (FU) of five years. The primary endpoint was mortality, and the secondary endpoints were any myocardial infarction (MI), target vessel and lesion revascularization (TVR and TLR, respectively), and stent thrombosis (ST) observed as definite, probable, or possible.
In this selected population with characteristics of complex PCI (99.1%), the long-term follow-up (mean 92.18 ± 35.5 months) estimates of all-cause death, cardiovascular death, and any myocardial infarction were 18.3%, 10.5%, and 9.3%, respectively. Both all-cause and cardiovascular deaths are significantly associated with three-vessel disease (HR 6.8; confidence of interval (CI) 95% 3.844-11.934;
< 0.001, and HR 4.7; CI 95% 2.265-9.835;
< 0.001, respectively). Target lesion (TLR) and target vessel revascularization (TVR) are associated with the presence of three-lesion disease on the LAD (HR 3.4; CI 95% 1.984-5.781;
< 0.001; HR 3.9 CI 95% 2.323-6.442;
< 0.001, respectively). Re-PCI for any cause occurred in 31.5% of patients and shows an increased risk for three-lesion stenting (HR 4.3; CI 95% 2.873-6.376;
< 0.001) and the treatment of bifurcation with two stents (HR 1.6; 95% CI 1.051-2.414;
= 0.028). Stent thrombosis rate at the 5-year FU was 4.4% (1.3% definite; 0.9% probable; 2.1% possible), including a 1.7% rate of very-late thrombosis. The stent length superior to 40 mm was not associated with poor outcomes (all-cause death
= 0.349; cardiovascular death
= 0.855; MI
= 0.691; re-PCI
= 0.234; TLR
= 0.805; TVR
= 0.087; ST
= 0.189).
At an FU of longer than five years, patients treated with stents longer than 30 mm in their LAD showed acceptable procedural results but poor outcomes.
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