Background To determine the prevalence of malnutrition, as assessed through the nutritional risk index (NRI), in patients undergoing transcatheter aortic valve implantation (TAVI) and the prognostic ...impact of this status. In the multivariate analysis (age, logistic EuroScore and renal function, estimated by MDRD4, were included), NRI was independently associated with mortality after TAVI implantation, with HR = 2.4, 95% CI 1.2- 5.1; p = 0.014.
Mitral regurgitation (MR) is a common entity in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), but its influence on outcomes remains controversial. The ...purpose of this meta-analysis was to assess the clinical impact of and changes in significant (moderate-severe) MR in patients undergoing TAVR, overall and according to valve design (self-expandable (SEV) vs balloon-expandable (BEV)).
All national registries and randomised trials were pooled using meta-analytical guidelines to establish the impact of moderate-severe MR on mortality after TAVR. Studies reporting changes in MR after TAVR on an individual level were electronically searched and used for the analysis.
Eight studies including 8015 patients (SEV: 3474 patients; BEV: 4492 patients) were included in the analysis. The overall 30-day and 1-year mortality was increased in patients with significant MR (OR 1.49, 95% CI 1.16 to 1.92; HR 1.32, 95% CI 1.12 to 1.55, respectively), but a significant heterogeneity across studies was observed (p<0.05). The impact of MR on mortality was not different between SEV and BEV in meta-regression analysis for 30-day (p=0.360) and 1-year (p=0.388) mortality. Changes in MR over time were evaluated in nine studies including 1278 patients. Moderate-severe MR (SEV: 326 patients; BEV: 192 patients) improved in 50.5% of the patients at a median follow-up of 180 (30-360) days after TAVR, and the degree of improvement was greater in patients who had received a BEV (66.7% vs 40.8% in the SEV group, p=0.001).
Concomitant moderate-severe MR was associated with increased early and late mortality following TAVR. A significant improvement in MR severity was detected in half of the patients following TAVR, and the degree of improvement was greater in those patients who had received a BEV.
Predictors of antiplatelet therapy discontinuation (ATD) during the first year after drug-eluting stent implantation are poorly known.
This was a prospective study with 3-, 6-, 9-, and 12-month ...follow-up of patients receiving at least 1 drug-eluting stent between January and April 2008 in 29 hospitals. Individual- and hospital-level predictors of ATD were assessed by hierarchical-multinomial regression analysis. ATD could be assessed in 1622 candidates for follow-up (82.5%). A total of 234 patients (14.4%) interrupted at least 1 antiplatelet therapy drug, predominantly clopidogrel (n=182, 11.8%). Bleeding events or invasive procedures led to ATD in 109 patients. This was predicted by renal impairment (odds ratio OR 2.81, 95% confidence interval CI 1.48 to 5.34), prior major hemorrhage (OR 3.77, 95% CI 1.41 to 10.03), and peripheral arterial disease (OR 1.78, 95% CI 1.01 to 3.15). Medical decisions led to ATD in 70 patients; this was predicted by long-term use of anticoagulant therapy (OR 3.88, 95% CI 1.26 to 11.98), undergoing the procedure in a private hospital (OR 13.3, 95% CI 1.69 to 105), and not receiving instructions about medication (OR 2.8, 95% CI 1.23 to 6.36). Thirty-nine patients interrupted ATD on their own initiative, mainly immigrants (OR 3.78, 95% CI 1.2 to 11.98) and consumers of psychotropic drugs (OR 2.58, 95% CI 1.3 to 5.12).
ATD during the first year after drug-eluting stent implantation is based mainly on patient decision or a medical decision not associated with major bleeding events or major surgical procedures. Individual- and hospital-level variables are important to predict ATD.
ABSTRACT Vascular access is an essential part of all interventional procedures whether coronary or structural. Over the last 15 to 20 years, in coronary interventions, traditional femoral access has ...been mostly replaced by the radial approach. Nonetheless, the femoral approach through both artery and vein is still the main approach for structural heart procedures. Over the last few years, femoral access has evolved from a puncture guided by anatomical references to more accurate ultrasound-guided approaches. The relatively recent introduction of interventions such as transcatheter aortic valve replacement has conditioned the use of large introducers and ultimately the need for specific hemostatic systems, above all, percutaneous closure devices. This manuscript reviews different anatomical concepts, puncture techniques, diagnostic assessments, and closure strategies of the main arterial and venous approaches for the diagnosis and treatment of different structural heart procedures.
Objectives
The aim of this analysis was to assess the effect of the coronary revascularization strategy during index admission on clinical outcomes among patients undergoing percutaneous coronary ...intervention (PCI) with multivessel coronary artery disease (MVD).
Background
The value of complete revascularization (CR) over incomplete revascularization (IR) in MVD patients is not fully established.
Methods
Patients with MVD defined as ≥2 major epicardial vessels with ≥50% stenosis were selected from the observational all‐comer e‐Ultimaster registry. Patients were treated with a sirolimus‐eluting thin‐strut coronary stent. Completeness of revascularization was physician assessed at the index procedure or an eventually staged procedure during the index hospitalization. Outcomes measures at 1 year were target lesion failure (TLF) (composite of cardiac death, target vessel‐related myocardial infarction MI, and clinically driven target lesion revascularization TLR), and patient‐oriented composite endpoint (POCE) (all‐cause mortality, MI, or revascularization). The inverse probability of treatment weights (IPTW) methodology was used to perform a matched analysis.
Results
The registry recruited 37,198 patients of whom 15,441 (41.5%) had MVD. CR on hospital discharge was achieved in 7413 (48.0%) patients and IR in 8028 (52.0%) patients. Mean age was 64.6 ± 11.1 versus 65.7 ± 11.0 years (p < 0.01), male gender 77.9% and 77.3% (p = 0.41) and diabetes 31.3% versus 33.4% (p = 0.01) for CR and IR, respectively. Chronic stable angina patients more commonly underwent CR (47.6% vs. 36.8%, p < 0.01). After propensity weighted analysis, 90.5% of CR patients were angina‐free at 1 year compared with 87.5% of IR patients (p < 0.01). TLF (3.3% vs. 4.4%; p < 0.01), POCE (6.8% vs. 10.8%; p < .01), and all‐cause mortality (2.3% vs. 3.1%; p < .01) were all lower in CR patients.
Conclusions
A physician‐directed use of a CR strategy utilizing sirolimus‐eluting thin‐strut stent results in optimized clinical outcomes and less angina in an all‐comer population. Our findings suggest that a CR should be aimed for.
ABSTRACT Introduction and objectives: After the positive pre-clinical and clinical results with Angiolite, a cobalt-chromium sirolimus-eluting stent, we decided to analyze its performance in a ...non-selected, real-world population: the RANGO registry. Methods: We conducted an observational, prospective, multicenter registry of patients with different clinical indications. All consecutive patients treated with percutaneous coronary intervention with, at least, 1 Angiolite stent and who gave their informed consent were included. The registry primary endpoint was the occurrence of target lesion failure (TLF) at 6, 12, and 24 months defined as cardiovascular death, myocardial infarction (MI) related to target vessel, and clinically driven target lesion revascularization. The secondary endpoints were the individual components of the primary endpoint, major adverse cardiovascular events (MACE: all-cause mortality, any MI, or any revascularization), and stent thrombosis. We describe the 2-year clinical results of the RANGO study in the entire population, in those who only received Angiolite stents, and in 2 predefined subgroups: diabetics and patients with small-vessels (≤ 2.5mm). Results: 646 patients (426 of them only received Angiolite stents) with a high-risk profile were recruited: prevalence of previous MI (18.4%), previous coronary revascularization (23.4%), clinical presentation as ST-segment elevation MI (23.1%), and multivessel disease (47.8%). At the 2-year follow-up, the rates of TLF, MACE, and stent thrombosis were 3.4%, 9.6%, and 0.9%, respectively. Similar results were observed among patients treated with Angiolite stents only: TLF, 3.1%; MACE, 8.0%; thrombosis, 0.7%. The rates were not significantly different for the diabetic (TLF, 3.0%; MACE, 14.1%; thrombosis, 1.0%), and small-vessel subgroups (TLF, 4.3%; MACE, 12.1%; thrombosis, 0%). Conclusions: In conclusion, the results of this observational registry on the use of Angiolite in a real-world population, including a high-risk population, corroborate the excellent results observed in previous studies, up to a 2-year follow-up. An extended 5-year follow-up is planned to discard the occurrence of late events.
Coronary artery disease (CAD) is a common co-morbidity in transcatheter aortic valve implantation (TAVI) patients, but the prognostic value of coronary revascularization before TAVI is currently ...unknown. The aim of the present study was to assess the impact of coronary revascularization in patients who underwent TAVI. Patients underwent TAVI from 2008 to 2016 were included in the study. Baseline SYNTAX score and residual SYNTAX score (rSS) after percutaneous coronary intervention were calculated. Based on rSS, patients were classified as complete revascularization (rSS = 0), reasonably incomplete revascularization (rSS >0 and <8), and incomplete revascularization (rSS ≥8). The primary objective was to evaluate the impact of CAD and rSS on major cardiovascular adverse events (MACEs). The secondary objective was to assess the impact of rSS on hospitalization for heart failure. A total of 349 patients (mean age 82.4 ± 5.7 years, 53% women) were included in the study. A total of 187 patients (53.6%) had CAD (mean baseline SYNTAX score 9.2 ± 8.1). Percutaneous coronary intervention was performed in 29.9% of patients, achieving reasonably incomplete revascularization in 45.4%, and incomplete revascularization in 24.5%. The mean follow-up was 35.2 ± 25.3 months. No differences were observed in MACE rate between the CAD and non-CAD groups, or between the different degrees of revascularization. Differences were also not seen in the different levels of revascularization and hospitalization due to heart failure. In patients who underwent TAVI in this study, no association was found between the presence of CAD or the degree of revascularization in a long-term follow-up.
Case Resolution With an 8.5% score in the Society of Thoracic Surgeons risk score for mortality rate, we decided to implant one Evolut PRO transfemoral bioprostheis on an underexpanded bioprosthesis. ...The computed tomography confirmed the lack of coverage of the bioprosthetic stent over the aortic annulus at the level of the Valsava, non-coronary and right coronary sinuses (figure 1), indicative of stent recoil of the stent harboring the bioprosthetic leaflets as the possible mechanism of periprosthetic failure and causing malapposition with the aortic annulus. The perimeter of the aortic annulus was 79.3 mm (minimum diameter: 22 mm; maximum diameter: 25 mm). Figure 1. Lack of coverage of the bioprosthetic stent over the aortic annulus at the level of the Valsava, non-coronary and right coronary sinuses (asterisk). The colored dots are indicative of the location of coronary sinuses. One self-expandable prosthesis was selected with leaflets at the supra-annular level, since it has already been confirmed that in valve-in-valve procedures, the hemodynamic outcome is better compared to the annular implantation that leaves a more significant trans-prosthetic gradient. Also, the position of the prosthesis inside the prosthesis needs to be optimal, which makes the Evolut R the perfect device for this kind of procedure for its...
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