bluuebunny/crossref_metadata_2025 huggingface dataset:
Long-term outcome of diabetic patients after unprotected left main percutaneous coronary interventions
Authors: Nemeth O , Piroth Z
Published: October 2024

Background

Diabetes mellitus (DM) represents an elevated risk in terms of percutaneous coronary intervention (PCI), especially in patients with significant left main (LM) disease.

Purpose

Our aims were to investigate the 60-month mortality and event-free survival of consecutive patients with DM undergoing unprotected LM PCI at our centre and sought to determine the independent predictors of event-free survival.

Methods

We included all patients undergoing unprotected LM PCI at our tertiary care centre between 1 January 2007 and 31 December 2014. The primary endpoint was the composite of all-cause mortality, myocardial infarction, and target lesion revascularization at 60 months. Survival curves were constructed using the Kaplan-Meier non-parametric estimator. ROC analysis was used to investigate the predictive power of conventional risk scores (SYNTAX, SYNTAX II, EuroSCORE II, additive and logistic EuroSCORE, ACEF, GRACE 2). Independent predictors were determined by univariate and multivariate analysis.

Results

A total of 513 patients (mean age 68 ± 12 years, 64% male) underwent unprotected LM PCI during this period, among these 310 (60%) were non-diabetic (non-DM) and 203 (40%) were diabetic (DM). In terms of indication, 157 (31%) elective and 356 (69%) acute LM PCI were performed. There was no significant difference between the non-DM and DM groups in terms of acute indication (218 (70%) vs. 138 (68%), p=0.574). Within the DM group, 135 (67%) were treated with oral antidiabetics (OAD) and 68 (33%) were treated with insulin (IDM). The mean survival (34.6 vs. 39.7 vs. 43.1 months, p=0.003) and event-free survival (29.3 vs. 34.7 vs. 39.3 months, p=0.001) were significantly lower in the IDM and OAD groups compared to non-DM, respectively. Of the risk scores, the SYNTAX score was the most predictive in diabetic patients (AUC=0.767). Based on the SYNTAX score, diabetic patients with a low SYNTAX score (<23) had less events (59% vs. 66%, p=0.043) than those having a moderate/high SYNTAX score (≥23). LVEF (HR 0.976; 95% CI, 0.965-0.987, p<0.001), right coronary artery occlusion (HR 2.031; 95% CI, 1.346-3.064, p=0.001), acute coronary syndrome (HR 1.861; 95% CI, 1.252-2.767, p=0.002), use of FFR (HR 0.481; 95% CI, 0.265-0.871, p=0.016), true bifurcation lesion (HR 1.559; 95% CI, 1.068-2.277, p=0.021) and newer DES generation (HR 0.706; 95% CI, 0.568-0.877, p=0.002) were predictors of event-free survival in diabetics by univariate analysis. Glomerular filtration rate (HR 0.982; 95% CI, 0.973-0.991, p<0.001) emerged as an independent predictor according to multivariate analysis.

Conclusion

Consecutive diabetic patients with significant unprotected LM stenosis have poor long-term outcome after LM PCI. Anatomical complexity of the lesions is a significant predictor of event-free survival. Careful intervention planning and the use of appropriate tools can improve the outcome in this high-risk population.
Clinical impact of performing esophagogastroduodenoscopy before percutaneous coronary intervention in patients with acute coronary syndrome patients and anaemia
Authors: Lai A , Tam T K , Yan B , Tan G M
Published: October 2024

Background

In patients presenting with acute coronary syndrome (ACS) and anaemia, esophagogastroduodenoscopy (EGD) is commonly performed to exclude an upper gastrointestinal source of bleeding prior to perform percutaneous coronary intervention (PCI). However, the diagnostic yield and clinical impact of EGD in this setting is uncertain.

Purpose

We aimed to investigate the clinical yield and impacts of EGD on the 1-year clinical outcomes in ACS patients with concomitant anaemia who underwent PCI.

Methods

We retrospectively analysed electronic health records of ACS patients who underwent PCI at 16 public hospitals from 2014-2018. Patients with anaemia (defined as haemoglobin (Hb) <11dl/L) and EGD before PCI during the same admission were identified. The primary outcomes were bleeding events including clinical GIB (as diagnosed by EGD), need for urgent EGD, need for transfusion, Hb drop of >3 dl/L and Hb <8 dl/L. Secondary outcomes were 12-month 4-point MACE including myocardial infarction (MI), stroke, subsequent PCI or CABG, or cardiovascular-related death. Propensity-score models with inverse probability of treatment weighting (IPTW) against EGD were developed for the comparisons. A weighted Cox Proportional Hazard Model was performed to estimate adjusted hazards ratio (aHR) with corresponding 95% confidence intervals (CI).

Results

Of 13,793 patients, 3625 (25%) had anaemia on admission and 12.8% (n=466/3625) underwent EGD. Most EGD findings were not accountable for overt GIB, with gastritis, gastric polyps and gastric erosion being the 3 most common EGD diagnoses. After IPTW, clinical outcomes of 466 patients with EGD were compared with 3159 patients without EGD. 12-month bleeding event rates were higher among EGD patients compared to non-EGD patients (59.7% vs. 27.6%, p< 0.01; aHR = 3.01, 95% CI 2.58-3.52, p<0.005). Overall, 12-month GIB rate was low 1.0%, with 4.1% in EGD patients and 0.57% in non-EGD patients (aHR=7.99, 95% CI 4.13-15.45, p<0.005). The 12-month cumulative MACE rate overall was 39.9% and no significant difference between EGD and non-EGD patients.

Conclusion

Our real-world data demonstrated that the presence of anaemia is common among ACS patients. The yield of EGD in identifying sources of upper GI bleeding was low and there was no difference in 12-month clinical outcome among EGD patients. Although EGD was associated with higher rates of 12-month bleeding events, the cause was unclear with very low incidence of upper GI bleeding events. Therefore, the benefits of routine EGD prior to PCI in ACS patients with anaemic is unclear.
Performance and safety of complex percutaneous coronary intervention in centres without on-site cardiac surgery: a multi-centre australian registry study.
Authors: Dayawansa N , Vogrin S , Lefkovits J , Brennan A , Dinh D , Reid C M , Stub D , Van Gaal W J , Shaw J A , Walton A , Oqueli E , Kaye D M , Cox N , Chan W
Published: October 2024

Background

Performing complex percutaneous coronary intervention (PCI) procedures in hospitals with no on-site cardiac surgery (NOSCS) remains controversial due to a lack of contemporary data and guideline support.

Methods

Victorian Cardiac Outcomes Registry data was analysed including all PCI cases in the state of Victoria, Australia, from 2014 to 2022. Patients were stratified by PCI at sites with on-site cardiac surgery (OSCS) or NOSCS. Complex PCI was defined as PCI to unprotected left main, bifurcation lesions, rotational atherectomy or intravascular lithotripsy use, severe left ventricular systolic dysfunction, chronic total occlusion, or vein graft PCI. The primary outcome was composite MACCE comprising all-cause mortality, stroke, non-fatal MI, emergency CABG, unplanned revascularisation, definite stent thrombosis and major bleeding (BARC 3 & 5) at 30-days. Risk ratio for average treatment effect in the NOSCS cohort was estimated using inverse probability treatment weighting.

Results

94,268 total PCI procedures (32.6% NOSCS) were analysed, including 12,459 complex PCI cases (28.7% NOSCS). Patients from NOSCS were younger (65.0 vs 67.4, p<0.001), less likely to have had previous PCI (29.5% vs 34.5%, p<0.001) or CABG (4.6% vs 8.0% p<0.001) and presented more frequently with acute coronary syndromes (NSTEMI [32.0% vs 28.0%, p<0.001; STEMI [23.3% vs 15.2%], p<0.001).

A propensity weighted sample of 30,850 OSCS patients and 30,692 NOSCS patients demonstrated no difference in adjusted 30-day MACCE (risk ratio 0.93, 95% CI 0.87-1.01, p=0.051) for all PCI procedures. In a propensity-weighted subgroup of 3,638 OSCS and 3,576 NOSCS patients who underwent complex PCI, there was also no difference in adjusted 30-day MACCE (risk ratio 0.97, 95%CI 0.86-1.09, p=0.60). Unadjusted rates of CABG at 30-days were very low (0.1 vs 0.1%, p=1.00).

Conclusion

Patients undergoing PCI and complex PCI at NOSCS centres had comparable 30-day outcomes to those treated at OSCS centres. Newer percutaneous therapies such as intravascular lithotripsy and percutaneous left ventricular assist devices may further improve safety and efficacy of high-risk PCI in NOSCS centres as operator experience increases. Increasing PCI and complex PCI capabilities at NOSCS is likely to increase equitable treatment access for more patients.
A simplified bedside model for acute kidney injury prediction after percutaneous coronary intervention
Authors: Balanescu D V , Fatema K , Lewis B R , Best P J , Gulati R , Herrmann J
Published: October 2024

Background

Concern for acute kidney injury (AKI) after percutaneous coronary intervention (PCI) is a major determinant in the decision to pursue cardiac catheterization if otherwise indicated. A bedside AKI risk prediction model derived from the National Cardiovascular Data Registry (NCDR), most recently updated in 2023, employs relatively complex parameters for AKI prediction.

Purpose

To test the efficacy of a simplified pre-procedural 5-variable bedside score for post-PCI AKI prediction based on the NCDR model.

Methods

We analyzed our institution’s NCDR-reported catheterization laboratory registry between Q2 2022 and Q1 2023. Inclusion criteria, variable selection, and definitions were based on the NCDR model. A bedside prediction model was validated, including 5 pre-procedural variables: anemia (hemoglobin <10 mg/dl), history of heart failure, stage 4 or 5 chronic kidney disease (glomerular filtration rate <30 mg/dl), cardiac arrest, and shock status.

Results

We included 840 patients, of which 593 (70.6%) were men. Mean age was 69 (±12.5). Most procedures were performed on an urgent basis (444, 52.9%). AKI developed in 107 (12.7%) patients. Compared to the non-AKI group, patients who developed AKI were older (age 74±11.5 vs 68.3 ±12.5), and more frequently had anemia (23.6% vs 7.4%), diabetes (51.4% vs 35.2%), severe frailty (45.8% vs 23.7%), heart failure (62.6% vs 29.7%), cardiac arrest (13.1% vs 2.9%), CKD (30.8% vs 6%), shock (12.1% vs 1.5%), and mechanical circulatory support (7.5% vs 2.9%), p<0.001. Utilizing integer scores, the simplified bedside model employing 5 pre-procedural variables demonstrated discrimination similar to the bedside NCDR model, with a C-statistic of 0.77 (0.60-0.88) and excellent calibration (intercept of 0.31 and slope of 1.03) (Figure), indicating the robust performance of the model (compared to bedside NCDR model with a C-statistic 0.793, intercept of -0.197, and slope of 0.957).

Conclusion

A simplified NCDR-based bedside score using 5 pre-procedural variables is an effective tool for predicting AKI as a complication of PCI, with comparable performance to the 2023 updated bedside NCDR AKI risk model.
Incidence and predictors of radial artery occlusion following transradial coronary procedures
Authors: Lounes M S , Allal K , Meftah A , Fedali Y , Ait Aider M , Ammari B , Allali A , Benkhedda S
Published: October 2024

Background

Transradial access for percutaneous coronary procedures has grown in popularity because of its advantages over the femoral approach. However, the benefit is overshadowed by an increased rate of radial artery occlusion (RAO). We aim to assess incidence and predictors of RAO after transradial catheterization. The anatomic variations of the radial artery (RA) were also studied.

Methods

This prospective study enrolled 427 patients who underwent coronary angiography or angioplasty via transradial access. An ultrasound evaluation of forearm arteries was performed. In case of RAO, another ultrasound check-up was performed after 1 month and 3 months of the procedure.

Results

Our study population includes 288 patients (32.6% female). The mean age was 61.9 ± 11.1 years. RAO occured in 48 patients (11.24%), among whom spontaneous recanalization was observed within 3 months in 15 patients (32.6%). On multivariate analysis, a younger age (OR 0.642 [CI 95%: 0.480 – 0.858], P = 0.031), low periprocedural systolic blood pressure, (OR 0.598 [CI 95%: 0.415 – 0.862], P = 0.007), a small radial diameter (OR 0.371 [CI 95%: 0.323 – 0.618], P = 0.031), insufficient anticoagulation (OR 0.287 [CI 95%: 0.163 – 0.505], P < 0.001), occlusive hemostasis (OR 0.128 [CI 95%: 0.047 – 0.353], P < 0.001), and a long duration of hemostasis emerged as independent predictors of radial occlusion.

The overall incidence of radial artery anatomic variations was 14,8% (n=63). Among these patients, 40 (63.5%) had a high radial origin, 18 (28.6%) had extreme radial artery tortuosity, and 5 (7.9%) had a full radioulnar loop.

Conclusion

The incidence and prevalence of radial artery occlusion is expected to increase. Insufficient heparinization and occlusive hemostasis are the main modifiable predictors. The preventive strategy should focus primarily on these 2 predictive factors.
Radial versus femoral access for rotational atherectomy angioplasty
Authors: Carvalho M , Cabral M , Goncalves C , Vazao A , Martins A , Guardado J , Morais J
Published: October 2024

Introduction

The transfemoral approach (TFA) is a potentially advantageous acess site for complicated and prolonged percutaneous coronary angioplasty like rotational atherectomy (RA). Despite this, there is mounting data that suggests the transradial approach (TRA), an alternative to the TFA acess, is linked to reduced rates of mortality and access site complications.

Aim

This study was conducted with the aim of providing a quantitative appraisal of clinical outcomes of TRA for patients undergoing RA procedure.

Methods

In this retrospective study, we analyzed all RA procedures performed from March 2013 to June 2019 at our single center institution. Primary endpoints were procedural success, in-hospital mortality, and major adverse cardiovascular events (MACE) during hospitalization.

Results

Of the 98 patients undergoing RA, the TRA approach was chosen for 79% patients, and the TFA approach for 21% patients. No significant difference in procedural success rates was observed (94% vs. 91%, p=0.19). The use of RA via TRA correlated with a lower contrast volume (p=0.027) and a decreased post-procedure hospital stay (p=0.005). After multivariate adjustment, TRA demonstrated a noteworthy reduction in in-hospital mortality odds (OR: 0.62; 95% CI: 0.44 to 0.87; p = 0.003), major bleeding (OR: 0.48; 95% CI: 0.33 to 0.70; p < 0.001), MACE (OR: 0.68; 95% CI: 0.51 to 0.89; p = 0.015), and 30-day mortality (OR: 0.68; 95% CI: 0.51 to 0.89; p = 0.015).

Conclusions

Even though RA is a complex procedure, employing radial access (TRA) might be associated with favorable outcomes. These include a lower contrast volume, shorter hospital stay, and reduced odds of in-hospital mortality, major bleeding, MACE, and 30-day mortality compared to femoral access (TFA).
Comparative assessment of extracellular volume metrics in predicting adverse outcomes in patients with transthyretin amyloid cardiomyopathy
Authors: Kronberger C , Willixhofer R , Ermolaev N , Poledniczek M , Duca F , Rettl R , Binder-Rodriguez C , Mascherbauer K , Dona C , Koschutnik M , Nitsche C , Badr Eslam R , Bergler-Klein J , Kastner J , Kammerlander A
Published: October 2024

Introduction

The indexed total extracellular volume of the myocardium (iECV) has recently been proposed to be superior in predicting adverse outcome in severe aortic stenosis as compared to conventional extracellular volume (ECV). So far, no study has assessed the comparative predictive performance of both measures in transthyretin amyloid cardiomyopathy (ATTR-CM).

Aim

We aimed to assess and compare the predictive performance of conventional ECV against iECV in determining adverse outcomes in patients with ATTR-CM.

Methods

From 2012 to 2023, patients with ATTR-CM undergoing contrast cardiac magnetic resonance (CMR) imaging prior to any specific treatment were enrolled. Both, conventional ECV and iECV were quantified on CMR alongside left ventricular volumetrics and late gadolinium enhancement. Adverse outcome was defined as a composite endpoint of hospitalization for heart failure and/or death.

Results

Analysis of 178 patients with ATTR-CM (82% males, mean age 77±8 years) revealed a mean conventional ECV of 47±13% and a mean iECV of 46±21 mL/m2, with a median follow-up of 2.5 years (IQR: 1.00-4.08 years). Conventional ECV was significantly associated with the composite endpoint (HR=1.03, 95%CI=1.01–1.05, p=0.006), outperforming iECV (HR=1.01, 95%CI=1.00–1.02, p=0.010). On multivariate analysis, adjusted for age, sex and left ventricular function, conventional ECV remained associated with the composite endpoint (p=0.002), while iECV demonstrated a slightly less significant association (p=0.003). Kaplan-Meier analysis, stratified by conventional ECV tertiles, revealed that patients in the highest tertile (ECV ≥53%) demonstrated the highest event rate (p = 0.043 by log rank test, see Figure 1A), in contrast to iECV (p=NS, Figure 1B).

Conclusions

High conventional ECV, among CMR fibrosis markers, is linked to heart failure hospitalizations and death in ATTR-CM, demonstrating superior prognostic value compared to iECV. Conventional ECV measurements may offer enhanced risk stratification for patients with ATTR-CM.
Side branch interventions late after MFM implantation
Authors: Polomski P , Petrov I , Stankov Z
Published: October 2024

Background

MFM prostheses were developed for the endovascular treatment of aortic and great vessel aneurysms. Implanted between two healthy segments of arterial vessel, they centralize blood flow and trough Bernoulli's principle. Thereby hemodynamic stress into the aneurismal sac is reduced. Meantime, the porosity along entire prosthesis length preserves all side branches (SB) patent. Results from real clinical practice confirm the high success rate (nearly 100%) of MFM prostheses regarding side branch preservation at one-year follow-up [1,2]. However, late after MFM implantation SB intervention may be required (due to atherosclerosis or others). The access to SB covered by MFM is challenging due to: impossible ostial engagement of the guiding catheter, distance between target vessel ostium and prosthesis, the necessary for all devices used to cross MFM mesh.

Materials and methods

For the period 2016-2020 we implanted a specific type of MFM prosthesis in order to treat aneurysm of the abdominal aorta in 34 patients. A total of 129 side branches was covered. Within a mean follow-up period of 5 years, 129 side branches were preserved and 7 affected by stenosis or occlusion (two of them asymptomatic). Intervention on the branch covered by the MFM prosthesis was necessary in 5 patients (two males, two females; mean age 68 years). One patient had endovascular celiac trunk stenosis, one patient had both celiac trunk and superior mesenteric artery stenoses, one patient had superior mesenteric artery stenosis, and one patient had left renal artery stenosis. All lesions were intervened through radial or brachial approach. Guiding 6F Judkins right catheter was navigated close to the target branch ostium and the MFM mesh was crossed with .014¨ coronary wire. When guidewire was placed into target vessel small low-profile, coronary balloon is advanced across the mesh of the multilayer stent. Anchor balloon technique was used in order for guiding catheter to cross the mesh gradually. Once the guiding catheter is engaged, the lesion was treated with balloon pre-dilation and implantation of a low-profile, high radial force stent.

Results

All 4 patients and 5 affected vessels were successfully endovascularly intervened. We did not observe any procedure complications. Immediate resolution of clinical symptoms was achieved. At 1 year follow-up with CT scan all treated branch arteries were patent.

Conclusions

In patients with previously implanted multilayer stents, the mesh can be crossed safely with readily available coronary devices together with the balloon anchor technique. As such, endovascular treatment of stent-covered visceral and renal arteries is possible without open surgery.Catheter stabilizationSMA successfully treated
Insights into retroperitoneal hemorrhage management: result from a tertiary cardiovascular center prospective cohort
Authors: Ghaffari Jolfayi A , Rezaeian A , Elahifar A , Bahadori M J , Sheibani M , Bashghareh P , Mehdizadeh K , Shahinfar H , Mohebbi B , Alemzadeh-Ansari M J , Khalilipur E , Farmani D , Pouraliakbar H R , Firouzi A , Sadeghipour P
Published: October 2024

Background

Although rare, retroperitoneal hemorrhage (RPH) during percutaneous cardiovascular interventions is still potentially fatal, poses a critical challenge, often necessitating swift and precise management strategies. Its management is still controversial, and available recommendations are mostly based on expert opinion, and not updated according to recent advancement in the field of interventional cardiology.

Purpose

To present the rate, clinical characteristics and modern management of patients complicating with RPH in a large tertiary cardiovascular center

Method

We collected prospectively all consecutive RPH events encountered in the catheterization laboratories of a large tertiary cardiovascular center during 2014-2022. Procedural data from all the diagnostic and therapeutic procedures performed in the same time period, were retrieved from electronic hospital records (EHR).

Results

Among 89,361 percutaneous cardiovascular diagnostic or therapeutic procedures performed on 69596 patients, 52 (0.058%) episodes (patients) of RPH, (mean age of 56.37±16.84 years with female sex predominance of 36 (69.23%)). Also 2 (3.8%) patients died due to RPH. Non-contrast abdominopelvic CT scan was the most common primary imaging modality for RPH diagnosis, followed by DSA angiography. Of note, 13 (25 %) of patients returned directly to catheterization laboratory for RPH evaluation. Thirty-one (59.6%) patients were ultimately treated conservatively and no patient treated surgically. Structural and peripheral procedures were more prone to RPH. Still a median time of 7.5 hours was needed for RPH diagnosis. Contralateral access was the dominant approach for treating RPH, and although balloon tamponade was used in 11 (52.4 %) patients, 17 (80.9 %) patients were treated ultimately with covered stents; deep femoral and internal iliac arteries were covered in 1 (5.9%) and 2 (11.8%) patients, respectively. Patients treated endovascularly for RPH had higher acute kidney injury and longer hospital stays. Further comprehensive analysis regarding the potential risk factors of RPH are pending.

Conclusion

Our preliminary analysis from a large tertiary cardiovascular center database, showed RPH is still rare, with acceptable mortality rate of 3.83%. Our data showed the necessity of more precise probability assessment tools to improve the diagnostic time.
How different types of cardiomyopathy with hypertrophic phenotype affect left atrial remodeling and function
Authors: De Raffele M , Teis A , Weerts J , Conte C , Junca G , Ferrer Sistach E , Cediel G , Bertini M , Bayes-Genis A , Delgado V
Published: October 2024

Background

Left atrial (LA) dysfunction is a common feature in hypertrophic cardiomyopathies. How the underlying etiology and pathophysiology of different cardiomyopathies affects LA remodeling and function remains unexplored.

Purpose

The aim of our study is to investigate the influence of various cardiomyopathies with hypertrophic phenotype on LA remodeling and function.

Methods

Patients with left ventricular (LV) hypertrophic phenotype who underwent cardiac magnetic resonance (CMR) were included. A group of patients with a normal CMR was included as a control group. CMR acquisitions used for clinical indication of heart failure diagnosis and etiology were retrospectively analyzed to obtain LA reservoir, conduit, and booster strain, left atrioventricular coupling index (LACI) and LA sphericity. Differences between groups were assessed. To investigate the independent clinical associates of LA reservoir, conduit and booster strain, multivariable linear regression analyses were performed.

Results

A total of 375 individuals were analyzed including 321 patients diagnosed with LV hypertrophy and 54 patients with a normal CMR. Of the 321 patients with LV hypertrophy, 148 were diagnosed with hypertrophic cardiomyopathy (HCM), 35 with cardiac amyloidosis (CA), 41 with hypertensive cardiomyopathy (HTN) and 97 with severe asymptomatic aortic stenosis (AS). CMR LA characteristic and strain analysis results are summarized in Figure 1. The indexed LA end-systolic volume (iLAVmax), indexed LA end-diastolic volume (iLAVmin) and LA sphericity were larger in patients with CA when compared to other groups (all p<0.05). CA patients displayed more left atrioventricular uncoupling (lower LACI) when compared to individuals with HCM, HTN, AS, and controls (all p<0.001), while no significant differences were observed across other groups. CA patients exhibited lower LA reservoir and booster strains compared to the other groups (all p<0.05), whereas no significant differences were observed across other hypertrophic phenotype diseases. Age, iLAVMax and LACI were independently associated with all the three LA strain components (Figure 2, all p<0.05).

Conclusions

LA remodeling and function are affected differently across the various etiologies of LV hypertrophy. CA patients exhibit more pronounced atrial involvement, whereas those with HCM, asymptomatic AS, and HTN display similar patterns of atrial dysfunction and remodeling. Additionally, CMR-derived iLAVmax and LACI are independently correlated with LA function.
Intravascular lithotripsy in the management of underexpanded stents
Authors: Sagris M , Soulaidopoulos S S , Vlachakis P V , Papanikolaou A P , Ktenopoulos N K , Tousoulis D T , Toutouzas K T , Tsioufis K T
Published: October 2024

Introduction

Stent underexpansion significantly heightens the risk of major adverse cardiac events (MACE), and available treatment options for this condition remain limited. Intravascular Lithotripsy (IVL) technology disrupts superficial and deep calcium by using localized pulsative sonic pressure waves, emerges as a promising tool for underexpanded stents.

Methods

Following PRISMA guidelines, we systematically explored PubMed, SCOPUS, and Cochrane databases up to September 3, 2023, for studies evaluating IVL's safety and efficacy in treating underexpanded stents. We gathered angiographic (QCA) and intracoronary imaging (OCT or IVUS) data, examining the stent's minimal diameter stenosis (MDS), minimal lumen diameter (MLD), minimal stent area (MSA), and minimal lumen area (MLA) pre- and post-IVL application. Procedural success constituted the efficacy endpoint, while peri-procedural complications, in-hospital-30-days and long-term mortality, and MACE were safety endpoints

Results

This meta-analysis comprised 21 studies including 669 patients and 673 treated lesions in underexpanded stent. The mean age was 73.2 ± 2.1 years, with an overall IVL procedural success rate of 93% [(95% Confidence Interval (CI): 88%-96%, I2=29%), while the in-hospital-30-days and long-term mortality incidence were 1% (95% CI: 1%-3%, I2=0%) and 3% (95% CI: 2%-6%, I2=0), respectively. The 30-days target lesion revascularization (TLR) was approximately 6% (95% CI: 3%-12%, I2=50%). There was a significant increase in the MDS [Standardized Mean Difference (SMD): +50.52%, 95% CI: 39.4-61.6, I2=94%)] and in MSA (SMD: +3.52, 95% CI: 2.47 to -4.58, I2=83%) immediately after IVL application. It was observed a significant increase in MLD (SMD: +1.54, 95% CI: 1.09 to 1.98, I2=95%) and in the MLA (SMD: +3.64, 95% CI: 2.62-4.66, I2=5%). Major procedural and device related complications were 3% (95% CI: 1%-6%, I2=0%) and 1% (95% CI: 0%-2%, I2=85%) respectively. Notably low rates were observed for stent thrombosis (0%, 95% CI: 0%-2%, I2=0%), dissections (1%, 95% CI: 1%-4%, I2=0%), perforations (1%, 95% CI: 1%-3%, I2=0%) and no-reflow (0%, 95% CI: 0%-1%, I2=0%).

Conclusions

IVL demonstrates promise as a safe and effective strategy for underexpanded stent treatment, characterized by low rates of periprocedural complications. Future prospective studies are now warranted to compare IVL to other lesion preparation strategies.30day All-Cause Mortality after IVL use.Minimum Stent Diameter after IVL use.
TAVI-related vascular access complications: are Viabahn stents a good option?
Authors: Ferreira A , Teixeira R , Rodrigues I , Grazina A , Teixeira B , Castelo A , Mendonca T , Morais L , Ramos R , Fiarresga A , Ferreira R C , Cacela D
Published: October 2024

Background

Vascular access complications (VACs) remain one of the biggest challenges when performing transcatheter aortic valve implantation (TAVI). Historically, concerns regarding stent placement in flexing points have been a deterrent to the percutaneous treatment of VACs, due to the potential development of claudication over time. The Viabahn stent, being a covered stent that offers flexibility and conformability, may be well-suited for deployment in these anatomies.

Purpose

This study aimed to evaluate the safety and efficacy of the iliofemoral Viabahn stenting for treating TAVI-related VACs.

Methods

Retrospective analysis of patients submitted to Viabahn stenting in the iliofemoral sector for TAVI-related VACs in a single tertiary centre between January 2017 and October 2023. Baseline characteristics, procedure data and complications were noted according to the Valve Academic Research Consortium-2.

Results

A total of 722 patients were submitted to transfemoral TAVI during the study period. Of these, 25 (3.6%) underwent Viabahn stenting to treat TAVI-related VACs and were included in this study. Patient mean age was 82.1±6.13 years, 61.2% were male. At the baseline, patients had a mean Euroscore II of 2.73±1.91. A unilateral access approach was used in 40% of cases. The median size of the main access sheath was 14 Fr [IQ 14-16], and the closure devices deployed were Manta® in 72%, and Perclose® in 28%. The Viabahn stent treated different types of VACS, including vessel rupture in 56%, acute dissection in 28% (12% with no antegrade flow), and failed sealing in 16%. The complicated artery was the common femoral in 82%, and the external iliac in 18%. Percutaneous treatment with Viabahn stenting was successful in 92% of cases. In two cases (8%), one of acute occlusion and one of vessel rupture, vascular surgery was required. During the hospital stay, there were no further vascular or hemorrhagic complications. After a mean follow-up of 15 months, 20% of patients were evaluated by Doppler which showed no signs of restenosis or stent complications. Only one patient experienced lower limb claudication at 1 year due to stent restenosis detected in the CT scan, which was managed with medical therapy. There were no other adverse vascular events during follow-up.

Conclusion

Our study suggests that Viabahn stenting emerges as a valuable therapeutic option, ensuring long-term safety and efficacy, in the complex realm of TAVI-related vascular complications.
Prognostic impact of left ventricular ejection fraction improvement after transcatheter aortic valve replacement
Authors: Reichl J , Stolte T , Pfenniger A , Boeddinghaus J , Leibundgut G , Kaiser C , Nestelberger T
Published: October 2024

Introduction

Transcatheter aortic valve replacement (TAVR) has become an efficient and save alternative to surgical aortic valve replacement (SAVR). While severe aortic stenosis as well as severe aortic regurgitation (AR) is known to negatively impact left ventricular ejection fraction (LVEF), prior studies have shown that TAVR can lead to improvement in LVEF. So far, little is known about the prognostic implication of LVEF-improvement as a sole predictor of outcomes.

Purpose

The aim of this study was to assess the prognostic significance of early LVEF improvement in patients undergoing TAVR.

Materials and Methods

Patients undergoing TAVR in a large tertiary university hospital have been consecutively included in a large prospective registry. Transthoracic echocardiography (TTE) was performed at baseline, after TAVR before discharge, at 1 month and annually thereafter. Significant LVEF improvement was defined as >10% relative increase of LVEF at 30 days compared to baseline LVEF. Primary outcome was all-cause mortality at 5 years. Secondary outcome were major adverse cardiovascular events (MACE), including death, non-fatal myocardial infarction, stroke, bleeding and unplanned re-interventions of the aortic valve.

Results

Among 1481 patients undergoing TAVR between September 2011 and June 2023, LVEF at baseline and at 30 days was available in 1013 patients. 665 patients (65.6%) had normal LVEF at baseline, whereas 348 patients (34.4%) had a reduced LVEF. Of these, 137 patients (13.5%) showed significant improvement of LVEF ≥10%) after 30 days, while 266 patients (26.3%) showed no significant LVEF-improvement (<10%). The combined patients with persevered LVEF at baseline had significantly better outcomes than those with impaired EF (p=<0.001). LVEF improvement was not associated with mortality at 5 years (p= 0.51), however with lower MACE rate at 5 years (p=0,024).

Conclusion

Normal LVEF before TAVR is an independent predictor for improved outcomes. In addition, early improvement of LVEF is associated with beneficial outcomes in patients undergoing TAVR.Course of LVEF after TAVROutcomes after TAVR
Predisposing and precipitating factors of post-operative delirium after transfemoral TAVI
Authors: Steinhaus K , Neuschaefer S , Beuthner B E , Waeschle R , Toischer K , Hasenfuss G , Puls M
Published: October 2024

Background

Transcatheter aortic valve implantation (TAVI) represents the treatment of choice for aortic stenosis (AS) patients at higher age (> 75y) or with relevant comorbidities. Post-operative delirium (POD) is a frequent complication which has been associated with worse outcome. Thus, preventive options are highly needed. The aim of our single-center study was to investigate predisposing and precipitating factors of POD after transfemoral TAVI, with a focus on the influence of anaesthesia.

Methods

Risk factors for POD after TAVI were analysed in 2 merged cohorts of 480 study patients (43% women; mean age 80 years), enrolled in 2017-2022 (n=375, TAVI in 95% in general anaesthesia) and in 2022-2024 (n=105, TAVI in 91% in local anaesthesia). Incidence of POD was evaluated retrospectively by nursing documentation, medical records, and DRG coding. The association of demographics, comorbidities, echo parameters, procedural parameters, anaesthesia, and peri-procedural complications with POD incidence was investigated.

Results

In total, 29 patients (6%) developed POD, with a tendency towards a lower incidence in the later cohort (6.7% vs. 3.8%; p=0.28). Regarding baseline characteristics, patients experiencing POD were more likely to be male (p=0.03), frail (Katz Index <6, p=0.049), and to suffer from low-gradient AS (p=0.005 for paradoxical, p=0.02 for classical low-flow, low-gradient AS; see also fig. 1A). Total procedure time was significantly longer in patients with POD (median, 86 vs. 62 min, p=0.004; fig 1B), and a tendency towards a more frequent implantation of other than ballon-expandable valves could be observed (p=0.07). Concerning the role of anaesthesia, POD did not differ significantly after general anaesthesia (n=24/360, 6.7%), conscious sedation (n=1/19, 5.3%), and local anaesthesia (n=4/100, 4%) (p=0.38). Regarding procedural complications, POD patients were characterized by lower minimum hemoglobin post-TAVI (9.3 vs. 10.1 g/dl, p=0.05; fig. 1C) and higher incidences of intra-procedural resuscitation (11% vs. 2%, p=0.03), cerebrovascular accidents (10% vs. 2%, p=0.04) and new permanent pacemaker implantations (25% vs. 10%, p=0.02).

In POD patients, long-term survival after TAVI was significantly reduced, with a median survival of only 2 years (Kaplan-Meier curves in fig. 2; p=0.001).

Conclusions

POD after TAVI stays common and unfavourable. The role of anaesthesia seems less pronounced than expected. Total procedure time and relevant anaemia after TAVI emerged as most important modifiable risk factors. Future research is warranted, since strategies to reduce precipitating factors for POD may have a significant impact on post-TAVI outcomes.Selected risk factors for PODConsequence of POD: Reduced Survival
Transcatheter aortic valve implantation in failed bioprosthetic or native valves: a systematic review and meta analysis
Authors: Kaddoura R , Dakhil Z , Ahmed A , Al-Hijji M
Published: October 2024

Background and purpose

Currently, there is no comparative assessment of pooled clinical outcomes between valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) for either failed transcatheter or surgical bioprosthetic aortic valves (TAV or SAV) and native aortic valve TAVI (NV-TAVI) for aortic stenosis. Thus, this systematic review investigated the clinical outcomes of ViV-TAVI compared with NV-TAVI.

Methods

A meta-analysis was conducted according to Cochrane Handbook and the PRISMA statement. A systematic literature search was performed, using EMBASE and MEDLINE from inspection to December 25, 2023, to explore the comparative outcomes between ViV-TAVI and NV-TAVI. RStudio software was used to calculate pooled odds ratio (OR) with 95% confidence intervals (CI). Random-effects model was used to allow a more conservative assessment.

Results

Eighteen cohort studies (n=65,350) met eligibility criteria. Studies were categorized into 2 groups according to initially implanted bioprosthetic valve: TAV-in-TAV (5 studies, n=14490) and TAV-in-SAV implantation (13 studies, n=50860). Each ViV-TAVI group was compared with NV-TAVI.

TAV-in-TAV implantation: There were no significant differences in all-cause mortality or stroke rates at ≥ 12 months between groups. The follow-up period was 12 months in all studies except in one (i.e., 24 months). Sensitivity analyses, by removing that study, did not show difference for both outcomes [(OR=1.25, 95%CI: 0.72-2.18) and (OR=1.14, 95%CI: 0.59-2.20), respectively].

TAV-in-TAV implantation was associated with higher rates of permanent pacemaker (PPM) insertion (OR=1.78, 95%CI: 1.10-2.88) within 30-day of follow-up. PPM insertion rate remained higher by 34% (OR=1.34, 95%CI: 1.02-1.76) even after removing the study that reported PPM insertion during index admission. Early conversion to open heart surgery and coronary occlusion (OR=3.75, 95%CI: 0.99-1417) did not differ between groups.

TAV-in-SAV implantation: TAV-in-SAV implantation did not significantly reduce the risk of all-cause mortality, but stroke risk was reduced by 19% at ≥ 12 months follow-up. Sensitivity analyses by removing the studies with 24 months follow-up yielded comparable results [(OR=0.88, 95%CI: 0.64-1.21) and (OR=0.81, 95%CI: 0.70-0.94), respectively].

TAV-in-SAV implantation was associated with lower rates of PPM insertion compared with NV-TAVI (OR=0.33, 95%CI: 0.17-0.62) within 30-day of follow-up. The risk remained significantly lower by 69% (OR=0.31, 95%CI: 0.10-0.92) upon removing the studies that reported PPM insertion during the index admission. Early conversion to open heart surgery and coronary occlusion (OR=1.88, 95%CI: 0.82-4.32) did not differ between groups.

Conclusion

In comparison with NV-TAVI, TAV-in-TAV implantation was associated with higher PPM insertion rates, whereas, TAV-in-SAV implantation was associated with lower stroke and PPM insertion rates without an impact on mortality.
Long-term outcomes after transcatheter aortic valve implantation: derivation and validation of the long-TAVI prediction model
Authors: Wenzl F A , Savvoulidis P , Wang P , Al-Och T , Yakupoglu H Y , Sukumar S , Baumann F , Davies M , Dalby M , Kabir T , Panoulas V , Mirsadraed S , Kalogeropoulos A P , Luescher T F
Published: October 2024

Background

Identification of high-risk individuals after transcatheter aortic valve implantation (TAVI) is essential to personalized care. Established risk models require a plethora of variables, fail to account for biomarker dynamics and imaging parameters, mostly focus on the short term, and offer limited predictive performance.

Purpose

We aimed to develop an easily applicable prediction model for long-term mortality or heart failure (HF) admission following TAVI.

Methods

Patients undergoing TAVI at a high-volume university centre in the United Kingdom (n = 990) were recruited into a prospective cohort study. Enrolled patients were divided into a development cohort (07/2007 – 12/2016) and a validation cohort (01/2017 – 11/2018) and followed for up to 15.1 (median 5.3, interquartile range [IQR] 2.8 – 7.4) years. Patient characteristics along with pre- and post-procedural imaging results and brain natriuretic peptide (BNP) levels before the procedure and at 3 months were recorded. A clinical risk score for long-term mortality and HF admission (i.e., Long-TAVI risk score) was derived using Cox regression and evaluated using time-dependent area under the receiver operating characteristics curve (AUC).

Results

Age at presentation was 79.8 (standard deviation [SD] 8.9) years, 961 (99.0%) patients had signs of heart failure, left ventricular ejection fraction was 52 (SD 11.2), and pre-TAVI BNP levels were 298.0 (interquartile range [IQR] 159.0 – 571.5) pg/mL. High BNP levels at presentation (higher vs. lower than 400 pg/mL: HR 1.50, 95% CI 1.17 – 1.92, P < 0.001) and dynamic changes in BNP with the first 3 months (low/high vs. low/low: 2.61, 95% CI 1.17 – 5.86, P = 0.020; high/high vs. low/low: 2.41, 95% CI 1.26 – 4.64, P = 0.008) were independent predictors mortality or HF admission. The simple 8-item Long-TAVI score accounts for periprocedural BNP dynamics and shows good discrimination (AUC 0.76, 95% CI 0.72 – 0.79) and calibration in the development cohort performing similarly well in the external validation cohort (AUC 0.70, 95% CI 0.63 – 0.77). Long-TAVI significantly outperformed the logistic EURO score (AUC 0.56, 95% CI 0.52 – 0.59, P < 0.001).

Conclusion

Both pre-TAVI BNP levels and periprocedural BNP trajectories are independently associated with long-term outcomes after TAVI. Accounting for clinical characteristics, imaging parameters, and circulating BNP levels, the newly developed Long-TAVI risk score achieves high performance and provides the first prediction model for long-term mortality or HF admission. Long-TAVI represents a novel tool for personalized risk assessment in patients undergoing TAVI.Correlation at baseline A) and FUP B)Score performance A) and risk groups B)
Leveraging mixed reality in mitraclip implantation: A preliminary case series toward a pilot study
Authors: Hecko J , Jiravsky O , Januska J , Hudec M , Precek D , Gajdusek L , Ranic I , Neuwirth R , Sknouril L
Published: October 2024

Introduction

The advent of mixed reality (MR) technology, particularly when combined with Hololens 2.0 and specialized software for three-dimensional DICOM image visualization, offers a promising avenue for enhancing the precision and spatial awareness in interventional cardiology procedures. This case series aims to preliminarily evaluate the impact of MR on MitraClip implantation processes, setting a foundation for an ensuing comprehensive pilot study.

Methods

We conducted a comparative analysis within a case series of four MitraClip implantations, categorizing them into two groups based on the utilization of MR support. We examined procedural efficiency, radiation metrics (SKIA and DAP), and operator stress indicators, including cortisol levels, heart rate variability, QTc interval, and subjective assessments through NASA TLX, STAI Y, and SSQ questionnaires.

Results

Initial findings from the MR-assisted procedures suggest a notable improvement in procedural efficiency and a reduction in operator stress. Specifically, MR use was associated with shorter procedural times (ranging from 60 to 130 minutes) and lower radiation exposure, with SKIA durations between 15.5 and 40.5 minutes. Moreover, operators in the MR group showed reduced cortisol levels (8.2-9.2 mmol/L), indicating decreased physiological stress. Heart rate variability analysis further supported superior stress management among MR-supported operators.

Subjective evaluations reinforced these physiological findings. NASA TLX scores in the MR group (13-20) markedly contrasted with those in the control group (30-45), signifying a significant reduction in perceived workload. SSQ scores remained minimal, implying good MR tolerability, and STAI Y scores (30-35) were lower than those in the control group (40-50), highlighting reduced anxiety levels during MR-assisted procedures.

Conclusion

This explorative case series lays the groundwork for a forthcoming pilot study, revealing MR's potential to not only streamline MitraClip implantation but also to alleviate operator stress. Both objective and subjective data advocate for expanded research to definitively ascertain MR's benefits in cardiac interventions, promising to refine procedural workflows and enhance patient outcomes. This series acts as a stepping stone towards a larger-scale evaluation that could solidify MR's role in the future of interventional cardiology.Operator's View and Technology PreviewFunction diagram
Right ventricular-pulmonary artery coupling and clinical outcomes after mitral transcatheter edge-to-edge repair: A meta-analysis
Authors: Theofilis P , Mantzouranis E , Vlachakis P K , Sakalidis A , Soulaidopoulos S , Tsioufis K
Published: October 2024

Introduction

Mitral transcatheter edge-to-edge repair (TEER) has gained prominence in the realm of cardiovascular care, as it has been proven to improve patient prognosis and quality of life. While the primary focus of such interventions is the mitral valve itself, understanding the broader impact of right ventricular function and pulmonary artery dynamics is crucial for a comprehensive assessment of clinical efficacy and patient outcomes. A newly recognized index, right ventricular-pulmonary artery (RV-PA) coupling, reflects the RV's ability to handle pulmonary afterload and is associated with adverse outcomes.

Purpose

This meta-analysis consolidates findings from diverse studies to systematically evaluate the association between RV-PA coupling parameters and the success of mitral TEER.

Methods

We conducted a systematic literature search for studies assessing RV-PA coupling indices at baseline in patients undergoing mitral TEER. We recorded the year of publication, method of RV-PA assessment, and the proposed cutoffs. The primary outcome of interest was the combined primary endpoint of included studies at maximal follow-up and the adjusted hazard ratios of RV-PA uncoupling were extracted if they were available. Secondary outcomes included mortality and post-operative mitral regurgitation at follow-up. Pooling of the hazard ratios was conducted according to a random effects model. I2 was chosen as the measure of between-study heterogeneity, with values exceeding 50% being significant.

Results

We identified a total of 316 studies, of which 8 were ultimately selected for data extraction and inclusion in the meta-analysis after screening of title/abstract/full-text. All but one study utilized the Tricuspid Annular Plane Systolic Excursion/Pulmonary artery systolic pressure (TAPSE/PASP) as the method of RV-PA assessment. According to the results of the meta-analysis, the presence of baseline RV-PA uncoupling was associated with a 2.3-fold increased risk of facing the combined primary endpoint at maximal follow-up (Figure, Panel A). All-cause mortality was also approximately 2.2-fold higher in cases of RV-PA uncoupling (Figure, Panel B). Finally, post-operative MR was 1.4-fold higher in cases of RV-PA uncoupling (Figure, Panel C). Significant between-study heterogeneity was detected in all the examined endpoints.

Conclusion: This meta-analysis indicates that RV-PA uncoupling at baseline represents an important prognostic marker in patients undergoing mitral TEER.Figure