Cardiovascular Revascularization Medicine最新文献

Background: Transaxillary transcatheter aortic valve implantation (TAx-TAVI) is the most used alternative access when severe iliofemoral disease renders transfemoral access infeasible. Compared to surgical transaxillary access, a true percutaneous approach using vascular closure devices (VCD) has advantages but can be challenging. Herein, we describe the impact of the "unilateral, suture-mediated, dry-closure technique" on vascular safety and efficacy in patients undergoing true percutaneous TAx-TAVI.

Methods: A total of 77 patients undergoing percutaneous TAx-TAVI were categorized into a cohort before (C1, n = 40) and after (C2, n = 37) implementation of the suture-based dry-closure technique using an upstream occlusion balloon. In C1, arteriotomy closure mainly consisted of plug-based VCD. The primary (safety) endpoint was occurrence of major or minor access-site related vascular complications in accordance with Valve Academic Research Consortium 3 criteria. Technical success rates (at exit from procedure room) were used to assess procedural efficacy.

Results: The mean age of the study population was 79 ± 7 years and 49 % were male. From C1 to C2, the Society of Thoracic Surgeons Predicted Risk of Mortality reduced numerically (from 4.1 to 3.6 %, p = 0.060). Procedures became more streamlined with use of local anesthesia in 100 % (83 % in C2) and the left axillary artery in 76 % (68 % in C2). The primary (safety) endpoint occurred in 34 % of the patients, but reduced from 45 % in C1 to 16 % in C2 (p = 0.011). Concurrently, there was a reduction in VCD failure (45 vs 14 % [incomplete arteriotomy closure in all 5 cases], p = 0.003), bleeding complications (45 vs 14 %, p = 0.003) and bailout vascular surgery/stenting (40 % vs. 16 %, p = 0.021). Technical success was 80 % in C1 and 87 % in C2 (p = 0.45) and median length of hospital stay reduced from 5 (25th-75th percentile: 2-7) to 3 days (25th-75th percentile: 2-5, p = 0.080).

Conclusions: The unilateral, suture-based dry-closure technique facilitates safe and effective access management in high-risk patients selected for percutaneous TAx-TAVI procedures.

Background: Cardiac amyloidosis (CA) results from the deposition of abnormally folded protein fibrils, leading to restrictive cardiomyopathy, valvular heart disease, and arrhythmias. Up to 15 % of patients with severe aortic stenosis (AS) have concomitant CA (AS-CA). We conducted this systematic review and meta-analysis to compare medical management, transcatheter aortic valve replacement (TAVR), and surgical AVR (SAVR) in AS-CA.

Methods: A comprehensive literature search was conducted for relevant studies from inception through January 20, 2024. Studies exploring outcomes in adult AS patients with and without CA receiving medical therapy, TAVR, or SAVR were included in this analysis.

Results: Fifteen studies including 253,334 patients (AS-CA 6704; AS alone 246,630) were identified. AS-CA patients had significantly higher all-cause mortality (RR = 2.60, 95 % CI 1.48-4.57, P = 0.0009) compared to AS alone. Among patients with AS-CA, TAVR was associated with lower all-cause mortality compared to both medical therapy (RR = 0.50, 95 % CI 0.29-0.89, P = 0.02) and SAVR (RR = 0.41, 95 % CI 0.22-0.78, P = 0.007). AS-CA patients undergoing TAVR were more likely to have paradoxical low-flow, low-gradient AS (RR = 1.56, 95 % CI 1.15-2.12, P = 0.04) at baseline and had a higher risk of post-TAVR acute kidney injury (RR = 1.95, 95 % CI 1.35-2.80, P = 0.0003) compared to patients undergoing TAVR for AS alone. There were similar risks of other post-TAVR complications, including major bleeding, vascular complications, stroke, and new pacemaker implantation between AS-CA and AS alone.

Conclusion: CA is associated with a higher mortality in patients with severe AS. In patients with concomitant AS and CA, TAVR is safe and associated with better survival than medical therapy or SAVR. SOCIAL MEDIA ABSTRACT: #Meta-Analysis: Cardiac amyloidosis is associated with increased mortality in severe AS. #TAVR is safe in amyloidosis & improves survival more than medical therapy or SAVR.

Background: The clinical impact of catheter-directed therapy (CDT) for pulmonary embolism (PE) on right ventricular function and procedural outcomes remains undefined.

Methods: This observational retrospective study included consecutive patients who underwent CDT for PE at San Giovanni Bosco Hospital, Italy, and First Department of Cardiology, Poznan University Clinical Hospital, Poland, between 2021 and 2023. Clinical characteristics, PE risk stratification, pre and post-interventional invasive pulmonary artery pressure (PAP), and Pulmonary Artery Pulsatility Index (PAPi) were collected. The primary endpoint was in-hospital death.

Results: Among 165 patients (53 % male, mean age 63 ± 5.6 years), 65.6 % had multiple PE risk factors. 32.7 % were classified as high-risk (HR) PE, and 67.3 % as intermediate-high risk (IHR). Treatments included transcatheter thrombolysis (17 %), FlowTriever device (10 %), and Indigo Cath8 or Lightning 12 device (73 %), with 7 % requiring ECMO support. In IHR patients, mean PAP significantly decreased from 31.7 ± 7.1 to 23.4 ± 6.1 mmHg (p < 0.01) and PAPi from 3.1 ± 0.1 to 2.9 ± 0.1 (p < 0.01). HR patients had no significant changes in PAP or PAPi overall, but those who survived without events showed significant reductions in PAP (29.1 ± 8.7 to 23.8 ± 5.5, p < 0.02) and increases in PAPi (1.5 ± 0.6 to 2.0 ± 0.5, p < 0.01). In the HR group, a delta PAPi >0.45 predicted positive outcomes with 65.7 % sensitivity and 75 % specificity (AUC 0.83).

Conclusion: CDT for PE significantly impacts PAP and PAPi in acute PE patients. Normalization of PAPi in IHR patients and its increase in HR patients may indicate procedural success and right ventricular recovery. Hemodynamic changes could serve as important markers for procedural efficacy and outcome assessment in these groups.

Background: Sex differences in the prevalence and characteristics of cardiac pathologies, including aortic stenosis (AS), are well-documented. For instance, females with severe AS exhibit lower degrees of calcification but higher levels of fibrosis compared to males. This study aims to evaluate sex-based differences in in-hospital outcomes among patients with AS undergoing balloon aortic valvuloplasty (BAV).

Methods: National Inpatient Sample database was queried from 2015 to 2019, identifying adult patients with severe nonrheumatic AS undergoing BAV using ICD-10 codes. Statistical analyses included Chi-Squared tests for initial comparisons followed by logistic regression to adjust for covariates.

Results: The study included 19,510 patients: 10,556 males (54.1 %) and 8954 females (45.9 %). Females demonstrated lower rates of post-procedural in-hospital mortality, acute kidney injury, infection, ventricular arrhythmias, and pneumothorax, however higher incidence of stroke or transient ischemic attack (TIA), red blood cell transfusions, vascular complications, and pericardial effusion. Adjusted analysis revealed female patients had lower mortality rates (OR 0.89; 95 % CI [0.79-1.0]; p = 0.042), but higher rates of red blood cell transfusions (OR 1.6; 95 % CI [1.4-1.8]; p < 0.001) and vascular complications (OR 1.5; 95 % CI [1.3-1.8]; p < 0.001), without significant difference in stroke (OR 1.1; 95 % CI [0.91-1.3]; p = 0.309).

Conclusions: Females undergoing BAV for severe AS experienced lower in-hospital mortality but higher rates of vascular complications and red blood cell transfusions compared to males. These findings underscore the importance of a sex-specific approach in the management of AS to reduce adverse outcomes and optimize patient care.

Background: The third-generation Fantom Encore bioresorbable scaffold (BRS), made with Tyrocore polymer, features full radiopacity, 95-115 μm strut thickness, and high expansion capacity. Currently, there is a lack of real-world data on this device.

Methods and results: We conducted a retrospective, single-center study involving 28 elective patients undergoing percutaneous coronary intervention (PCI) for 43 de novo coronary lesions with implantation of the Fantom Encore BRS. Mean age was 66.6 ± 8.5 years (male 82.1 %). Number of target lesions/patient was 1.54 ± 0.99, and 89.3 % of patients had single-vessel disease; most lesions were type C (58.1 %). Number of BRS/lesion was 1.02 ± 0.15, with a mean maximum scaffold diameter/lesion of 3.39 ± 0.41 mm and a mean scaffold length/lesion of 24.8 ± 8.17 mm. Plaque debulking was necessary in 32.6 % of lesions and IVUS was employed in 74.4 % of lesions. Acute technical success was achieved in 97.7 % of cases. Clinical follow-up was available in 96.4 % of cases. At a median of 18 months (range: 9-31 months) no patient experienced major adverse cardiovascular events (MACE); notably, no scaffold thrombosis was reported. Angiographic follow-up was performed in 50 % of patients at a median of 17 months (range: 6-35), with no documented cases of target lesion failure.

Conclusion: Fantom Encore BRS shows good potential in delivering safe and effective PCI outcomes in patients with stable coronary artery disease, including those with complex coronary lesions.

Background: There is an increasing preference of utilizing valve-in-valve transcatheter aortic valve replacement (ViV TAVR) after bioprosthetic valve failure. However, updated large-scale analysis investigating early-mortality after the patients underwent ViV TAVR is limited.

Objective: This study aimed to assess in-hospital early mortality and analyze the factors associated with in-hospital early mortality among patients who underwent ViV TAVR.

Methods: Using the all-payer, nationally representative National Readmission Database, our study included patients aged 18 years or older who had ViV TAVR between 2017 and 2020. We categorized the cohort into two groups depending on the occurrence of in-hospital early mortality (death within 30 days after the procedure). Based on the ICD-10, we identified the trend of in-hospital early mortality after ViV TAVR and further analyzed the significant factors associated with it.

Results: After adjustment, a total of 11,009 patients who had ViV TAVR were included in this study. 329 (3.0 %) had in-hospital early mortality and 10,680 (97.0 %) without. There was a decreasing trend in in-hospital early mortality from 3.3 % in 2017 to 1.0 % in 2020, but it was insignificant (p = 0.71). In multivariable analysis, the independent factors associated with in-hospital early mortality were chronic liver disease (adjusted odds ratio [aOR]: 3.62; 95 % confidence interval [CI]: 1.96-6.71, p < 0.01), coagulation disorder (aOR: 1.77; CI: 1.16-2.68, p < 0.01) and pulmonary hypertension (aOR: 1.78; CI: 1.18-2.68, p < 0.01). Among patients who died during early readmission following ViV TAVR, the most common cardiac cause and non-cardiac cause of readmission were heart failure (15.4 %) and infection (23.1 %), respectively.

Conclusion: The in-hospital early mortality following ViV TAVR was low at 3.0 %. The independent factors associated with in-hospital early mortality post-procedurally were chronic liver disease, coagulation disorder, and pulmonary hypertension.

Coronary microvascular dysfunction (CMD) is an important clinical disease spectrum which has gained widespread attention due to chronic anginal symptoms, and worse clinical outcomes, with or without obstructive coronary artery disease (CAD). Coronary microcirculatory dysfunction is due to a wide array of mechanisms such as inflammation, platelet aggregation, vessel wall collagen deposition, imbalance of nitric oxide, free radicals, and sympathetic/parasympathetic simulation. As noted in this supplement, CMD can occur as a primary disease or co-exist with multi-array of diverse cardiac conditions such as CAD (old infarct), hypertrophic cardiomyopathy, Takotsubo cardiomyopathy, hypertension, or infiltrative diseases. CMD, which is often under diagnosed, leads to increase in medical expenses, decrease in quality of life, exacerbation of underlying conditions such as heart failure and even increased mortality. CMD presents a challenge for patients as well as physicians to manage. In this chapter, we review CMD and focus on its endotypes, techniques for microcirculatory assessment, associated tips and tricks and available treatment options.

Background: The Danish-German Cardiogenic (DanGer) Shock Trial reported lower mortality with a percutaneous micro-axial flow pump compared to standard care in patients with STEMI-related cardiogenic shock. It remains unclear how the DanGer Shock trial population compares to randomized controlled trials (RCTs) and real-world registries studying temporary mechanical circulatory support (tMCS) for acute myocardial infarction with cardiogenic shock (AMICS).

Methods: A systematic review and meta-analysis of RCTs and registries involving tMCS for AMICS was performed. Patient characteristics and outcomes were compared to those in the DanGer Shock Trial.

Results: From 2005 to 2023, seven RCTs (1201 patients) and ten registries (2100 patients) were analyzed. DanGer Shock patients had fewer comorbidities, lower blood pressure, lower Left ventricular ejection fraction (LVEF), higher heart rates, and shorter times to tMCS initiation (5.5 ± 2.7 vs. 19.1 ± 38.3 h, p < 0.0001) than RCT patients. They required shorter tMCS durations, less mechanical ventilation, and inotropic support. DanGer patients experienced fewer bleeding events, infections, and limb ischemia, with similar 30-day mortality but higher stroke rates. Compared to registry patients, DanGer Shock patients had fewer comorbidities but required longer tMCS, more mechanical ventilation, and inotropic support, with fewer complications and lower 30-day mortality.

Conclusion: DanGer Shock patients had better survival despite worse initial hemodynamics, possibly due to fewer comorbidities, earlier tMCS initiation, and an algorithmic treatment approach.