Eurointervention最新文献

Background: Evidence supporting the clinical superiority of the Watchman FLX with respect to its previous iteration, the Watchman 2.5, is still sparse.

Aims: We aimed to compare the Watchman FLX and Watchman 2.5 in terms of device-related complications and clinical outcomes.

Methods: All consecutive left atrial appendage closures (LAACs) completed with implantation of a Watchman device at two high-volume centres between July 2018 and January 2023 were considered. Based on the type of implanted device, patients were assigned to either the Watchman FLX or Watchman 2.5 group. The study endpoints included device-related thrombus (DRT) and peridevice leak (PDL), as evaluated by transoesophageal echocardiography (TOE), and stroke rate at the longest available follow-up. Propensity score matching (PSM) analysis was used to minimise baseline differences between groups.

Results: After performing PSM, 1,128 patients were included in each group. In the TOE follow-up, performed at a mean of 2.3 months, both DRT (0.2% vs 3.1%; hazard ratio [HR] 0.35, 95% confidence interval [CI]: 0.21-0.38; p=0.017) and PDL (21.0% vs 30.6%; HR 0.68, 95% CI: 0.59-0.77; p=0.031) were significantly lower in the Watchman FLX group compared with the Watchman 2.5 group. At a mean of 1.6 years of follow-up, the stroke rate was numerically lower in the Watchman FLX group compared with the Watchman 2.5 group (3.4% vs 5.1%; HR 0.56, 95% CI: 0.15-1.69; p=0.078).

Conclusions: In a large dual-centre cohort of consecutive, successful LAAC procedures using two iterations of the Watchman device, the Watchman FLX was associated with significantly lower rates of both DRT and PDL compared to the Watchman 2.5.

Background: Despite excellent long-term results, patients who have undergone valve-sparing root repair (VSRR) or a Bio-Bentall procedure may require a future secondary valve-related intervention.

Aims: We aimed to assess the feasibility of transcatheter valve-in-root procedures in patients who have previously undergone either a VSRR or a root replacement with a Bio-Bentall, in anticipation of lifetime management.

Methods: Between 2012 and 2022, 537 patients underwent a VSRR or a Bio-Bentall procedure in our institution. In 363 patients, a postoperative computed tomography angiography was available (VSRR n=250; Bio-Bentall n=113) to evaluate the feasibility of a transcatheter valve-in-root implantation. Annulus area, annulus-to-coronary distance, coronary ostium size, and the valve-to-coronary distance (VTC) were measured using dedicated software.

Results: After VSRR, 4.8% of patients had an annulus area over 840 mm², thus being unsuitable for a valve-in-root procedure. In 12.4% of cases after a Bio-Bentall procedure, the annulus area was below 300 mm², which complicates valve-in-root implantation due to potential patient-prosthesis mismatch. The annulus-to-coronary distance for both coronary arteries was significantly higher after VSRR compared to Bio-Bentall (right coronary artery: 18.0±5.8 mm vs 12.5±5.4 mm; p<0.001; left coronary artery [LCA]: 11.6±4.6 mm vs 8.0±4.5 mm; p<0.001). Out of a total of 98 coronary ostia located below the upper frame level, 63.3% had a VTC below 4 mm. The VTC to the LCA was significantly larger after Bio-Bentall with a Valsalva graft, with a median of 4.95 (interquartile range [IQR] 4.2-5.9) mm compared with 3.1 (IQR 2.3-4.2) mm (p<0.001) in patients who had a straight graft implanted.

Conclusions: The feasibility of a future transcatheter valve-in-root procedure depends on the anatomical conditions of the aortic root after the initial operation. A high reimplantation of coronary ostia, the choice of the vascular graft, and a foresighted valve sizing may facilitate a future transcatheter valve-in-root implantation.

Secondary mitral regurgitation (SMR) is frequent among patients with heart failure (HF) with reduced ejection fraction (HFrEF), and it is strongly associated with increased mortality, frequent hospitalisations, and poor quality of life. The mechanisms underlying SMR are multifactorial. While guideline-directed medical therapy and cardiac resynchronisation therapy remain the cornerstone of HFrEF management, many patients with significant SMR continue to experience significant symptoms and adverse outcomes. Managing SMR within the context of HF necessitates a multifaceted approach. Transcatheter edge-to-edge repair (TEER) has emerged as a transformative intervention, demonstrating improvements in survival, functional capacity, and HF-related hospitalisations in clinical trials and real-world registries in selected patients. This review provides a comprehensive overview of the evidence supporting TEER, focusing on procedural and follow-up outcomes, and its role in reshaping the therapeutic approach for HF patients with SMR. Additionally, we highlight the critical role of patient selection and identify predictors of poor outcomes as key determinants of TEER success.

Background: Transcatheter heart valve (THV) deformation after transcatheter aortic valve implantation (TAVI) using the self-expanding ACURATE platform has been associated with impaired clinical outcomes in a randomised trial. Procedural factors associated with THV deformation remain incompletely understood.

Aims: We aimed to investigate procedural factors associated with valve underexpansion, mainly derived from preprocedural computed tomography angiography (CTA) imaging.

Methods: A single-centre, retrospective, observational study was carried out, including patients who underwent TAVI with an ACURATE THV between January 2014 and December 2022, with available CTA and procedural fluoroscopy. Aortic calcium volume was quantified using 3mensio software. Fluoroscopy was used to determine valve frame underexpansion.

Results: Of 3,027 patients, 480 were eligible (74 [15.4%] with an underexpanded and 406 [84.6%] with an expanded ACURATE THV). There were no differences regarding baseline clinical and procedural characteristics. Preprocedural CTA assessment showed more calcium at the annulus level in underexpanded versus expanded THVs (60.3 [interquartile range [IQR] 21.3; 135.2] mm³ vs 45.3 [IQR 15.8; 96.1] mm³, respectively; p=0.042), while post-dilatation was less frequently performed in underexpanded compared to expanded THVs (44.6% vs 64.8%, respectively; p=0.001). Multivariable regression analysis revealed that annulus calcium volume (odds ratio [OR] 2.333, 95% confidence interval [CI]: 1.331-4.089; p=0.003) and post-dilatation (OR 0.350, 95% CI: 0.203-0.602; p<0.001) were significantly associated with underexpanded THVs. Sensitivity analysis using annulus calcium volume as a dichotomised variable (>54 mm³) confirmed the significant association with valve frame underexpansion (OR 2.38, 95% CI: 1.37-4.19; p=0.002).

Conclusions: Annular calcium volume was shown to be associated with underexpanded ACURATE THVs, while post-dilatation may reduce valve deformation.

Background: Current guidelines recommend beta blockers after myocardial infarction (MI) regardless of left ventricular ejection fraction (LVEF), aiming to reduce reinfarction and ventricular arrhythmias. However, recent trials have challenged this practice in patients without reduced LVEF. Whether beta blocker withdrawal in these patients increases short-term or recurrent ischaemic events remains uncertain.

Aims: We aimed to evaluate the short-term ischaemic safety of beta blocker withholding or withdrawal at hospital discharge in patients with MI and LVEF >40% and to determine the effect of beta blocker therapy on a broad composite ischaemic endpoint.

Methods: This is a post hoc analysis of the REBOOT trial, in which patients with MI and LVEF >40% were randomised to beta blocker therapy or no beta blocker at discharge. The incidence of short-term (3-month) and recurrent ischaemic events (a composite of cardiac death, reinfarction, sustained ventricular tachycardia/fibrillation, resuscitated cardiac arrest, or unplanned revascularisation) was assessed overall and according to prior beta blocker use.

Results: From the 8,438 patients in the intention-to-treat population of the trial, information regarding beta blocker history was available for 8,401. Of these, 12.1% were on chronic beta blocker therapy before MI. Overall, withholding or withdrawing beta blockers was not associated with increased short-term ischaemic risk (hazard ratio [HR] 1.13, 95% confidence interval [CI]: 0.74-1.72). Over a median follow-up of 3.7 years, there were no differences in recurrent ischaemic events between groups (HR 0.98, 95% CI: 0.82-1.16), nor significant interactions with prior beta blocker therapy. In patients who were on a beta blocker before the index MI, randomisation to no beta blocker (withdrawal) was not associated with an increased risk of ischaemic events during trial follow-up (composite ischaemic endpoint HR 0.93, 95% CI: 0.64-1.34).

Conclusions: In patients with MI and LVEF >40%, beta blocker withholding or withdrawal at discharge was not associated with increased short-term or recurrent ischaemic events, supporting the safety of this strategy in contemporary clinical practice.