Catheterization and Cardiovascular Interventions最新文献

Background: Vascular and bleeding complications remain a concern after transfemoral transcatheter aortic valve replacement (TAVR). The impact of the sheath type on these complications remains unclear.

Methods: The prospective MARVEL registry study analyzed enrolled 500 patients undergoing large-bore transfemoral procedures and arteriotomy closure with the MANTA vascular closure device from 10 hospitals in Europe and Canada. We stratified these patients according to type of sheath used (expandable or conventional). A propensity-matched analysis was performed using VARC-2 major or minor vascular and bleeding complications as the primary endpoint. The secondary endpoint was time to hemostasis.

Results: We identified 196 propensity-matched pairs. Major vascular complications occurred in 3.6% in the expandable sheath group and 4.1% in the conventional sheath group (p = 1.0). Minor vascular complications occurred in 5.6% in the expandable sheath group and 4.6% in the conventional sheath group (p = 0.819). There were no significant differences in bleeding complications between groups. Time to hemostasis after MANTA closure was significantly shorter in the expandable sheath group (30 vs. 60 s, p < 0.001).

Conclusions: A propensity-matched analysis demonstrated no significant differences in vascular complication rates with MANTA arteriotomy closure after removal of large bore expandable or conventional sheaths. Time to hemostasis was significantly shorter in the expandable sheath group.

Background: Protruding coronary artery stents can adversely affect transcatheter aortic valve replacement (TAVR) procedure. Current evidence on the topic is limited.

Aims: We aim to study the clinical feasibility and safety of flaring of protruding coronary artery stents before TAVR to reduce interaction with transcatheter heart valves.

Methods: Twenty consecutive patients with 22 protruding coronary stents were optimized with a dual-diameter balloon before TAVR. Procedural success, stent and valve geometry on angiogram, periprocedural and subsequent clinical outcomes as well as valve hemodynamics on echocardiography were evaluated.

Results: Procedural success was achieved in 100% of coronary procedure and TAVR without any major complication directly related to the flaring of stents. There was no coronary artery obstruction after TAVR or visible stent or valve deformity. All valves had normal hemodynamics immediately post-deployment with none having clinically significant aortic insufficiency. One patient had inpatient mortality unrelated to coronary stent optimization. One valve had hemodynamic valve degeneration on follow-up which was unrelated to coronary stent flaring and the patient was asymptomatic.

Conclusion: Flaring of protruding coronary stents before TAVR is technically feasible and safe and can potentially minimize stent-valve interaction for during of after TAVR.

Introduction: In patients with chronic coronary syndromes (CCS), the benefit of percutaneous coronary intervention (PCI) added to optimal medical therapy (OMT) remains unclear. The indication to PCI may be driven either by angiographic evaluation or ischemia assessment, thus depicting different potential strategies which have not yet been thoroughly compared.

Methods: Randomized controlled trials (RCTs) comparing OMT versus PCI angio-guided or versus PCI non-invasive or invasive ischemia guided were identified and compared via network meta-analysis. Major adverse clinical events (MACE), as defined by each included trial, were the primary endpoint, while cardiovascular (CV) death, myocardial infarction (MI), and unplanned revascularization the secondary ones.

Results: 18 studies, encompassing 17,512 patients, were included, with a mean follow-up of 3.5 years. PCI guided by ischemia defined either invasively or not was associated with a reduced risk of MACE compared with OMT alone. Furthermore, PCI guided by non-invasive assessment of ischemia was associated with a reduced risk of MI compared with OMT (hazard ratio [HR]: 0.61 [95% confidence interval: 0.37-0.94). This strategy ranked best also in preventing CV death. Notably, iFR and FFR guided approaches showed the highest probability of performing best for reduction of subsequent revascularizations.

Conclusion: In patients with CCS, ischemia-guided PCI, either by invasive or non-invasive assessment, resulted in a reduced risk of MACE compared with OMT alone. The use of invasive or non-invasive tests influenced the benefit of ischemia-driven PCI: non-invasive tests significantly reduced risk of MI compared with OMT, while iFR or FFR showed the highest probability of reducing the need of subsequent revascularization.

Background: The co-existence of severe aortic stenosis (AS) and hypertrophic cardiomyopathy (HCM) is not uncommon. Surgical intervention is the gold standard management. Patients with high surgical risk might undergo transcatheter aortic valve replacement (TAVR). However, TAVR outcomes are unclear in this population. We aimed to investigate the impact of HCM on the outcomes of TAVR.

Aim: We aim to investigate the outcomes of TAVR in patients with HCM.

Methods: We systematically searched PubMed, EMBASE, and Scopus for studies that compared outcomes of TAVR procedure between patients with HCM and those without it. Using the random-effects model, the odds ratios (OR) with 95% confidence interval (CI) were reported.

Results: We screened 102 articles and identified three observational cohort studies. Compared to patients who underwent TAVR without underlying HCM, TAVR for AS co-existed with HCM was associated with higher rates of mortality (OR 5.79; 95% CI: 3.38; 9.91, p < 0.0001), cardiogenic shock (OR 4.55; 95% CI: 3.40; 6.08, p < 0.0001), aortic dissection (OR 4.95; 95% CI: 3.17; 7.74, p < 0.0001), vascular complications (OR 2.10; 95% CI: 1.27; 3.47, p = 0.004), and renal impairment (OR 1.80; 95% CI: 1.36; 2.40, p < 0.0001). There was no difference between the comparison groups in terms of complete heart block, new permanent pacemaker implantation, or bleeding.

Conclusion: In patients with severe AS and HCM, TAVR was associated with significantly higher occurrence of mortality, cardiogenic shock, aortic dissection, vascular complications, and renal impairment as well as the need for mechanical ventilation than patients who did not have HCM.

Aortic annular rupture is a rare and usually fatal complication of TAVR. We report the case of a sub-annular aortic rupture contained in the right ventricle and percutaneously repaired. The procedure was complicated by new-onset severe tricuspid regurgitation related to tricuspid injury during wire externalization and immediately treated by transcatheter edge-to-edge repair.

Background: The role of Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) is still unclear in patients with STEMI undergoing PCI in the current second-generation DES era.

Aims: This study aimed to evaluate the trends and outcomes of IVUS-guided PCI in patients with STEMI.

Methods: We used the National Inpatient Sample (NIS) database from 2016 to 2021. The primary endpoint of this study is all-cause in-hospital mortality. Secondary endpoints include trends of PCI hospitalizations, trends of mortality, length of stay, and cost of hospitalization.

Results: There were data for 819,645 hospitalizations for STEMI, of which 91.2% (n = 74,7860) utilized angiography-guided PCI, 8.4% (n = 68,985) utilized IVUS-guided PCI and 0.3% (n = 2800) utilized OCT-guided PCI. In-hospital mortality for IVUS-guided PCI was 4.6% (n = 3190) versus 6.0% (n = 44,935) for angiography-guided PCI with an adjusted OR 0.75 (0.68-0.81, p < 0.001). In-hospital mortality for OCT-guided PCI was 3.4% (n = 95) versus 6.0% (n = 44,935) for angiography-guided PCI with an adjusted OR 0.67 (0.43-1.06, p = 0.09).

Conclusions: IVUS/OCT-guidance was increasingly utilized over the years and was associated with a significantly reduced adjusted odds of in-hospital mortality. Large-scale, long-term randomized data are needed to better ascertain where IVUS/OCT may be best utilized for optimization of PCI for STEMI.

Background: Despite advancements in valve implantation devices, vascular access complications (VAC) remain a significant cause of morbidity and mortality for those undergoing transcatheter aortic valve replacement (TAVR). We describe pre-operative imaging analysis of the aortoiliac and femoral arterial beds using the TransAtlantic intersociety consensus (TASC) score, ilio-femoral tortuosity, and procedural characteristics to identify anatomic risk factors predictive of VAC in TAVR.

Methods: Consecutive patients undergoing TAVR from 2012 to 2022 at a single North Dakota hospital were retrospectively reviewed. Pre-operative computed tomography angiography (CTA) was used for vascular analysis of the infrarenal aorta, iliac, and femoral vascular beds. Wilcoxon signed-rank test was used for non-normally distributed or t-test for normally distributed continuous variables and Chi-square or Fisher's exact tests for categorical variables were utilized to examine the association of each variable with vascular complications.

Results: One thousand eighty-nine patients were evaluated with 80 patients identified with VAC. Aortoiliac disease burden of the iliac arteries and posterior wall calcification of the common femoral artery (CFA) were predictive of VAC. Iliofemoral tortuosity and skin to CFA depth were not. Left sided CFA versus right CFA access was associated (p < 0.001). Pretreatment of diseased iliac vessels decreased odds of VAC (OR 0.21, 95% CI, 0.08-0.56).

Conclusion: Our study highlights the importance of preoperative peripheral vascular assessment for TAVR. We identify aortoiliac disease burden, posterior CFA calcification, and left sided common femoral access as risk factors for VAC. A structured approach to the preoperative assessment may optimize planning and enhance outcomes in TAVR.

Background: Extubation of the coronary guiding catheter may affect flow and pressure measurements in the coronary vessel during invasive coronary angiography (ICA).

Aim: This study aims to investigate the impact of guiding catheter extubation on fractional flow reserve (FFR), coronary flow reserve (CFR), and the index of microcirculatory resistance (IMR).

Methods: This predefined subgroup analysis of the Dan-NICAD 2 study included patients with chronic coronary syndrome referred to ICA based on a coronary computed tomography angiography. Thermodilution was performed in all vessels evaluated with 30%-90% diameter stenosis on a visual estimate. The primary endpoints were FFR, CFR, and IMR changes when the guiding catheter was extubated from the coronary ostium. Three-dimensional quantitative coronary angiography analysis was conducted to evaluate whether the proximal flow area, defined as the area of the guiding catheter subtracted from the area of the vessel ostium, correlated with the changes in FFR, CFR, and IMR.

Results: In 84 patients, coronary physiological measurements were performed twice: once with the guiding catheter intubated and once extubated. FFR decreased during guiding catheter extubation (0.82 ± 0.09 vs. 0.80 ± 0.10) with a mean difference of 0.02, 95% CI [0.01-0.03], p < 0.001. Following extubation, eight patients (8.7%) showed FFR values shifting from > 0.80 to ≤ 0.80. IMR increased during guiding catheter extubation (16.8 ± 8.50 vs. 21.4 ± 16.1) with mean difference of 4.67 [95% CI 1.74-7.60], p = 0.002. No significant changes in CFR were observed; intubated 3.09 ± 1.31 vs 2.84 ± 1.30; difference mean 0.25, [95% CI -0.07 to 0.56], p = 0.12. No significant correlations were found between the proximal flow area and the difference in FFR, CFR, and IMR from intubated to extubated: (r -0.14, p = 0.23), (r -0.11, p = 0.34), and (r -0.16, p = 0.17), respectively.

Conclusion: Extubating the guiding catheter decreased FFR and increased IMR. This resulted in an FFR decrease from > 0.80 to ≤ 0.80 in 8.7% of patients. CFR remained unchanged. No significant correlation was found between FFR/IMR changes and proximal flow area.

Background: The new Amplatzer Steerable Delivery Sheath is a delivery system designed to improve ease-of-use and procedural results of left atrial appendage closure (LAAC). We aimed to compare procedural results after switching our LAAC program at a tertiary care center with the Amulet device to the Steerable Delivery Sheath, with a control group of LAAC employing the standard sheath.

Methods: The first n = 32 consecutively treated patients at our site using the Amulet device with the Steerable Delivery Sheath were included in this retrospective analysis. As a control-group, n = 39 consecutive patients treated with the Amulet device before the switch to the new sheath were used.

Results: LAAC was successful in all patients in both groups (100%). Contrast use and fluoroscopy time were numerically higher in the steerable sheath group (steerable sheath vs. control group: contrast use 70 ± 23 vs. 55 ± 50 mL, p = 0.09, fluoroscopy time 12.7 ± 4.6 vs. 10.2 ± 6.6 min, p = 0.3). Fluoroscopy time and dose decreased after 3 months while contrast use remained unchanged. Complete sealing rate was high in both groups (steerable sheath vs. control group 97% vs. 95%, p > 0.9) and periprocedural complication rate was low, without any periprocedural stroke, vascular complications, or death in both cohorts.

Conclusions: LAAC with the Amplatzer Amulet steerable delivery sheath is feasible and safe. Fluoroscopy time and dose suggest a learning curve with the new sheath.