We report the case of a 3-year-old asymptomatic girl (12 kg, 96 cm) who was diagnosed with a large iatrogenic left ventricular pseudoaneurysm (LVP) on follow-up ultrasound, 14 months after apical muscular ventricular septal defect (VSD) closure with a 10 mm Amplatzer Muscular VSD occluder (Abbott, USA) due to device erosion. The LVP was successfully occluded using detachable Penumbra coils, with complete thrombo-exclusion confirmed at 12-month follow-up.
Background: Intravascular ultrasound (IVUS)-guided optimization of suboptimal fractional flow reserve (FFR) following percutaneous coronary intervention (PCI) results in a significant increase in both post-PCI FFR and minimal lumen and stent areas (MLA and MSA, respectively). However, the impact of clinical presentation with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) versus chronic coronary syndrome (CCS) on the efficacy of PCI optimization remains unknown.
Methods: This was a prespecified subgroup analysis of the FFR REACT trial comparing IVUS-guided PCI optimization versus no further treatment in 291 patients with a post-PCI FFR < 0.90. Post-PCI physiology and pre optimization IVUS findings were compared between patients presenting with NSTE-ACS versus CCS, as well as optimization strategy, final FFR and IVUS findings.
Results: Out of 291 patients, 130 (44.7%) presented with NSTE-ACS. Median post-PCI FFR was similar in patients with NSTE-ACS and CCS (0.85 for both, p = 0.55). Pre optimization IVUS findings did not differ significantly between both groups and subsequent optimization strategy was comparable (p = 0.71). In both NSTE-ACS and CCS, optimization resulted in a significant increase (p < 0.01 for all) of similar magnitude in median FFR (0.02 vs. 0.03, p = 0.80), MLA (0.37 vs. 0.50 mm2, p = 0.46) and MSA (0.29 vs. 0.32 mm2, p = 0.61), respectively. The clinical impact of IVUS-guided optimization on 2-year target vessel failure showed no signs of heterogeneity based on clinical presentation (interaction p = 0.36).
Conclusions: In patients undergoing FFR-directed IVUS-guided optimization, post-PCI FFR, pre optimization IVUS findings and optimization strategy did not differ significantly between patients presenting with either NSTE-ACS or CCS, with comparable improvements in FFR, MLA and MSA.
Background: The management of Transcatheter Aortic Valve Implantation (TAVI) patients with a small aortic annulus (SAA) postures a substantial challenge, increasing the risk of patient- prosthesis mismatch (PPM) and overall mortality.
Aims: This study aimed to compare the hemodynamic and clinical outcomes of transcatheter balloon-expandable valve (BEV) versus transcatheter self-expandable valve (SEV) in SAA.
Methods: We conducted propensity score matching (PSM) of severe AS patients with SAA who underwent trans-femoral TAVR and enrolled to the Israeli TAVR registry between the years 2008 and 2023. SAA was defined as an aortic-valve annulus area ≤ 430 mm2. Since the BEV used have a smaller size cut-off, an additional analysis on very small aortic annulus (vSAA) as defined as aortic-valve annulus area ≤ 345 mm2 was performed.
Results: The study included 1364 consecutive patients with SAA of (BEV n = 485; SEV n = 879) at a mean age of 82 ± 7 years, of whom the vast majority were female (83%). Propensity-matched groups comprised of 329 and 122 paired for the SAA and vSAA patients, respectively. As compared to BEV in the SAA and vSAA analyses, SEV showed lower rates of postprocedural of LBBB (32% vs. 22% and 41% vs. 22%; both p < 0.01, respectively), however, higher rates of major vascular complications (2% vs. 7% and 2% vs. 12%; both p < 0.01, respectively) and major or life-threatening bleeding but only in vSAA group (17% vs. 9.1%, p = 0.009). One-month mortality was higher in the SEV versus BEV in both SAA and vSAA comparisons (2% vs. 0.6%, p = 0.048 and 3% vs. 0%, p = 0.018; respectively). A nonsignificant trend of higher 5-year mortality was observed in univariate models, noted mainly in vSAA patients (22% vs. 19%, p = 0.385; 24% vs. 15%, p = 0.073).
Conclusions: The present analysis observed higher rates of major vascular complications and 1-month mortality in SAA and vSAA treated with SEV. A similar nonsignificant trend toward long-term mortality for the vSAA group was observed and should be evaluated in larger cohorts.
Background: Quantitative flow ratio (QFR) and FFRangio are angiography-based technologies used to perform functional assessment of coronary lesions from angiographic images, validated across multiple clinical studies. There is limited information on the learning curves associated with each technology.
Aims: This study aims to compare the learning curves of QFR and FFRangio in evaluating coronary stenoses, focusing on changes in analysis speed and accuracy compared to invasive measurements.
Methods: A team of five blinded investigators, including two nurses, one medical student, and one physician in training, underwent identical standardized training on both technologies. The time taken for each analysis and the computed FFR values were documented and compared against the invasive gold standard.
Results: A total of 270 lesions (54 coronary lesions in 44 patients) were retrospectively analyzed. The median invasive FFR value was 0.88 [IQR 0.5, 0.9]. The median time for analysis with QFR and FFRangio was 245 [IQR 62, 319] and 252 [IQR 82, 315] s, respectively (p = 0.171). Both QFR and FFRangio demonstrated a significant reduction in the time required for analysis as experience increased (p < 0.01). Regarding accuracy, the median difference with invasive FFR for QFR and FFRangio was 0.06 [IQR: 0, 0.12] and 0.06 [IQR: 0, 0.12], respectively (p = 0.620). Both technologies reached a performance plateau early on, exhibiting comparable results throughout the study.
Conclusion: Initial training in QFR and FFRangio enables quick attainment of maximal performance, but further practice primarily enhances analysis speed while maintaining accuracy, for both software.
Background: Acute myocardial infarction-related cardiogenic shock (AMICS) is a severe complication associated with exceedingly high mortality rates. While mechanical circulatory support (MCS) has emerged as a potential intervention, the evidence base for independent MCS use remains weak. In contrast, systematic reviews of observational studies have revealed significant mortality reduction when a combination of MCS was used: VA-ECMO in conjunction with a left ventricular (LV) unloading device (Impella or IABP). The ongoing dilemma concerning the selection between two LV unloading devices (VA-ECMO + Impella vs. VA-ECMO + IABP) warrants further investigation and clarification.
Aim: This is the first systematic review and meta-analysis assessing the short-term efficacy and safety of VA-ECMO + Impella versus VA-ECMO + IABP in treatment of AMICS.
Methods: A systematic search was performed on the EMBASE, MEDLINE, and Cochrane databases. Studies reporting the short-term (30-day/inpatient) mortality and complications of adult patients with AMICS treated with VA-ECMO + Impella and VA-ECMO + IABP were included. Subgroup analysis was performed including studies with ACS predominant CS (CS etiology 100% by AMI).
Results: Four observational studies with 14,247 patients were included. There was no significant difference in mortality between VA-ECMO + Impella and VA-ECMO + IABP (56.5% vs. 66.5%; OR, 0.90; 95% CI, 0.79-1.02; p = 0.09). However, VA-ECMO + Impella was associated with significantly lower mortality in patients with ACS predominant CS (53.2% vs. 67.7%; OR, 0.72; 95% CI, 0.62-0.85; p < 0.0001). VA-ECMO + Impella was concomitantly associated with a significantly higher risk of complications.
Conclusions: When comparing LV unloading devices in patients with AMICS requiring a combination of MCS, VA-ECMO + Impella was superior in mortality reduction only in the cohort where 100% of CS was caused by AMI.
Background: Mitral valve transcatheter edge-to-edge repair (M-TEER) was initially indicated for central degenerative mitral regurgitation (DMR) lesions, but advancements in technology have enabled successful treatment in an increasing number of noncentral DMR patients.
Aims: This study aims to compare procedural outcomes and prognosis between noncentral DMR patients, outside clinical trial anatomical criteria, and central DMR patients undergoing M-TEER.
Methods: Drug-refractory moderate-to-severe DMR patients treated with M-TEER at Fuwai Hospital from January 2021 to February 2024 were retrospectively analyzed. Patients were categorized into central (N = 77) and noncentral (N = 59) lesion groups. Baseline characteristics, procedural outcomes, and prognoses were collected and compared.
Results: There were no significant differences in baseline characteristics and preoperative echocardiographic parameters between the groups except for left ventricular ejection fraction. Both groups exhibited similar procedural success rates (central: 93.51% vs. noncentral: 91.53%, p = 0.92) with comparable procedural complication rates. The ideal M-TEER success rate at discharge for noncentral DMR patients was similar to that for central DMR patients (83.05% vs. 71.43%, p = 0.11). Kaplan-Meier analysis indicated similar 3-year recurrence-free survival rates (noncentral: 94.9% vs. central: 90.3%, p = 0.46). Cox regression analysis identified higher discharge mitral valve gradient and a leaflet-to-annulus index ≤ 1.2 as independent risk factors for recurrence or death.
Conclusion: Noncentral DMR patients undergoing M-TEER achieve similar procedural success rates without increased risk of complications compared to central DMR patients. The seemingly higher success rate in noncentral DMR patients may be due to the smaller impact on valve area, warranting further investigation.
The ruptured sinus of Valsalva aneurysm (RSOV), a rare but well-recognized clinical entity, is invariably a form of left-to-right shunt due to rupture into right-sided chambers. It causes profound hemodynamic effects, especially when the rupture is acute. Like most other left-to-right shunts, it was only a matter of time before this rare defect also became amenable to transcatheter closure (TCC). Since the first report of TCC of RSOV by Cullen et al. in 1994 using the Rashkind umbrella, in recent times, there has been a spate of case reports, brief communications, and interesting case presentations at interventional meetings using the much more user-friendly and effective devices. We report a case of a 59-year-old female diagnosed with RSOV (noncoronary cusp to right atrium) treated with device closure by using a vascular plug through a retrograde approach without resorting to the usual antegrade technique involving the formation of an arteriovenous loop.
Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide, particularly among complex high-risk and indicated patients (CHIP). Revascularization is often beneficial for these patients; however, it requires thorough risk stratification and close multidisciplinary collaboration between cardiologists and cardiac surgeons to optimize outcomes. Personalized treatment plans, including percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), are crucial in this context. In this report, we present a case of a 70-year-old man with left main trunk bifurcation lesions, referred to as a "Four Forks Lesion," who was successfully revascularized using a PCI strategy, resulting in a favorable prognosis.
Background: Although the latest studies failed to prove the benefit of routine intra-aortic balloon pump (IABP) use in patients with acute myocardial infarction (MI) presenting with cardiogenic shock, the benefit of IABP utilization in selected cases in "real world" practice is unknown.
Aims: We sought to follow temporal trends in IABP use in a real-world cohort of acute coronary syndrome (ACS).
Methods: We evaluated IABP utilization and patient outcomes from the Acute Coronary Syndrome in Israel Survey (ACSIS) between the years 2000 and 2021. Temporal trends and outcomes with IABP at two time periods were set: early (before 2012) and late (after 2012).
Results: Out of 18,662 ACS patients, 3.7% received IABP. The rate of IABP use was 4.5% in the early period and decreased to ~2.5% in the late period (p < 0.001). Patients treated with IABP in the early period had more frequently reduced ejection fraction (64.5% vs. 53.2%, p < 0.01) and presented mostly with ST-elevation MI (71.0% vs. 62.4%, p = 0.04). Cardiogenic shock on admission and in-hospital occurred equally in both periods (14.6% vs. 17.1%, p = 0.66; 42.8% vs. 41.9%, p = 0.90, respectively). Thirty-day mortality and MACE were comparable between time periods (28% vs. 30.7%, p = 0.547; 43.6% vs. 44.1%, p = 0.978, respectively) however bleeding complications were significantly higher in the later period (4.8% vs. 11.2%, p = 0.04).
Conclusions: Our real-world ACS data demonstrated a 50% reduction in the utilization of IABP among acute MI patients in the last decade. A comparable poor prognosis with IABP across time periods, suggest sustainable worse outcome in routine albeit selective clinical practice.
Background: The impact of below-the-knee (BK) runoff after drug-coated balloon (DCB) treatment in femoropopliteal (FP) lesions has not been well investigated.
Methods: This retrospective multicenter observational study enrolled 291 consecutive patients with lower extremity artery disease who underwent endovascular therapy with DCBs for FP lesions between January 2018 and December 2021. Patients were classified into four groups based on the BK runoff. Outcome measures included primary patency, freedom from clinically driven target lesion revascularization (CD-TLR) and amputation, and overall survival rates at 24 months. The predictors of restenosis at 24 months were also investigated.
Results: In total, 43, 98, 117, and 33 patients were classified into three, two, one, and no BK runoff groups, respectively. In three, two, one, and no BK runoff groups, the primary patency rates were 72.1%, 67.3%, 61.4%, and 44.1% (p = 0.028); freedom from CD-TLR rates were 87.1%, 78.8%, 71.7%, and 47.1% (p < 0.001); freedom from amputation rates were 95.2%, 97.9%, 92.8%, and 91.5% (p = 0.499); and overall survival rates were 89.4%, 83.2%, 76.6%, and 61.2% (p = 0.007), respectively, at 24 months. Multivariate analysis showed that chronic limb-threatening ischemia, no BK runoff, Lutonix use, and residual stenosis > 30% were independent predictors of primary patency loss at 24 months. The risk score, calculated as the number of predictors, reflected the risk of restenosis.
Conclusion: No BK runoff was associated with worse midterm primary patency, freedom from CD-TLR, and overall survival rates than at least one BK runoff.
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