Transcatheter aortic valve implantation (TAVI) is a highly specialized technique offering a new therapeutic option to patients at high risk for conventional surgery. However, despite continuous improvements in operators expertise and device technology, complications associated with this catheter procedure are not uncommon. We report an unusual case of late contained rupture of the aortic annulus, combining a para-aortic false aneurysm and a ventricular septal defect, after the placement of an Edwards Sapien prosthesis. © 2012 Wiley Periodicals, Inc.
Background—There is a scarcity of long-term data from large-scale drug-eluting stent registries with a large enough sample to evaluate low-frequency events such as stent thrombosis (ST).
Myocardial fractional flow reserve (FFR) has emerging clinical utility and prognostic value in medically stabilized patients with non–ST-segment elevation myocardial infarction (NSTEMI). The aim of this study was to investigate whether measurement of FFR compared to coronary angiography alone improves diagnostic efficiency in patients with NSTEMIs. One hundred consecutive patients with NSTEMIs who had previously undergone clinically indicated FFR measurements were included. In a simulated decision exercise, 5 interventional cardiologists retrospectively and independently reviewed the clinical history and coronary angiogram of each patient and then made a treatment decision. FFR results were then disclosed, and the same cardiologists were asked to review their initial treatment decisions.
Growth of the ageing population, advances in imaging techniques, newly available percutaneous interventions, and emphasis on the central role of the Heart Team in risk assessment and treatment selection1 combine to place valvular heart disease (VHD) at the centre of developments in cardiovascular medicine and surgery. However, VHD is poorly researched in comparison with other areas of cardiac disease, both at a basic scientific and clinical level. Until recently, there have been virtually no randomized controlled trials and international guidelines are largely based on expert consensus. Principal limitations to quality research are the diverse nature of patients with VHD, inability to identify individuals at the earliest stages of disease, and a lack of financial support and an appropriate investigational infrastructure.
I am delighted to provide readers of the European Heart Journal with an overview of scientific data relating to Coronary Intervention in 2012. This article aims to summarize the important publications and presentations; it includes a summary of the main interventional meetings (ACC, EuroPCR, ESC, TCT, and AHA) together with a selection of important publications from the major general and specialist journals.
This brief review focuses on recent developments in the role of echocardiography for illuminating the pathophysiology of cardiac valve disease.
The year of 2012 has seen many significant publications in cardiac imaging, particularly in the modalities of cardiovascular magnetic resonance and cardiac computed tomography. This article will review in brief some of the most important studies with a particular emphasis on the new evidence base for perfusion imaging both by cardiovascular magnetic resonance and computed tomography.
Background—Atrial fibrillation (AF) is an important risk factor for stroke and is common among elderly patients undergoing transcatheter aortic valve implantation. The aim of this study was to assess the impact of AF on clinical outcomes among patients undergoing transcatheter aortic valve implantation.
The present study sought to assess the effectiveness of local anesthesia with conscious sedation (LACS) during transcatheter aortic valve implantation (TAVI). On its introduction, TAVI was mostly performed with the patient under general anesthesia (GA); however, evidence supporting the use of less-invasive LACS has been increasing. The data from 174 consecutive patients who underwent TAVI by way of the femoral artery from December 2007 to December 2011 were analyzed. GA was mainly used in early phase of the study (n = 44); this was gradually shifted to LACS in the late phase (n = 130). The clinical outcomes were compared for those patients who received GA versus LACS. The incidence and causes of “LACS failure,” defined as conversion to GA from LACS during TAVI, were also assessed. The rates of procedural success and 30-day mortality were not different between the 2 groups (93.3% vs 95.3%, p = 0.60; 6.7% vs 7.8%, p = 0.55, respectively). Although the clinical backgrounds of the patients showed differences, these results were not significant after adjusting for other influential confounders. The intensive care unit stay and hospital stay were longer in the GA group than in the LACS group (3.9 ± 2.2 vs 3.3 ± 1.5 days, p = 0.044; and 12.2 ± 8.3 vs 8.1 ± 6.5 days, p = 0.001, respectively). LACS failure occurred in 6 patients (4.6%), and the causes were multifactorial, as follows: cardiac tamponade in 2, cardiac arrest in 2, myocardial infarction in 1, and stroke in 1. In conclusion, transfemoral TAVI with the patient under LACS could be successfully performed in most patients, with the advantage of early recovery, although the perioperative risks involved in the TAVI procedure should be considered.
Aims Provocation tests of coronary artery spasm are useful for the diagnosis of vasospastic angina (VSA). However, these tests are thought to have a potential risk of arrhythmic complications, including ventricular tachycardia (VT), ventricular fibrillation (VF), and brady-arrhythmias. We aimed to elucidate the safety and the clinical implications of the spasm provocation tests in the nationwide multicentre registry study by the Japanese Coronary Spasm Association.
Despite drug eluting stents (DES), as compared to bare metal stents, have reduced in-stent restenosis, complex and long lesions remains a challenge for interventional cardiologist. Their treatment is often associated with an unfavorable outcome, related to in-stent restenosis, stent thrombosis, and target lesion revascularization. These complications may derive from the contact between metallic structures and coronary artery endothelium, and consequent overexpression of platelet activating factors, growth factors, and inflammatory cytokines. Recently, an additional mechanism has emerged as new cause of these complications: “stent fracture.” Several factors are involved in this phenomenon including material and stent platform, target vessel features, stent implantation technique, and implant duration. We reported a case of 69 years old man with rare early and complex DES fractures on right coronary that caused acute coronary syndrome 36 hr after a previous percutaneous coronary intervention.© 2012 Wiley Periodicals, Inc.
Acute kidney injury (AKI) is associated with a poor prognosis after transcatheter aortic valve replacement (TAVR). A paucity of data exists regarding the incidence and effect of AKI after TAVR using the new recommended Valve Academic Research Consortium criteria. At Columbia University Medical Center, 218 TAVR procedures (64.2% transfemoral, 35.8% transapical) were performed from 2008 to July 2011. The creatinine level was evaluated daily until discharge. Using the Valve Academic Research Consortium definitions, the 30-day and 1-year outcomes were compared between patients with significant AKI (AKI stage 2 or 3) and those without significant AKI (AKI stage 0 or 1). Significant AKI occurred in 18 patients (8.3%). Of these 18 patients, 10 (55.6%) had AKI stage 3 and 9 (50%) required dialysis. AKI was associated with a lower baseline mean transvalvular gradient (37.6 ± 11.4 vs 45.6 ± 14.8 mm Hg for no AKI, p = 0.03). After TAVR, the AKI group had a greater hemoglobin decrease (3.6 ± 2.0 vs 2.4 ± 1.3 g/dl, p = 0.01), greater white blood cell elevation at 72 hours (21.09 ± 12.99 vs 13.18 ± 4.82 × 103/μl, p = 0.001), a more severe platelet decrease (118 ± 40 vs 75 ± 43 × 103/μl, p <0.0001), and longer hospitalization (10.7 ± 6.4 vs 7.7 ± 8.5 days, p <0.001). One stroke (5.6%) occurred in the AKI group compared with 3 (1.5%) in the group without AKI (p = 0.29). The 30-day and 1-year rates of death were significantly greater in the AKI group than in the no-AKI group (44.4% vs 3.0%, hazard ratio 18.1, 95% confidence interval 6.25 to 52.20, p <0.0001; and 55.6% vs 16.0%, hazard ratio 6.32, 95% confidence interval 3.06 to 13.10, p <0.0001, respectively). Periprocedural life-threatening bleeding was the strongest predictor of AKI after TAVR. In conclusion, the occurrence of AKI, as defined by the Valve Academic Research Consortium criteria, is associated with periprocedural complications and a poor prognosis after TAVR.
Aims The obesity paradox refers to the epidemiological evidence that obesity compared with normal weight is associated with counter-intuitive improved health in a variety of disease conditions. The aim of this study was to investigate the relationship between body mass index (BMI) and mortality in patients with acute coronary syndromes (ACSs).
Drug-eluting stents (DES) have significantly improved the rate of target vessel revascularization in comparison with bare metal stents. DES fracture was not reported in multicenter randomized clinical trials, but several case reports of DES fracture have been published, mostly with sirolimus-eluting stents. DES fracture is associated with stent restenosis and thrombosis. We report a zotarolimus-eluting stent fracture in an aortocoronary saphenous vein graft (SVG) bypass. The patient presented with chest pain and a non-ST-elevation myocardial infarction. He underwent cardiac catheterization that showed a complete fracture of a zotarolimus-eluting stent in the ostium of a sequential SVG to the diagonal and obtuse coronary arteries. His management included coronary angioplasty and retrieval of the proximal fractured segment. We discuss the potential causes for this stent fracture and suggest caution when using a DES in an ostial location of a SVG bypass, especially in a highly mobile vessel. © 2012 Wiley Periodicals, Inc.
Although transcatheter aortic valve implantation (TAVI) for severe aortic stenosis is becoming an established technique, the effect of gender-related differences is poorly described. We performed a gender-based comparison of high-risk patients undergoing TAVI with the self-expandable CoreValve Revalving System for severe aortic stenosis to evaluate early and mid-term clinical outcomes. From the Italian prospective CoreValve registry, 659 consecutive patients (55.8% women) who underwent TAVI were included in the present study. We analyzed the gender-based differences in terms of clinical, angiographic, and procedural features and the differences in the rate of early and mid-term major adverse cardiac and cerebrovascular events
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