Limited data exist regarding the risk of coronary obstruction due to sinus sequestration in valve-in-valve transcatheter aortic valve replacement (TAVR); data are derived from post-TAVR computed tomography (CT) analysis, and the incidence has been low in clinical experience (1). As valve-in-valve TAVR is predicted to increase due to late failed TAVR valves, further information is required on management of coronary obstruction due to sinus sequestration.
Although valve-in-valve transcatheter aortic valve (TAV) replacement has become valid treatment of bioprosthetic valve failure, coronary artery occlusion remains a recognized risk. Traditional “snorkel” or “chimney” stenting is not feasible for TAV-in-TAV due to stent interaction between 2 transcatheter valve frames. Modified techniques such as balloon-assisted BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) provide a potential alternative to lacerate and increase transcatheter leaflet splay, allowing adequate coronary perfusion (1). In low- and intermediate-risk patients, the option for surgical explant is a higher-risk procedure that often necessitates aortic root replacement and coronary reimplantation. Herein, we describe a hybrid approach for patients who are candidates for surgical intervention that avoids complex aortic root surgery and optimizes placement of TAV-in-TAV.
Despite improvements in transcatheter aortic valve replacement (TAVR), post-TAVR percutaneous coronary intervention and periprocedural coronary occlusion represent major issues. To assess the interactions between TAVR prostheses, coronary ostia, and percutaneous coronary intervention devices, we tested TAVR-related coronary techniques using Visible Heart methodologies (1). This study complied with the guidelines by the Institutional Animal Care and Use Committee (University of Minnesota). The selected TAVR system was Evolut self-expandable prosthesis (Medtronic, Minneapolis, Minnesota). Procedures were conducted under fluoroscopic guidance by 2 expert interventional cardiologists, while endoscopic visualization was simultaneously recorded. Coronary cannulation and percutaneous coronary intervention were performed after single Evolut self-expandable prosthesis implantation and after transcatheter aortic valve–in–transcatheter aortic valve. The collected endoscopic footages highlighted the jailed coronary artery ostia appearance and the optimal cannulation achieved in challenging scenarios (Figures 1 and 2, Videos 1 and 2). Furthermore, 2 stent-based techniques for intraprocedural coronary occlusion prevention/management were tested. In particular, the “classic” chimney/snorkel procedure and the novel orthotopic snorkel stenting technique (2) were directly visualized and the obtained results were assessed by micro–computed tomography (Figures 3 and 4, Videos 3 and 4).
A 70-year-old man with symptomatic aortic stenosis and regurgitation was referred for transcatheter aortic valve replacement. Pre-procedural computed tomography showed a quadricuspid aortic valve (QAV) (Figure 1). The annular perimeter and area were 83.3 mm and 527.7 mm2, respectively.
Increasing data support valve-in-valve as an alternative to redo-surgery. Little is known about durability and modes of bioprosthesis failure; however, the key limitation is high post-procedural gradients with small bioprostheses. We present a case of valve-in-valve-in-valve transcatheter aortic valve replacement (TAVR) that required an innovative do-it-yourself (DIY) crossing catheter.
COVID-19–related respiratory disease is associated with significant morbidity and mortality, especially in elderly patients. In contrast to other forms of pneumonia, patients with COVID-19 pneumonia have preserved lung compliance, but disproportionate hypoxemia and wider right-to-left shunt (RLS) fraction (1). Although hypoxemia is thought to be secondary to respiratory failure, one should also be aware of alternative diagnoses. A 76-year-old woman with a previous history of pulmonary embolism, on life-long anticoagulation, presented to hospital with fever and dyspnea; she was diagnosed with COVID-19. Because her resting oxygen saturation was 82% on room air, and she remained hypoxic on high-flow oxygen, she was intubated. A computed tomography pulmonary angiogram ruled out a new pulmonary embolism; chest x-ray and computed tomography of the thorax demonstrated mild atelectasis in the left lower lobe that resolved over the week. However, she remained hypoxemic, out of keeping with her pulmonary findings. A transthoracic echocardiogram demonstrated a new diagnosis of Ebstein anomaly with moderate tricuspid regurgitation and RLS through a patent foramen ovale (PFO). In view of these findings, she was brought to the cardiac catheterization laboratory. Her mean right atrial pressure was 10 mm Hg; main pulmonary artery pressure was 31/13 mm Hg (mean of 20 mm Hg), with mean left atrial (LA) pressure of 11 mm Hg. While intubated, on a fraction of inspired oxygen of 0.2, pulmonary venous saturation was 94%, whereas aortic saturation was 82%, suggestive of a significant pulmonary venous–to-aortic stepdown.
Although the 3 authorized vaccines for COVID-19 appear to be very safe (1–3), the vaccines are quite new and dedicated for a new disease, which calls for even very rare events to be shared and discussed broadly with the medical community. Therefore, we would like to present a clinical case of a serious adverse event, possibly linked to 1 of the vaccines for COVID-19.
The considerable mortality and morbidity associated with atrial fibrillation (AF) pose a substantial burden on patients and health care services. Although the management of AF historically focused on decreasing AF recurrence, it evolved over time in favor of rate control. Recently, more emphasis has been placed on reducing adverse cardiovascular outcomes using rhythm control, generally by using safe and effective rhythm-control therapies (typically antiarrhythmic drugs and/or AF ablation). Evidence increasingly supports early rhythm control in patients with AF that has not become long-standing, but current clinical practice and guidelines do not yet fully reflect this change. Early rhythm control may effectively reduce irreversible atrial remodeling and prevent AF-related deaths, heart failure, and strokes in high-risk patients. It has the potential to halt progression and potentially save patients from years of symptomatic AF; therefore, it should be offered more widely.
Interest in the use of mechanical circulatory support for patients presenting with cardiogenic shock is growing rapidly. The Impella (Abiomed Inc), a microaxial, continuous-flow, short-term, ventricular assist device (VAD), requires meticulous postimplantation management. Because systemic anticoagulation is needed to prevent pump thrombosis, patients are exposed to increased bleeding risk, further aggravated by sepsis, thrombocytopenia, and high shear stress–induced acquired von Willebrand syndrome. The precarious balance between bleeding and thrombosis in percutaneous VAD–supported cardiogenic shock patients is often the main reason that patient outcomes are jeopardized, and there is a lack of data addressing optimal anticoagulation management strategies during percutaneous VAD support. Here, we present a parallel anti-Factor Xa/activated partial thromboplastin time-guided anticoagulation algorithm and discuss pitfalls of heparin monitoring in critically ill patients. This review will guide physicians toward a more standardized (anti)coagulation approach to tackle device-related morbidity and mortality in this critically ill patient group.
Sodium glucose cotransporter-2 (SGLT2) inhibitors improve cardiorenal outcomes in patients with type 2 diabetes mellitus, chronic kidney disease, and chronic heart failure. SGLT2 inhibitors also reduce the risk of cardiovascular mortality and hospitalization for heart failure among patients with type 2 diabetes mellitus and a remote history of myocardial infarction (MI). As a result of the growing body of evidence in diverse disease states, and the hypothesized mechanisms of action, it is reasonable to consider the potential of SGLT2 inhibition to improve outcomes in patients with acute MI as well if initiated early after presentation. Whether these therapies are efficacious and safe to use early in the course of acute coronary heart disease remains relatively unexplored. Here, we describe the contemporary data and continuing evidence gap for considering the use of SGLT2 inhibitors early following an acute MI to reduce cardiovascular morbidity and mortality.
Background Pivotal trials of percutaneous left atrial appendage occlusion (LAAO) used specific postprocedure treatment protocols.
Clinical, laboratory, and autopsy findings support an association between coronavirus disease-2019 (COVID-19) and thromboembolic disease. Acute COVID-19 infection is characterized by mononuclear cell reactivity and pan-endothelialitis, contributing to a high incidence of thrombosis in large and small blood vessels, both arterial and venous. Observational studies and randomized trials have investigated whether full-dose anticoagulation may improve outcomes compared with prophylactic dose heparin. Although no benefit for therapeutic heparin has been found in patients who are critically ill hospitalized with COVID-19, some studies support a possible role for therapeutic anticoagulation in patients not yet requiring intensive care unit support. We summarize the pathology, rationale, and current evidence for use of anticoagulation in patients with COVID-19 and describe the main design elements of the ongoing FREEDOM COVID-19 Anticoagulation trial, in which 3,600 hospitalized patients with COVID-19 not requiring intensive care unit level of care are being randomized to prophylactic-dose enoxaparin vs therapeutic-dose enoxaparin vs therapeutic-dose apixaban. (FREEDOM COVID-19 Anticoagulation Strategy [FREEDOM COVID]; NCT04512079)
Bioprosthetic valve dysfunction (BVD) and bioprosthetic valve failure (BVF) may be caused by structural or nonstructural valve dysfunction. Both surgical and transcatheter bioprosthetic valves have limited durability because of structural valve deterioration. The main objective of this summary of experts participating in a virtual workshop was to propose standardized definitions for nonstructural and structural BVD and BVF following aortic or mitral biological valve replacement with the goal of facilitating research reporting and implementation of these terms in clinical practice. Definitions of structural BVF, based on valve reintervention or death, underestimate the true incidence of BVF. However, definitions solely based on the presence of high transprosthetic gradient at a given echocardiogram during follow-up overestimate the incidence of structural BVD and BVF. Definitions of aortic or mitral structural BVD must therefore include the confirmation by imaging of permanent structural changes to the leaflets alongside evidence of deterioration in valve hemodynamic function at echocardiography follow-up
Objectives The authors sought to examine the outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusions (CTOs).
Objectives This study sought to compare the pharmacodynamic effects of pre-hospitally administered P2Y12 inhibitor prasugrel in crushed versus integral tablet formulation in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).
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