Perspective Chapter: Valve-in-Valve Transcatheter Aortic Valve Replacement (ViV) for Failed Bioprosthetic Valves

Aortic valve disease remains the second most common valvular heart disease worldwide. Surgical aortic valve replacement (SAVR) with mechanical or bioprosthetic valves and transcatheter aortic valve replacement (TAVR) with bioprosthetic valves are both approved therapies for patients with severe aortic stenosis (AS) across all surgical risk categories. On the other hand, SAVR remains the mainstay of treatment for severe aortic regurgitation (AR) with TAVR reserved for selected patients at prohibitive surgical risk. Both surgical and transcatheter bioprosthetic valves are prone to bioprosthetic valve failure (BVF) due to various etiologies, and can lead to restenosis, regurgitation, or a combination of both. BVF can now be addressed by repeat valve replacement whether surgical or valve-in-valve TAVR (ViV). ViV is a desirable option for elderly patients at high surgical risk and requires meticulous planning with pre-operative CT imaging to optimize outcomes and minimize complications

Rotational atherectomy for calcified lesions during ST-segment elevation myocardial infarction: a case series and literature review

BACKGROUND: ST elevation myocardial infarction (STEMI) has traditionally been a relative contraindication for the utilization of rotational atherectomy (RA). However, in severely calcified lesions, RA may be necessary to facilitate stent delivery. CASE SUMMARY: Three patients who present with STEMI are found to have severely calcified lesions on intravascular ultrasound. Equipment was unable to pass the lesions in all three cases. Rotational atherectomy was therefore performed to allow for stent passage. All three cases had achieved successful revascularization with no intraoperative or post-operative complications. The patients remained angina-free the rest of their hospitalization and at the 4 month follow-up. DISCUSSION: Rotational atherectomy for calcific plaque modification during STEMI when equipment will not pass is a feasible and safe therapeutic option

COMPARISON OF TRANSRADIAL VERSUS TRANSFEMORAL ACCESS FOR PERCUTANEOUS CORONARY INTERVENTION IN STEMI PATIENTS: A META-ANALYSIS OF RANDOMIZED TRIALS

BackgroundTransradial access (TRA) is increasingly being used for percutaneous coronary intervention (PCI) in ST- segment elevation myocardial infarction (STEMI) in lieu of transfemoral access (TFA). We conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of the two approaches in STEMI-PCI.MethodsPubMed, Cochrane, Embase databases and major national conference proceedings were systematically searched for RCTs comparing TRA and TFA in patients undergoing PCI for STEMI. Efficacy outcomes studied were all-cause mortality, major adverse cardiovascular events (MACE), myocardial infarction (MI), and stroke. Safety outcomes included major bleeding and vascular complications. Risk ratios (RR) and 95 % Confidence Intervals (CI) were calculated using random effects model.Results17 trials met our inclusion criteria with a total of 12018 patients (TRA: 5958 and TFA: 6060). At a mean follow-up of 4.8 +/- 8.2 months, rates of all-cause mortality (RR: 0.71, 95% CI = 0.57 - 0.88), major bleeding (RR: 0.59, 95% CI = 0.45 - 0.77), and vascular complications (RR: 0.42, 95% CI = 0.32 - 0.56) were lower in TRA compared with TFA (Figure 1), while there was no difference in rates of MACE, MI, or stroke between groups. Hospital length of stay was lower in the TRA group.ConclusionTRA is associated with better short-term survival and lower rates of major bleeding and vascular complications compared with TFA in STEMI patients undergoing PCI

Meta-Analysis of Transradial vs Transfemoral Access for Percutaneous Coronary Intervention in Patients With ST Elevation Myocardial Infarction.

Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared with TFA in STEMI patients undergoing PCI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and recent major scientific conference sessions from inception to October 15th, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infarction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N = 12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.57 to 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 to 0.77), and vascular complications (RR: 0.42, 95%CI: 0.32 to 0.56) compared with TFA. There was no difference in the incidence of myocardial infarction (MI), stroke, or procedure duration between the 2 groups. The difference in all-cause mortality between TRA and TFA was statistically nonsignificant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI