Subclavian Access for Transcatheter CoreValve® Aortic Prosthesis Implantation: Data from the Brazilian Registry

ABSTRACTBackgroundTransfemoral access is the preferred approach for transcatheter aortic valve implantation. However, some situations, such as the presence of peripheral vascular disease, preclude the use of such access. In these cases, subclavian access is an alternative approach for this procedure. This study aimed at evaluating the Brazilian experience using the subclavian approach for transcatheter CoreValve® prosthesis implantation.MethodsAortic valve area<1cm2, aortic valve ring≥20mm and≤27mm (26mm and 29mm CoreValve®), ascending aorta≤43mm and subclavian artery with a diameter≥6mm, without significant obstructive lesions, marked tortuosity and excess calcification were requisites for the procedure. The access through the subclavian artery was obtained by surgical dissection and, under direct vision, a subclavian artery puncture was performed. Once artery access was obtained, the standard technique was used.ResultsBetween January 2008 and April 2012, 8 patients with peripheral vascular disease underwent CoreValve® prosthesis implantation through the subclavian artery in 4 institutions. The procedure was successful in all cases with reduction of the mean transvalvular pressure gradient from 46.4±17.5mmHg to 9.3±3.6mmHg (P=0.0018) and improvement of symptoms. At 30 days and after 275±231 days of follow-up, 87.5% and 62.5% of the patients, respectively, were free from major adverse events (death, myocardial infarction, stroke and urgent cardiac suregery).ConclusionsIn the Brazilian experience, the subclavian access was a safe and effective alternative for transcatheter CoreValve® implantation

Multimodality imaging methods and systemic biomarkers in classical low-flow low-gradient aortic stenosis: Key findings for risk stratification

ObjectivesThe aim of the present study is to assess multimodality imaging findings according to systemic biomarkers, high-sensitivity troponin I (hsTnI) and B-type natriuretic peptide (BNP) levels, in low-flow, low-gradient aortic stenosis (LFLG-AS).BackgroundElevated levels of BNP and hsTnI have been related with poor prognosis in patients with LFLG-AS.MethodsProspective study with LFLG-AS patients that underwent hsTnI, BNP, coronary angiography, cardiac magnetic resonance (CMR) with T1 mapping, echocardiogram and dobutamine stress echocardiogram. Patients were divided into 3 groups according to BNP and hsTnI levels: Group 1 (n = 17) when BNP and hsTnI levels were below median [BNP &lt; 1.98 fold upper reference limit (URL) and hsTnI &lt; 1.8 fold URL]; Group 2 (n = 14) when BNP or hsTnI were higher than median; and Group 3 (n = 18) when both hsTnI and BNP were higher than median.Results49 patients included in 3 groups. Clinical characteristics (including risk scores) were similar among groups. Group 3 patients had lower valvuloarterial impedance (P = 0.03) and lower left ventricular ejection fraction (P = 0.02) by echocardiogram. CMR identified a progressive increase of right and left ventricular chamber from Group 1 to Group 3, and worsening of left ventricular ejection fraction (EF) (40 [31–47] vs. 32 [29–41] vs. 26 [19–33]%; p &lt; 0.01) and right ventricular EF (62 [53–69] vs. 51 [35–63] vs. 30 [24–46]%; p &lt; 0.01). Besides, there was a marked increase in myocardial fibrosis assessed by extracellular volume fraction (ECV) (28.4 [24.8–30.7] vs. 28.2 [26.9–34.5] vs. 31.8 [28.9–35.5]%; p = 0.03) and indexed ECV (iECV) (28.7 [21.2–39.1] vs. 28.8 [25.4–39.9] vs. 44.2 [36.4–51.2] ml/m2, respectively; p &lt; 0.01) from Group 1 to Group 3.ConclusionsHigher levels of BNP and hsTnI in LFLG-AS patients are associated with worse multi-modality evidence of cardiac remodeling and fibrosis

Segurança e eficácia dos stents farmacológicos eluidores de biolimus com polímero biodegradável: análise do registro EINSTEIN (Evaluation of Next-generation drug-eluting STEnt IN patients with coronary artery disease)

OBJETIVO: Avaliar a incidência de eventos adversos cardíacos maiores (morte cardíaca, infarto agudo do miocárdio ou necessidade de nova revascularização do vaso-alvo) em 1 ano em pacientes do "mundo real". MÉTODOS: O registro EINSTEIN é um estudo observacional prospectivo, unicêntrico, que incluiu consecutivamente 103 pacientes (152 lesões) tratados com o stent BiomatrixTM, eluidor de biolimus A9 e polímero biodegradável. RESULTADOS: A média das idades foi de 65,0±12,4 anos; o gênero masculino representou 83,5% dos pacientes; e 37,9% deles eram diabéticos. Em 1 ano, eventos adversos cardíacos maiores ocorreram em 11,7% dos pacientes, incluindo 2,9% de morte cardíaca, 4,9% de infarto agudo do miocárdio sem supradesnivelamento do segmento ST e 3,9% de revascularização do vaso-alvo. Trombose de stent esteve presente em apenas 1% (1 paciente) após o seguimento clínico de 1 ano. CONCLUSÃO: O presente registro sugere que os novos stents farmacológicos eluidores de biolimus A9 com polímero biodegradável são seguros e eficazes em pacientes da prática clínica diária, com baixas taxas de eventos adversos cardíacos maiores no longo prazo