Use of Double Stiff Wire Allows Successful Transfemoral Transcatheter Aortic Valve Implantation Through Extreme Thoracic Aorta Tortuosity

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467 Update on supra-annular sizing of transcatheter aortic valve prostheses in raphe-type bicuspid aortic valve disease according to the LIRA method

Abstract Aims Transcatheter Aortic Valve Replacement (TAVR) in patients with bicuspid aortic valve (BAV) still represents a challenge due to the peculiar anatomy and the lack of consensus for the optimal CT scan sizing method for prosthesis selection. Recent evidences have shown that transcatheter heart valve (THV) anchoring in BAV patients might occur at the raphe-level, known as the LIRA (Level of Implantation at the RAphe) plane. Furthermore, a novel supra-annular sizing method based on the measurement of the perimeter at the raphe-level (LIRA-method) was shown to be safe and effective in 20 consecutive BAV patients with severe aortic stenosis. The purpose of this study was to confirm the safety and the efficacy of the LIRA method in a larger study population. Methods and results the LIRA plane method was applied to all consecutive patients with raphe-type BAV disease between November 2018 to September 2021 in our centre. We prospectively sized TAVI prosthesis according to the manufacture recommendations on the basis of baseline CT scan perimeters at the LIRA plane. Post-procedural device success, defined according to Valve Academic Research Consortium-2 (VARC-2) criteria, was evaluated in the overall cohort. Forty-four patients were identified as having a raphe-type BAV disease at pre-TAVI CT scans. Mean patient age was 80 ± 6.2 years and 74% were males; median Society of Thoracic Surgeons (STS) predicted risk of mortality score was 4.3 (3.0–6.5). Three different BAV anatomies (36 patients with BAV type 1 with calcific raphe, 5 patients with BAV type 1 with fibrotic raphe, and 3 patients with BAV type 2) were implanted with different types of TAVI prostheses (6 Acurate Neo 2,16 Acurate Neo, 21 Core Valve Evolut R/Pro , 1 Lotus) sized prospectively according to the LIRA plane method. In all patients, there was a significant discrepancy between LIRA and virtual basal ring (VBR) measurements with LIRA plane perimeter smaller than VBR perimeter (mean perimeter LIRA 73.1 ± 8.3 mm vs. mean perimeter VBR 81.5 ± 6.6 mm; P < 0.001). The prostheses were sized according to the manufacture recommendations on the basis of the LIRA plane perimeter (diameter prosthesis implanted/diameter prosthesis according to LIRA plane = 1) (DPI/DP LIRA = 1) and significantly downsized according to the VBR perimeter (DPI/DP VBR 0.89; P < 0.001). The median prosthesis size was 25 mm (23–27). Pre-dilatation was frequently performed (86%) with a median balloon size of 20 mm (18–22), whereas post-dilatation was applied in 27% of the cases with a median balloon size of 23 mm (20–26). The LIRA plane method appeared to be highly successful (100% VARC-2 device success) with no procedural mortality, no valve migration, residual trivial/mild paravalvular leak with no cases of moderate-severe regurgitation and low transprosthetic gradient (residual mean gradient of 8.3 ± 3.5 mmHg) with no cases of mean gradient >20 mmHg pre-discharge. The rate of new pacemaker implantation was 9%. Conclusions Supra-annular sizing according to the LIRA plane method confirmed to be safe with a high device success in a larger study population. The application of the LIRA plane method might optimize TAVI prosthesis sizing in patients with raphe-type BAV disease

Complicated Bi-Pella Support: Acute Mitral Regurgitation and Bailout MitraClip Repair

During the last decades, the use of mechanical circulatory support devices (MCS) has increased exponentially. In this scenario, a fully percutaneous approach to biventricular cardiogenic shock has ..

In BCR-ABL1 Positive B-Cell Acute Lymphoblastic Leukemia, Steroid Therapy Induces Hypofibrinogenemia

Hypofibrinogenemia (HF) in adult acute lymphoblastic leukemia (ALL) of B lineage is uncommon and mostly associated with asparaginase (ASP) delivery. Since we noticed a significant reduction in fibrinogen (FBG) plasma levels even before the first ASP dose, we aim to assess the levels of FBG during induction treatment and explore if the FBG fall correlated with therapies other than asparaginase and/or specific leukemia biological features. We retrospectively analyzed FBG levels in 115 patients with B-ALL. In 74 (64%) out of 115 patients FBG decline occurred during the steroid prephase. In univariate analysis, such a steroid-related HF was significantly associated with BCR-ABL1 rearrangement (p = 0.00158). None of those experiencing HF had significant modifications of liver function tests during induction treatment. Our retrospective study suggests that in B-ALL, steroid therapy can also induce HF and that such an event is preferentially observed in patients carrying BCR-ABL1 rearrangements. The pathogenesis of this phenomenon is still unclear. We attempt to explain it by applying the International Society of Thrombosis and Hemostasis-Disseminated Intravascular Coagulation score (ISTH-DIC score); nonetheless additional studies are needed to clarify further the mechanisms of HF in this subset of patients

Clinical significance of occult central nervous system disease in adult acute lymphoblastic leukemia. A multicenter report from the Campus ALL Network

In acute lymphoblastic leukemia, flow cytometry detects more accurately leukemic cells in patients' cerebrospinal fluid compared to conventional cytology. However, the clinical significance of flow cytometry positivity with a negative cytology - occult central nervous system disease - is not clear. In the framework of the national Campus ALL program, we retrospectively evaluated the incidence of occult central nervous system disease and its impact on outcome in 240 adult patients with newly diagnosed acute lymphoblastic leukemia. All cerebrospinal fluid samples were investigated by conventional cytology and flow cytometry. The presence of ≥10 phenotypically abnormal events, forming a cluster, was considered as flow cytometry positivity. No central nervous system involvement was documented in 179 patients, while 18 were positive by conventional morphology and 43 were occult central nervous system disease positive. The relapse rate was significantly lower in central nervous system disease negative patients and the disease-free and overall survival were significantly longer in central nervous system disease negative patients than in those with manifest or occult central nervous system disease positive. In multivariate analysis, the status of manifest and occult central nervous system disease positivity was independently associated with a worse overall survival. In conclusion, we demonstrate that in adult acute lymphoblastic leukemia patients at diagnosis flow cytometry can detect occult central nervous system disease at high sensitivity and that the status of occult central nervous system disease positivity is associated with an adverse outcome. (Clinicaltrials.gov NCT03803670

The Alfieri’s edge-to-edge technique for mitral valve repair: from a historical milestone of cardiac surgery to the origin of the transcatheter era

After 30 years since its introduction, the edge-to-edge technique has become one of the most popular and adopted worldwide for surgical repair of mitral regurgitation. The success of this procedure could possibly be explained by its unique simplicity and high level of reproducibility. Indeed, it possesses the ability of being very versatile and it has been used in a wide spectrum of mitral valve pathologies and lesions: from degenerative to functional disease, from posterior to anterior leaflet lesions, including commissural defects. The rapidity of this easy surgical gesture has also enhanced its application in minimally invasive approaches. Finally, it has become a true milestone for the era of transcatheter correction of mitral regurgitation. Here, we describe the history and evolution of this breakthrough in the world of cardiac surgery

Transcatheter mitral repair and replacement: state of the art and future directions

Many patients affected by severe mitral regurgitation (MR) do not currently undergo surgery, mainly because of the high surgical risk due to old age, impaired left ventricular function and comorbidities. Consequently, many transcatheter devices are emerging with the purpose of treating MR in a less-invasive fashion, using different approaches and addressing different anatomic targets. The most widely used device in the clinical setting at present is the MitraClip system (Abbott Vascular, Inc., Menlo Park, CA, USA), which 'clips' the mitral leaflets together to force coaptation, and has shown optimal safety and acceptable clinical results, despite the high-risk profile of the patients in which it is commonly used. Other repair technologies include percutaneous neochordae implantation, direct and indirect annuloplasty, and reshaping of the left ventricle, but these are still undergoing limited clinical trials or preclinical experience. The combination of different repair techniques is likely to be required to achieve good long-lasting results. Transcatheter mitral valve implantation is also under development, and has already been carried out successfully in the context of valve-in-valve, whereas in the native scenario it remains an open challenge because of the particular anatomic and physiologic features of the mitral complex; hence, various prostheses using different concepts are emerging, and the first human cases have already been treated. Because data on the safety, efficacy and durability of all transcatheter mitral therapies are still limited, they are currently reserved to high-risk and inoperable patients, and their application requires an integrated Heart-Team approach. However, they represent the natural evolution of surgery and promise to expand treatment options and improve patient outcomes in the near future

Comparison of Outcomes of Percutaneous MitraClip Versus Surgical Repair or Replacement for Degenerative Mitral Regurgitation in Octogenarians

Octogenarians affected by mitral regurgitation (MR) are an increasing high-risk population. MitraClip repair is emerging as a promising option for this kind of patients. In this retrospective study, the outcomes of patients aged ≥80 years, affected by isolated degenerative MR, who underwent isolated transcatheter (n = 25) or surgical (n = 35, 29 repairs and 6 replacements) mitral intervention from September 2008 to February 2014 were compared. MitraClip patients had higher mean age (84.5 ± 3.2 vs 81.9 ± 2.0 years, p 2 (p 2 was 70% versus 100%, respectively (p 2 was not significantly associated with follow-up mortality in this elderly setting. After the introduction of MitraClip, octogenarian patients with isolated degenerative MR receiving mitral treatment significantly increased (p <0.01). In conclusion, MitraClip patients, despite being older, more symptomatic, and affected by more co-morbidities showed significantly reduced postoperative complications. Two-year mortality was higher in the MitraClip group likely because of co-morbidities. Transcatheter mitral repair resulted in more octogenarians being treated compared with the past

ACUTE KIDNEY INJURY FOLLOWING MITRACLIP IMPLANTATION: INCIDENCE, PREDICTS FACTORS AND PROGNOSTIC VALUE

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