DOES PRE-EXISTING AORTIC REGURGITATION PROTECTS FROM DEATH IN PATIENTS WHO DEVELOP PARAVALVULAR LEAK AFTER TRANSCATHETER AORTIC VALVE IMPLANTATION?

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Total Endovascular Aortic Arch Repair: From Dream to Reality

The gold-standard therapy for the treatment of aortic arch pathologies is conventional open surgery. Recently, total endovascular aortic arch replacement with branched stent-grafts has been introduced into clinical practice with the aim of reducing invasiveness especially in selected high-risk patients. The aim of this review is to describe the two most commonly used branched devices for endovascular arch stent-grafting: Nexus (Endospan, Herzlia, Israle) and RelayBranch (Terumo Aortic, Glasgow, United Kingdom). Nexus is a CE-certified off-the-shelf, single branch, double stent graft system. It consists of two different components: a main module for the aortic arch and the descending aorta with a side-branch for the brachiocephalic artery (BCA), and a curved module for the ascending aorta that lands into the sino-tubular junction and connects to the main module through a side-facing self-protecting sleeve. Nexus may be used in urgent-emergency cases and also in patients with only one suitable supra-aortic target vessel but, on the other hand, it makes cerebral blood flow dependent on one source vessel only. The RelayBranch Thoracic Stent-Graft System is a custom made, double branched endograft with a wide window on its superior portion to accommodate two inner tunnels for BCA and left common carotid artery connection; bilateral cervical accesses are generally used to advance guidewires for catheterization of the inner tunnels in a retrograde fashion. RelayBranch can be customized on every patient’s specific anatomy and provides a double blood source for the brain, but it cannot be used in urgent-emergency conditions. Therefore, in order to optimize outcomes, the choice of the most appropriate device should be made considering pros and cons of each system and patient’s anatomy by an experienced aortic team. In conclusion, total endovascular aortic arch exclusion is a promising reality in selected high-risk patients

An Unexpected Finding

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Unravelling the (arte)fact of increased pacemaker rate with the Edwards SAPIEN 3 valve

none11Early data on the Edwards SAPIEN 3 valve (S3-THV) have shown low rates of paravalvular leaks and vascular complications but relatively high 30-day permanent pacemaker implantation (PPMI) rates. No direct comparisons on clinical outcomes including PPMI rates are available for the S3-THV and the Edwards SAPIEN XT (XT-THV). We aimed to compare the 30-day PPMI rates in patients treated with the two prostheses and to assess the interplay among valve type, depth of implantation and PPMI rate.mixedTarantini, Giuseppe; Mojoli, Marco; Purita, Paola; Napodano, Massimo; D'Onofrio, Augusto; Frigo, Annachiara; Covolo, Elisa; Facchin, Michela; Isabella, Giambattista; Gerosa, Gino; Iliceto, SabinoTarantini, Giuseppe; Mojoli, MARCO ALBERTO; Purita, PAOLA ANGELA MARIA; Napodano, Massimo; D'Onofrio, Augusto; Frigo, ANNA CHIARA; Covolo, Elisa; Facchin, Michela; Isabella, Giambattista; Gerosa, Gino; Iliceto, Sabin

Impact of Changes in Left Ventricular Ejection Fraction on Survival After Transapical Aortic Valve Implantation

BACKGROUND: This single-center retrospective study assessed the variation of left ventricular ejection fraction (LVEF) after transapical transcatheter aortic valve implantation and its effect on survival. We also evaluated the effect of sheath diameter on LVEF. METHODS: We analyzed data of all consecutive patients who underwent transapical transcatheter aortic valve implantation with the Sapien (Edwards Lifesciences, Irvine, CA) device (and its evolutions) between 2009 and 2015. We analyzed the difference between preoperative LVEF and LVEF at discharge (\u394EF = LVEFpost-op - LVEFpre-op) and considered its interquartile range (\ub15%) as the cutoff. Patients were divided in three groups: (1) improved LVEF (\u394EF 65 +5%); (2) unchanged LVEF (\u394EF -5% to +5%), and (3) worsened LVEF (\u394EF 64 -5%). Survival was evaluated with Kaplan-Meier analysis, and logistic regression multivariable analysis was used to determine independent predictors of LVEF improvement. RESULTS: Data of 122 patients were analyzed. Patients in the three groups were distributed as follows: (group 1) 27 patients (22.1%), (group 2) 69 (56.6%), and (group 3) 26 (21.3%). The mean \u394EF was 12.7% \ub1 4.7% in group 1 and -10.8% \ub1 3.9% in group 3. The \u394EF was more likely to improve in patients with preoperative LVEF of less than 0.35 (p = 0.014). There were no significant differences in survival (p = 0.41), rehospitalization (p = 0.472), and New York Heart Association Functional Classification (p = 0.307) among the groups. The use of the smallest available sheath (18F) was not associated with a significant change of \u394EF. CONCLUSIONS: LVEF worsened in a small number of patients after transapical transcatheter aortic valve implantation, but this change was not associated with worse postoperative outcomes. Patients with a low LVEF showed better improvement. The progressive reduction of sheath diameter does not have a significant effect on LVEF changes