Transcatheter Bioprosthetic Aortic Valve Durability: Where do we Stand?

Transcatheter aortic valve implantation (TAVI) was initially reserved for inoperable or high surgical risk patients with severe symptomatic aortic valve stenosis, but after the recent publication of randomized studies comparing TAVI to surgical aortic valve replacement (AVR) among intermediate risk (PARTNER 2 and SURTAVI) and low risk patients (PARTNER 3 and Evolut Low Risk), the momentum for further expansion of TAVI at the expense of AVR seems irreversible. The main obstacle before the wider application of TAVI for intermediate and lower risk patients is the uncertainty regarding bioprosthetic valve durability and the potential for structural deterioration and dysfunction over time. A concise overview regarding bioprosthetic valve durability issues, the relevant current scientific data and their importance for TAVI patient selection and management is herein presented. Rhythmos 2020;15(1):72-76

No-Reflow Phenomenon: A Major Issue Concerning Revascularization in Acute Coronary Syndromes

The no-reflow phenomenon (NRp), a dreaded complication of primary and also of any complex percutaneous coronary intervention (PCI), is characterized by insufficient myocardial perfusion in a territory of a coronary artery without evidence of mechanical obstruction. Microvascular injury is the underlying mechanism of NRp and its manifestation is not only impaired TIMI flow (<3), but also impaired TIMI myocardial perfusion grade (TMPG) which should be assessed in case of chest pain, persistent ST segment elevation or hemodynamic compromise despite the presence of TIMI III flow. The NRp mechanism is multifaceted, the evidence base for its treatment is inconsistent and limited, but its predictors are well known. The armamentarium against NRp consists of preventive and therapeutic strategies, both mechanical and pharmacological. A brief overview of all the above issues concerning NRp is attempted herein. Rhythmos 2019;14(2):27-30

An Undersized Stent Does Not Forgive

Stent thrombosis is a rare complication of percutaneous coronary intervention (PCI) with potential devastating results. Stent undersizing and malapposition are major risk factors of stent thrombosis and have been strongly associated with early stent thrombosis. However, despite the continuous progress of interventional cardiology, there is no consensus regarding optimal management of this medical emergency. Herein, we present a case of subacute stent thrombosis that manifested as a severe inferior ST-elevation myocardial infarction four days after an initial PCI of the right coronary artery. A stepwise treatment approach was followed aiming initially to achieve flow TIMI III without stenting during primary PCI. During a revision procedure, stent undersizing and malapposition were identified as underlying mechanisms of stent thrombosis using intravascular imaging guidance and treated successfully with corrective PCI. Further evidence is needed to refine the optimal treatment strategy in the setting of stent thrombosis. Rhythmos 2019;14(2):31-34.

Chronic Thoracic Aortic Dissection: How to Treat, When to Intervene

Thoracic aortic dissection (AD) is associated with increased morbidity and mortality. Acute aortic syndrome is the first presentation of the disease in most cases. While acute AD management follows concrete guidelines because of its urgent and life-threatening nature, chronic AD is usually overlooked, although it concerns a wide spectrum of patients surviving an acute event. Acute AD survivors ultimately enter a chronic aortic disease course. Patients with chronic thoracic AD (CTAD) require lifelong surveillance and a proportion of them may present with symptoms and late complications demanding further surgical or endovascular treatment. However, the available data concerning the management of CTAD is sparse in the literature. The management of patients with CTAD is challenging as far as determining the best medical therapy and deciding on intervention are concerned. Until recently, there were no guidelines or recommendations for imaging surveillance in patients with chronic AD. The diagnostic methods for imaging aortic diseases have been improved, while the data on new endovascular and surgical approaches has increased significantly. In this review, we summarize the current evidence in the diagnosis and management of CTAD and the latest recommendations for the surgical/endovascular aortic repair of CTAD