Comparison of transcarotid versus transapical transcatheter aortic valve implantation outcomes in patients with severe aortic stenosis and contraindications for transfemoral access

Background: The purpose of this study was to compare the safety and clinical outcomes of transcarotid (TC) and transapical access (TA) transcatheter aortic valve implantation (TAVI) patients whom the transfemoral approach (TF) was not feasible. Methods: The analysis included consecutive patients with severe symptomatic aortic stenosis treated from 2017 to 2020 with TC-TAVI or TA-TAVI in two high-volume TAVI centers. The approach was selected by multidisciplinary heart teams after analyzing multislice computed tomography of the heart, aorta and peripheral arteries, transthoracic echocardiography and coronary angiography. Results: One hundred and two patients were treated with alternative TAVI accesses (TC; n = 49 and TA; n = 53) in our centers. The groups were similar regarding age, gender, New York Heart Association class, and echocardiography parameters. Patients treated with TC-TAVI had significantly higher surgical risk. The procedural success rate was similar in both groups (TC-TAVI 98%; TA-TAVI 98.1%; p = 0.95). The rate of Valve Academic Research Consortium-2 defined clinical events was low in both groups. The percentage of new-onset rhythm disturbances and permanent pacemaker implantation was similar in TC and TA TAVI (4.1% vs. 11.3%; p = 0.17 and 10.2% vs. 5.7%; p = 0.39, respectively). In the TA-TAVI group, significantly more cases of pneumonia and blood transfusions were observed (11% vs. 0%; p = 0.01 and 30.2% vs. 12.2%; p = 0.03). The 30-day mortality was similar in TC and TA groups (4.1% vs. 5.7%; p = 0.71, respectively). Conclusion: Both TC and TA TAVI are safe procedures in appropriately selected patients and are associated with a low risk of complications

Lewozymendan w terapii ostrych zespołów wieńcowych powikłanych ostrą niewydolnością serca

Levosimendan is an inodilator that improves myocardial contractility, thus increasing left ventricle ejection fraction and cardiac index. Simultaneously with vasodilatatory effect, levosimendan reduces cardiac preload and afterload, improving coronary flow. In contrast to other inotropes and vasopressors, levosimendan does not increase myocardial oxygen consumption and has anti-stunning effect in myocardial infarction. According to an extensive spectrum of action, levosimendan seems to be most beneficial in a group of patients with acute heart failure and pulmonary congestion complicating acute coronary syndrome. Another beneficial group seems to be patients under beta-adrenergic blockade with chronic administration of beta-receptor blockers. So far, in this particular clinical aspect, there is a paucity of large, randomized clinical trials comparing levosimendan to standard inotropic support pharmacotherapy according to short- and long-term survival.Lewozymendan, jako inodylatator zwiększa kurczliwość mięśnia sercowego, frakcję wyrzutową lewej komory (LVEF) oraz wskaźnik sercowy (CI), jednocześnie powodując wazodylatację, co skutkuje obniżeniem obciążenia wstępnego i następczego serca z poprawą przepływu wieńcowego. Mechanizm działania lewozymendanu, w przeciwieństwie do innych leków inotropowych oraz wazopresorów, sprawia, że nie wzrasta zapotrzebowanie mięśnia sercowego na tlen. Dodatkowo lek ten zmniejsza obszar ogłuszonego mięśnia sercowego w zawale,co świadczy o jego kardioprotekcyjnym działaniu. Biorąc pod uwagę spektrum działania lewozymendanu, wydaje się, że szczególną grupą pacjentów odnoszących korzyść z terapii tym lekiem są pacjenci z ostrym zespołem wieńcowym powikłanym ostrą niewydolnością serca z obrzękiem płuc oraz pacjenci przewlekle przyjmujący beta-blokery. Jednakże w tym szczególnym aspekcie klinicznym brakuje dużych, randomizowanych badań klinicznych porównujących lewozymendan ze standardową farmakoterapią zapewniającą wsparcie inotropowe pod względem przeżycia zarówno krótko-, jak i długoterminowego

Clinical outcomes following large vessel coronary artery perforation treated with covered stent implantation : clinical outcomes following large vessel coronary artery perforation treated with covered stent implantation

Data on the clinical outcomes comparing synthetic fluorocarbon polymer polytetrafluoroethylene- (PTFE, GraftMaster) and polyurethane- (Papyrus) covered stents (CSs) to seal coronary artery perforations (CAPs) are limited. We aimed to evaluate 30-day and 1-year clinical outcomes after PCI complicated by CAP and treated with CS. We assessed 106 consecutive patients with successful CAP sealing (122 CSs): GraftMaster (51 patients, 57 CSs) or Papyrus CS (55 patients, 65 CSs). The primary endpoint was the occurrence of major adverse cardiac events (MACE), defined as the composite of cardiac death, target lesion revascularisation (TLR), and myocardial infarction (MI). The mean age of subjects was 69 ± 9.6 years (53.8% males). No significant differences were identified between the GraftMaster and Papyrus groups at the 30-day follow-up for MACE, cardiac death, MI and stent thrombosis (ST), while significantly lower rate of TLR and TVR (p = 0.02) were confirmed in the Papyrus group. At one year, differences remained similar between stents for MACE, a trend towards a lower rate of TLR (p = 0.07), MI (p = 0.08), and ST (p = 0.08), and higher for cardiac death (p = 0.07) was observed in the Papyrus group. This real-life registry of CAP illustrated that the use of Papyrus CS is associated with lower rates of TLR and TVR at 30-day follow-up in comparison to the GraftMaster CSs and no significant differences between both assessed CS at one year of follow-up

Long-term outcomes following drug-eluting balloons versus thin-strut drug-eluting stents for treatment of recurrent restenosis in drug-eluting stents

BACKGROUND: There is limited data on the optimal revascularization strategy in patients with recurrent in-stent restenosis (R-ISR). AIMS: To compare the long-term outcomes of patients treated with either a thin-strut DES (thin-DES) or a drug-eluting balloon (DEB) for R-ISR in a drug-eluting stent (DES). METHODS: A multicenter DEB-DRAGON registry was used to retrospectively identify patients with R-ISR who received either a thin-DES or a DEB. Propensity score matching was applied to adjust for baseline differences. Primary outcome was target lesion revascularization (TLR). RESULTS: Out of 311 patients (mean age 67 years, 63% male) with R-ISR, 86 (27.7%) were treated with a thin-DES and 225 (72.3%) with a DEB. Median follow-up was 2.6 years. TLR occurred in 18 (20.9%) of patients who received thin-DES and 61 (27.1%) patients treated with DEB (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.33–0.98; log-rank P = 0.04). The difference remained significant in a propensity score-matched cohort of 57 patients treated with thin-DES and 57 patients treated with a DEB (17.5 vs. 33.3% respectively; HR, 0.38; 95% CI, 0.17–0.86; P = 0.01). The risks of device oriented adverse cardiac events and all-cause mortality were similar after thin-DES or DEB in both unadjusted and propensity score-matched cohorts. In a multivariable Cox proportional hazard model the treatment with a thin-DES was an independent predictor of a TLR-free survival (HR, 0.33; 95% CI 0.13–0.84; P = 0.02). CONCLUSIONS: In patients with R-ISR implantation of a thin-DES is associated with lower risk of repeated revascularization compared with angioplasty with a DEB

Procedural and 1-year outcomes following large vessel coronary artery perforation treated by covered stents implantation: Multicentre CRACK registry.

BackgroundData regarding the clinical outcomes of covered stents (CSs) used to seal coronary artery perforations (CAPs) in the all-comer population are scarce. The aim of the CRACK Registry was to evaluate the procedural, 30-days and 1-year outcomes after CAP treated by CS implantation.MethodsThis multicenter all-comer registry included data of consecutive patients with CAP treated by CS implantation. The primary endpoint was the composite of major adverse cardiac events (MACEs), defined as cardiac death, target lesion revascularization (TLR), and myocardial infarction (MI).ResultsThe registry included 119 patients (mean age: 68.9 ± 9.7 years, 55.5% men). Acute coronary syndrome, including: unstable angina 21 (17.6%), NSTEMI 26 (21.8%), and STEMI 26 (21.8%), was the presenting diagnosis in 61.3%, and chronic coronary syndromes in 38.7% of patients. The most common lesion type, according to ACC/AHA classification, was type C lesion in 47 (39.5%) of cases. A total of 52 patients (43.7%) had type 3 Ellis classification, 28 patients (23.5%) had type 2 followed by 39 patients (32.8%) with type 1 perforation. Complex PCI was performed in 73 (61.3%) of patients. Periprocedural death occurred in eight patients (6.7%), of which two patients had emergency cardiac surgery. Those patients were excluded from the one-year analysis. Successful sealing of the perforation was achieved in 99 (83.2%) patients. During the follow-up, 26 (26.2%) patients experienced MACE [7 (7.1%) cardiac deaths, 13 (13.1%) TLR, 11 (11.0%) MIs]. Stent thrombosis (ST) occurred in 6 (6.1%) patients [4(4.0%) acute ST, 1(1.0%) subacute ST and 1(1.0%) late ST].ConclusionsThe use of covered stents is an effective treatment of CAP. The procedural and 1-year outcomes of CAP treated by CS implantation showed that such patients should remain under follow-up due to relatively high risk of MACE

Long-term outcomes following drug-eluting balloon or thin-strut drug-eluting stents for treatment of in-stent restenosis stratified by duration of dual antiplatelet therapy (DEB-Dragon Registry)

INTRODUCTION: Data regarding the duration of dual antiplatelet therapy (DAPT) in patients with drug-eluting stent restenosis (DES-ISR) treated with percutaneous coronary intervention (PCI) and drug-eluting balloons (DEB) or DES are not unambiguous. AIM: To evaluate the relationship between long-term outcomes and the length of DAPT in patients treated with PCI due to DES-ISR with DEB or DES. MATERIAL AND METHODS: Overall, a total of 1,367 consecutive patients with DES-ISR, who underwent PCI with DEB or DES between 2008 and 2019 entered the study. The mean length of the follow-up was 1,298.7 ±794 days. We assessed study endpoints according to the duration of DAPT (≤ 3 vs. > 3 and ≤ 6 vs. > 6 months) before and after propensity score matching (PSM): stroke, target lesion revascularisation (TLR), target vessel revascularisation (TVR), myocardial infarction (MI), death and device oriented composite endpoints (DOCE). Kaplan-Meier estimates were created to differentiate long-term outcomes. RESULTS: Pairwise contrast analysis considering type of PCI (DES vs. DEB) and duration of DAPT (≤ 6 vs. > 6 months) before PSM revealed superiority of DES + DAPT > 6 months vs. DEB + DAPT > 6 months for DOCE (p 6 months is related to a higher stroke rate (p = 0.01) when compared to ≤ 6 months. CONCLUSIONS: Treatment with DAPT in patients with DES-ISR is related to better long-term outcomes in the case of PCI with DES than DEB. DAPT > 6 months is related to the greater rate of strokes, independently of the type of treatment (DES and DEB) than DAPT ≤ 6 months