Early and mid-term outcome of patients with low-flow-low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves

Peer reviewe

Optimization of left ventricular pacing site plus multipoint pacing improves remodeling and clinical response to cardiac resynchronization therapy at 1 year

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Multipoint pacing by a left ventricular quadripolar lead improves the acute hemodynamic response to CRT compared with conventional biventricular pacing at any site

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Early and mid-term outcome of patients with low-flow-low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves

Patients with non-paradoxical low-flow-low-gradient (LFLG) aortic stenosis (AS) are at increased surgical risk, and thus, they may particularly benefit from transcatheter aortic valve replacement (TAVR). However, data on this issue are still limited and based on the results with older-generation transcatheter heart valves (THVs). The aim of this study was to investigate early and mid-term outcome of TAVR with newer-generation THVs in the setting of LFLG AS. Data for the present analysis were gathered from the OBSERVANT II dataset, a national Italian observational, prospective, multicenter cohort study that enrolled 2,989 consecutive AS patients who underwent TAVR at 30 Italian centers between December 2016 and September 2018, using newer-generation THVs. Overall, 420 patients with LVEF <= 50% and mean aortic gradient <40 mmHg were included in this analysis. The primary outcomes were 1-year all-cause mortality and a combined endpoint including all-cause mortality and hospital readmission due to congestive heart failure (CHF) at 1 year. A risk-adjusted analysis was performed to compare the outcome of LFLG AS patients treated with TAVR (n = 389) with those who underwent surgical aortic valve replacement (SAVR, n = 401) from the OBSERVANT I study. Patients with LFLG AS undergoing TAVR were old (mean age, 80.8 +/- 6.7 years) and with increased operative risk (mean EuroSCORE II, 11.5 +/- 10.2%). VARC-3 device success was 83.3% with 7.6% of moderate/severe paravalvular leak. Thirty-day mortality was 3.1%. One-year all-cause mortality was 17.4%, and the composite endpoint was 34.8%. Chronic obstructive pulmonary disease (HR 1.78) and EuroSCORE II (HR 1.02) were independent predictors of 1-year mortality, while diabetes (HR 1.53) and class NYHA IV (HR 2.38) were independent predictors of 1-year mortality or CHF. Compared with LFLG AS treated with SAVR, TAVR patients had a higher rate of major vascular complications and permanent pacemaker, while SAVR patients underwent more frequently to blood transfusion, cardiogenic shock, AKI, and MI. However, 30-day and 1-year outcomes were similar between groups. Patients with non-paradoxical LFLG AS treated by TAVR were older and with higher surgical risk compared with SAVR patients. Notwithstanding, TAVR was safe and effective with a similar outcome to SAVR at both early and mid-term

Sex-Specific Considerations in Degenerative Aortic Stenosis for Female-Tailored Transfemoral Aortic Valve Implantation Management

The impact of sex on pathophysiological processes, clinical presentation, treatment options, as well as outcomes of degenerative aortic stenosis remain poorly understood. Female patients are well represented in transfemoral aortic valve implantation (TAVI) trials and appear to derive favorable outcomes with TAVI. However, higher incidences of major bleeding, vascular complications, and stroke have been reported in women following TAVI. The anatomical characteristics and pathophysiological features of aortic stenosis in women might guide a tailored planning of the percutaneous approach. We highlight whether a sex-based TAVI management strategy might impact on clinical outcomes. This review aimed to evaluate the impact of sex from diagnosis to treatment of degenerative aortic stenosis, discussing the latest evidence on epidemiology, pathophysiology, clinical presentation, therapeutic options, and outcomes. Furthermore, we focused on technical sex-oriented considerations in TAVI including the preprocedural screening, device selection, implantation strategy, and postprocedural management

Стан та перспективи конкурентоспроможності галузі національного господарства в умовах глобалізації

Метою дослідження є узагальнення нових теоретичних положень розвитку галузей економіки в умовах глобалізації, визначення загальних конкурентних переваг хімічної галузі України та практичних напрямів сучасного розвитку економіки країни

Prevalence, predictors, and outcomes of patient prosthesis mismatch in women undergoing TAVI for severe aortic stenosis: Insights from the WIN-TAVI registry

Objective: To evaluate the incidence, predictors and outcomes of female patients with patient-prosthesis mismatch (PPM) following transcatheter aortic valve intervention (TAVI) for severe aortic stenosis (AS). Background: Female AS TAVI recipients have a significantly lower mortality than surgical aortic valve replacement (SAVR) recipients, which could be attributed to the potentially lower PPM rates. TAVI has been associated with lower rates of PPM compared to SAVR. PPM in females post TAVI has not been investigated to date. Methods: The WIN-TAVI (Women's INternational Transcatheter Aortic Valve Implantation) registry i

Prolonged higher dose methylprednisolone vs. conventional dexamethasone in COVID-19 pneumonia: a randomised controlled trial (MEDEAS)

Dysregulated systemic inflammation is the primary driver of mortality in severe COVID-19 pneumonia. Current guidelines favor a 7-10-day course of any glucocorticoid equivalent to dexamethasone 6 mg·day-1. A comparative RCT with a higher dose and a longer duration of intervention was lacking

Transcatheter aortic valve implantation

Although surgery with prosthetic valve replacement is the gold standard for severe aortic stenosis (AS) treatment, there are still about one third of patients that are not operated because of inoperability criteria or high surgical risk. Therefore, with the ageing of global population, the lengthening in life-expectancy and the consequent growing need to treat elderly patients with severe AS, there is a wide population who would benefit from a less invasive way of replacing the aortic valve. Transcatheter aortic valve implantation (TAVI) allows the aortic valve to be implanted without a sternotomy, with beating heart and without the need for routine cardiopulmonary support. This technique, pioneered by Alain Cribier and co-workers in 2002, has been used in more than 20,000 patients throughout the world. Currently, two transcatheter devices are approved for clinical use and are commercially available in Europe, i.e. the balloon expandable device (Edwards Sapien XT valve, Edwards LifeSciences) and the self-expandable (SE) device (CoreValve Revalving System; Medtronic). The acute success rate of this procedure is now increasing to about 95% in expert hands. In addition, several studies have shown that these prosthetic valves maintain good hemodynamic characteristics over both the shortand medium-term. However, we must await long-term results on potential complications and on the durability of transcatheter valves before this treatment approach can be applied to younger patients or to patients at low surgical risk. In this study we report our perspective single centre experience about TAVI in a high volume centre, the Department of Cardiac, Thoracic and Vascular Sciences of the University of Padua, using both balloon expandable and SE devices, through all the currently available vascular approaches. We report on early and follow up results, focusing on both clinical outcome and haemodynamic performance of the devices. We also investigated some peculiar fields of application, such as the treatment of bioprosthesis dysfunction, and speculated on the main potential procedural complications, such as the conduction disorders and the periprosthesis leakage. We strongly believe that, once some current limitations and concerns are overcome, this emerging technique will have a very fast and wide spread. However, it should not be forgotten that, in order to guarantee the extraordinary success of this new minimally invasive procedure, the heart team approach should remain a key-point. This will allow to select the best device and the most appropriate vascular access for each patient, as well as to guarantee the best technical result and the necessary post-procedural care.Sebbene la chirurgia tradizionale sia la tecnica di scelta per il trattamento della stenosi aortica serrata, nella pratica clinica tuttavia circa un terzo dei pazienti non viene sottoposto a chirurgia sostitutiva per inoperabilità o eccessivo rischio chirurgico. Con l’aumentare dell’età media della popolazione, l’entità di questo problema è destinato ad aumentare, per cui vi è una sempre più ampia popolazione di pazienti che potrebbe beneficiare di tecniche operatorie meno invasive. L’impianto di valvola aortica per via transcatetere (TAVI) consente di applicare una protesi aortica evitando la sternotomia, l’arresto cardioplegico e senza la necessità di circolazione extracorporea. Questa tecnica è stato introdotta nel 2002 da Alain Cribier e dai suoi collaboratori e oggigiorno nel mondo sono stati eseguiti ormai oltre 20.000 interventi di TAVI. Attualmente esistono due dispositivi transcatetere approvati per uso clinico e disponibili in commercio in Europa, la valvola espandibile su palloncino (Edwards Sapien XT, Edwards Lifesciences) e la valvola auto-espandibile (CoreValve Revalving System, Medtronic). Il tasso di successo procedurale di questa procedura è attualmente in aumento e supera il 95% in mani esperte. Inoltre, diversi studi stanno dimostrando che queste protesi valvolari hanno buone caratteristiche emodinamiche sia a breve che a medio termine. Tuttavia, è necessario attendere risultati più a lungo termine sulle potenziali complicanze e sulla durata di queste valvole transcatetere, prima che questo tecnologia possa essere applicata anche in pazienti più giovani o a minor rischio chirurgico. In questo studio è riportata la nostra esperienza prospettica monocentrica nell’ambito della TAVI, raccolta in un centro ad alto volume, il Dipartimento di Scienze Cardiache, Toraciche e Vascolari dell'Università di Padova, utilizzando entrambi i dispositivi, espandibile su pallone ed autoespandibile, tramite tutti i gli approcci vascolari attualmente disponibili. Sono riportati i risultati immediati ed al follow-up, sia dal punto di vista del miglioramento clinico che della performance emodinamica delle protesi. Sono stati analizzati anche alcuni campi particolari di applicazione della metodica, come ad esempio il trattamento della disfunzione di bioprotesi, e abbiamo discusso sulle principali potenziali complicanze procedurali, come ad esempio i disturbi della conduzione cardiaca e i leak periprotesici. Dall’esperienza fino ad ora maturata, noi siamo fermamente convinti che, non appena alcune attuali limitazioni ed alcune perplessità saranno chiarite, questa tecnica emergente subirà una rapidissima ed ampia diffusione. Tuttavia non bisogna dimenticare che, per continuare a garantire lo straordinario successo di questa nuova metodica, il concetto di heart team, e quindi di una stretta collaborazione fra diversi specialisti, deve rimanere un punto centrale e irrinunciabile, per poter selezionare la miglior protesi ed il più appropriato approccio in ogni paziente, oltre che per garantire un perfetto risultato tecnico e le necessarie cure ed assistenze post-procedurali