Emergently Alteration of Procedural Strategy During Transcatheter Aortic Valve Replacement to Prevent Coronary Occlusion: A Case Report

BackgroundCoronary occlusion is an uncommon but fatal complication of transcatheter aortic valve replacement (TAVR) with a poor prognosis.Case PresentationA patient with symptomatic severe bicuspid aortic valve stenosis was admitted to a high-volume center specializing in transfemoral TAVR with self-expanding valves. No anatomical risk factors of coronary occlusion were identified on pre-procedural computed tomography analysis. The patient was scheduled for a transfemoral TAVR with a self-expanding valve. Balloon pre-dilatation prior to prosthesis implantation was routinely used for assessing the supra-annular structure and assessing the risk of coronary occlusion. Immediately after the tubular balloon inflation, fluoroscopy revealed that the right coronary artery was not visible, and the flow in the left coronary artery was reduced. The patient would be at high-risk of coronary occlusion if a long stent self-expanding valve was implanted. Therefore, our heart team decided to suspend the ongoing procedure. A transapical TAVR with a 23 mm J-valve was performed 3 days later. The prosthesis was deployed at a proper position without blocking the coronary ostia and the final fluoroscopy showed normal flow in bilateral coronary arteries with the same filling as preoperatively.DiscussionOur successful case highlights the importance of a comprehensive assessment of coronary risk and a thorough understanding of the TAVR procedure for the heart team. A short-stent prosthesis is feasible for patients at high risk of coronary occlusion. Most importantly TAVR should be called off even if the catheter has been introduced when an extremely high risk of coronary obstruction is identified during the procedure and no solution can be found

Development and validation of a cognitive dysfunction risk prediction model for the abdominal obesity population

ObjectivesThis study was aimed to develop a nomogram that can accurately predict the likelihood of cognitive dysfunction in individuals with abdominal obesity by utilizing various predictor factors.MethodsA total of 1490 cases of abdominal obesity were randomly selected from the National Health and Nutrition Examination Survey (NHANES) database for the years 2011–2014. The diagnostic criteria for abdominal obesity were as follows: waist size ≥ 102 cm for men and waist size ≥ 88 cm for women, and cognitive function was assessed by Consortium to Establish a Registry for Alzheimer’s Disease (CERAD), Word Learning subtest, Delayed Word Recall Test, Animal Fluency Test (AFT), and Digit Symbol Substitution Test (DSST). The cases were divided into two sets: a training set consisting of 1043 cases (70%) and a validation set consisting of 447 cases (30%). To create the model nomogram, multifactor logistic regression models were constructed based on the selected predictors identified through LASSO regression analysis. The model’s performance was assessed using several metrics, including the consistency index (C-index), the area under the receiver operating characteristic (ROC) curve (AUC), calibration curves, and decision curve analysis (DCA) to assess the clinical benefit of the model.ResultsThe multivariate logistic regression analysis revealed that age, sex, education level, 24-hour total fat intake, red blood cell folate concentration, depression, and moderate work activity were significant predictors of cognitive dysfunction in individuals with abdominal obesity (p < 0.05). These predictors were incorporated into the nomogram. The C-indices for the training and validation sets were 0.814 (95% CI: 0.875-0.842) and 0.805 (95% CI: 0.758-0.851), respectively. The corresponding AUC values were 0.814 (95% CI: 0.875-0.842) and 0.795 (95% CI: 0.753-0.847). The calibration curves demonstrated a satisfactory level of agreement between the nomogram model and the observed data. The DCA indicated that early intervention for at-risk populations would provide a net benefit, as indicated by the line graph.ConclusionAge, sex, education level, 24-hour total fat intake, red blood cell folate concentration, depression, and moderate work activity were identified as predictive factors for cognitive dysfunction in individuals with abdominal obesity. In conclusion, the nomogram model developed in this study can effectively predict the clinical risk of cognitive dysfunction in individuals with abdominal obesity

Cerebral Ischemic Lesions after Transcatheter Aortic Valve Implantation in Patients with Non-Calcific Aortic Stenosis

Evidence for transcatheter aortic valve implantation (TAVI) is scarce among patients with non-calcific aortic stenosis, and it is not known whether aortic valve calcification is associated with new cerebral ischemic lesions (CILs) that are detected by diffusion-weighted magnetic resonance imaging. So, our study enrolled 328 patients who underwent transfemoral TAVI using a self-expanding valve between December 2016 and June 2021 from the TORCH registry (NCT02803294). A total of 34 patients were finally confirmed as non-calcific AS and the remaining 294 patients were included in the calcific AS group. Incidence of new CILs (70.6% vs. 85.7%, p = 0.022), number of lesions (2.0 vs. 3.0, p = 0.010), and lesions volume (105.0 mm3 vs. 200.0 mm3, p = 0.047) was significantly lower in the non-calcific AS group. However, the maximum and average lesion volumes were comparable between two groups. Non-calcific AS was associated with lower risk for developing new CILs by univariate logistic regression analysis [Odds ratio (OR): 0.040, 95% confident interval (CI): 0.18–0.90, p = 0.026] and multivariate analysis (OR: 0.031, 95% CI: 0.13–0.76, p = 0.010). In summary, non-calcific AS patients had a lower risk of developing new cerebral ischemic infarction after TAVI compared to calcific AS patients. However, new ischemic lesions were still found in over 70% of patients

Trimethylamine N-Oxide Levels Are Associated with Severe Aortic Stenosis and Predict Long-Term Adverse Outcome

Objective: Trimethylamine N-oxide (TMAO), a pathological microbial metabolite, is demonstrated to be related to cardiovascular diseases. This study was (1) to investigate the association between TMAO and aortic stenosis and (2) to determine the prognostic value of TMAO for predicting mortality after transcatheter aortic valve replacement (TAVR). Methods: 299 consecutive patients (77 (72–81) years, 58.2% male, Society of Thoracic Surgeons (STS) score 5.8 (4.9–9.3)) with severe aortic stenosis and 711 patients (59 (52–66) years, 51.9% male) without aortic stenosis were included in this retrospective study. A total of 126 pairs of patients were assembled by Propensity Score Matching. The primary outcome was all-cause mortality using survival analyses stratified by TMAO quartiles. Results: Patients with severe aortic stenosis had higher TMAO levels (3.18 (1.77–6.91) μmol/L vs. 1.78 (1.14–2.68) μmol/L, p p = 0.028) and higher late cumulative mortality (34.2% vs. 19.1%, log-rank p = 0.004). In Cox regression multivariate analysis, higher TMAO level remained an independent predictor (hazard ratio 1.788; 95% CI 1.064–3.005, p = 0.028) of all-cause mortality after adjusting for STS score, N-terminal pro b-type natriuretic peptide, and maximum velocity. Conclusions: The TMAO level was higher in aortic stenosis patients. Elevated TMAO was associated with poor adverse outcome after TAVR