Balloon Aortic Valvuloplasty in the Transcatheter Aortic Valve Replacement Era: A "Die-Hard" Procedure

Percutaneous balloon aortic valvotomy (also known as balloon aortic valvuloplasty [BAV]) was first described in 1984 by Lababidi and Neuhaus1 and was reported for the treatment of congenital aortic..

YP10-03 Cross-cultural psychiatry, liaison psychiatry and other major challenges for modern psychiatrists

Beyond the awareness that psychiatry and contemporary medicine have undergone a dramatic change in recent years, walking the first steps as recently-qualified consultants in psychiatry is a major challenge. As a consequence of changes in society, technological progress and restricted funding availability, modern psychiatrists have to face problems that are new, and difficult to be faced, but also representing an opportunity to grow and contribute massively to medicine.This is particularly true in two specific fields, cross-cultural psychiatry and consultation-liaison psychiatry. The former is defined as psychiatry of disorders influenced by the cultural background; the latter is defined as the care of psychiatric disturbances in the medically ill. Though generic, these definitions highlight what is challenging in these branches of psychiatry: the disposition towards an inter-disciplinary approach to human illnesses. Both deepen their roots in the bio-psycho-social paradigm of George Engel and were in fact frequently mentioned in Engel's writings as the future of psychiatry. Training and clinical experience in cross-cultural and consultation-liaison psychiatry are to be major components of the curriculum of psychiatric trainees.Therefore, the role of psychiatrists and psychiatrists-to-be in the contemporary scientific community and society must be a strong one: on the side of scientific knowledge, by marking the complex, systemic nature of physiopathology and therapy; on the side of epistemology, by marking the paradoxes of bio-medicine; on the side of organization of health care, by promoting the need for a person-oriented approach to illness; and finally on the side of culture, society and ethics

Correlation Between Sagittal Balance and Mechanical Distal Junctional Failure in Degenerative Pathology of the Spine: A Retrospective Analysis

Study design Retrospective cohort study. Objectives This study aimed to investigate the failure of the caudal end of lumbar posterior fixation in terms of pre-operative and post-operative spinopelvic parameters, correction performed, demographic and clinical data. Methods The lumbar, thoraco-lumbar and lumbo-sacral posterior fixations performed with pedicle screws and rods in 2017-2019 were retrospectively analyzed. As 81% failures occurred within 4 years, an observational period of 4 years was chosen. The revision surgeries due to the failure in the caudal end were collected in the junctional group. Fixations which have not failed were gathered in the control group. The main spinopelvic parameters were measured for each patient on standing lateral radiographs with the software Surgimap. Demographic and clinical data were extracted for both groups. Results Among the 457 patients who met the inclusion criteria, the junctional group included 101 patients, who required a revision surgery. The control group collected 356 primary fixations. The two most common causes of revision surgeries were screws pullout (57 cases) and rod breakage (53 cases). SVA, PT, LL, PI-LL and TPA differed significantly between the two groups (P = .021 for LL, P < .0001 for all the others). The interaction between the two groups and the pre-operative and post-operative conditions was significant for PT, SS, LL, TK, PI-LL and TPA (P < .005). Sex and BMI did not affect the failure onset. Conclusions Mechanical failure is more likely to occur in patients older than 40 years with a thoraco-lumbar fixation where PT, PI-LL and TPA were not properly restored

Antithrombotic Therapy in Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has recently emerged as an effective alternative to medical treatment or surgical aortic valve replacement in all symptomatic patients with severe aortic stenosis and high or prohibitive risk and in intermediate risk when transfemoral access is feasible. Patients undergoing TAVR are often at high risk for either bleeding or cerebrovascular complications, or both, so adjuvant antithrombotic therapies are commonly used before, during and after the procedure. Today, there is no clear evidence on the best antithrombotic regimen in this context. In this review, we will try to go through the mechanisms involved in bleeding and embolic complications and we will discuss the current points of antithrombotic treatment in patients during and after TAVR, with or without oral anticoagulation (OAC) indication

Transcatheter aortic valve replacement in obese patients: procedural vascular complications with the trans-femoral and trans-carotid access routes

Obesity; Transcarotid; TransfemoralObesidad; Transcarotídea; TransfemoralObesitat; Transcaròtida; TransfemoralOBJECTIVES Obesity may increase the risk of vascular complications in transfemoral (TF) transcatheter aortic valve replacement (TAVR) procedures. The transcarotid (TC) approach has recently emerged as an alternative access in TAVR. We sought to compare vascular complications and early clinical outcomes in obese patients undergoing TAVR either by TF or TC vascular access. METHODS Multicentre registry including obese patients undergoing TF- or TC-TAVR in 15 tertiary centres. All patients received newer-generation transcatheter heart valves. For patients exhibiting unfavourable ileo-femoral anatomic characteristics, the TC approach was favoured in 3 centres with experience with it. A propensity score analysis was performed for overcoming unbalanced baseline covariates. The primary end point was the occurrence of in-hospital vascular complications (Valve Academic Research Consortium-2 criteria). RESULTS A total of 539 patients were included, 454 (84.2%) and 85 (15.8%) had a TF and TC access, respectively. In the propensity-adjusted cohort (TF: 442 patients; TC: 85 patients), both baseline and procedural valve-related characteristics were well-balanced between groups. A significant decrease in vascular complications was observed in the TC group (3.5% vs 12% in the TF group, odds ratio: 0.26, 95% CI: 0.07–0.95, P = 0.037). There were no statistically significant differences between groups regarding in-hospital mortality (TC: 2.8%, TF: 1.5%), stroke (TC: 1.2%, TF: 0.4%) and life-threatening/major bleeding events (TC: 2.8%, TF: 3.8%). CONCLUSIONS In patients with obesity undergoing TAVR with newer-generation devices, the TC access was associated with a lower rate of vascular complications. Larger randomized studies are warranted to further assess the better approach for TAVR in obese patients

Prevalence and time course of post-stroke pain: A multicenter prospective hospital-based study

OBJECTIVE: Pain prevalence data for patients at various stages after stroke. DESIGN: Repeated cross-sectional, observational epidemiological study. SETTING: Hospital-based multicenter study. SUBJECTS: Four hundred forty-three prospectively enrolled stroke survivors. METHODS: All patients underwent bedside clinical examination. The different types of post-stroke pain (central post-stroke pain, musculoskeletal pains, shoulder pain, spasticity-related pain, and headache) were diagnosed with widely accepted criteria during the acute, subacute, and chronic stroke stages. Differences among the three stages were analyzed with χ(2)-tests. RESULTS: The mean overall prevalence of pain was 29.56% (14.06% in the acute, 42.73% in the subacute, and 31.90% in the chronic post-stroke stage). Time course differed significantly according to the various pain types (P < 0.001). The prevalence of musculoskeletal and shoulder pain was higher in the subacute and chronic than in the acute stages after stroke; the prevalence of spasticity-related pain peaked in the chronic stage. Conversely, headache manifested in the acute post-stroke stage. The prevalence of central post-stroke pain was higher in the subacute and chronic than in the acute post-stroke stage. Fewer than 25% of the patients with central post-stroke pain received drug treatment. CONCLUSIONS: Pain after stroke is more frequent in the subacute and chronic phase than in the acute phase, but it is still largely undertreated

Long-term Transcatheter Aortic Valve Durability

Transcatheter aortic valve implantation (TAVI) has become the standard of care for high-risk and inoperable surgical patients and a valid alternative to surgery for low- and intermediate-risk patients with severe, symptomatic aortic stenosis. It is increasingly being used for younger, lower-risk patients, so it is important to ensure the durability for long-term transcatheter aortic valves. The lack of standard definitions of structural valve degeneration (SVD) had made comparison among studies on prosthetic valve durability problematic. The 2017 standardised definitions of SVD by the European Association of Percutaneous Cardiovascular Intervention), the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery, and the 2018 definitions by the Valve In Valve International Data group, has generated an increased uniformity in evaluations. This article examines the potential mechanisms and rates of SVD of transcatheter bioprostheses and the role of redo TAVI as a treatment option

Impact of Morbid Obesity and Obesity Phenotype on Outcomes After Transcatheter Aortic Valve Replacement

Teixit adipós epicàrdic; Obesitat mòrbida; Teixit adipós subcutaniTejido adiposo epicárdico; Obesidad mórbida; Tejido adiposo subcutáneoEpicardial adipose tissue; Morbid obesity; Subcutaneous adipose tissueBackground There is a paucity of outcome data on patients who are morbidly obese (MO) undergoing transcatheter aortic valve replacement. We aimed to determine their periprocedural and midterm outcomes and investigate the impact of obesity phenotype. Methods and Results Consecutive patients who are MO (body mass index, ≥40 kg/m2, or ≥35 kg/m2 with obesity‐related comorbidities; n=910) with severe aortic stenosis who underwent transcatheter aortic valve replacement in 18 tertiary hospitals were compared with a nonobese cohort (body mass index, 18.5–29.9 kg/m2, n=2264). Propensity‐score matching resulted in 770 pairs. Pre–transcatheter aortic valve replacement computed tomography scans were centrally analyzed to assess adipose tissue distribution; epicardial, abdominal visceral and subcutaneous fat. Major vascular complications were more common (6.6% versus 4.3%; P=0.043) and device success was less frequent (84.4% versus 88.1%; P=0.038) in the MO group. Freedom from all‐cause and cardiovascular mortality were similar at 2 years (79.4 versus 80.6%, P=0.731; and 88.7 versus 87.4%, P=0.699; MO and nonobese, respectively). Multivariable analysis identified baseline glomerular filtration rate and nontransfemoral access as independent predictors of 2‐year mortality in the MO group. An adverse MO phenotype with an abdominal visceral adipose tissue:subcutaneous adipose tissue ratio ≥1 (VAT:SAT) was associated with increased 2‐year all‐cause (hazard ratio [HR], 3.06; 95% CI, 1.20–7.77; P=0.019) and cardiovascular (hazard ratio, 4.11; 95% CI, 1.06–15.90; P=0.041) mortality, and readmissions (HR, 1.81; 95% CI, 1.07–3.07; P=0.027). After multivariable analysis, a (VAT:SAT) ratio ≥1 remained a strong predictor of 2‐year mortality (hazard ratio, 2.78; P=0.035). Conclusions Transcatheter aortic valve replacement in patients who are MO has similar short‐ and midterm outcomes to nonobese patients, despite higher major vascular complications and lower device success. An abdominal VAT:SAT ratio ≥1 identifies an obesity phenotype at higher risk of adverse clinical outcomes.This study was supported by Fundación Interhospitalaria para la Investigación Cardiovascular (FIC Foundation) via an unrestricted grant from Abbott