Description and validation of TAVIApp: A novel mobile application for support of physicians in the management of aortic stenosis - Management of aortic stenosis with TAVIApp

Background. Aortic stenosis (AS) is the most common heart valve disease in developed countries. The advent of transcatheter aortic valve implantation (TAVI) significantly improved patients' outcome but made clinical management more complex. The aim of the present study was to describe TAVIApp, a mobile app we developed to guide the management of AS, and test its efficacy. Methods and Results. Clinical cases comprising 42 patients with AS were blindly evaluated by (A) an interventional cardiologist, assisted by the Heart Team (EXPERT), (B) young residents in cardiology, and (C) a young resident supported by TAVIApp. There was poor concordance between Group A and Group B with low performance by young residents (k=0.52; p<0.001). However, concordance increased to an optimal value when young residents were supported by TAVIApp (k=1.0; p<0.001) for the diagnosis of severe AS and eligibility assessment. Furthermore, regarding the selection of the most appropriate prosthesis size, concordance to Group A was poor without TAVIApp support (Group B) (k=0.78; p=0.430), but excellent with TAVIApp (k=1.0; p<0.001). Conclusions. This study is the first describing and validating a new mobile application to support the management of AS. TAVIApp supports cardiologists in the evaluation of stenosis severity, eligibility for TAVI or AVR, and selection of the most appropriate prosthesis size in individual patients

Migration of a stent from left main and its retrieval from femoral artery: A case report

Rationale:Embolization of a deployed stent is a rare complication and its mechanism remains unclear in most cases.Patient concerns:A 52-year-old man underwent coronary angiography for effort angina, revealing an 80% stenosis of the proximal left anterior descending (LAD) involving the distal left main (LM). After luminal sizing with intravascular ultrasound two drug-eluting stents were deployed (5.0 × 12 mm and 3.5 × 15 mm) to cover the LM-LAD lesion. After postdilatation, the proximal stent had disappeared from the LM.Diagnoses:The missing stent was found in the right deep femoral artery.Interventions:A new 5.0 × 15 mm stent was deployed onto the LM-LAD ostium, in overlapping with the previously implanted. Then, the stent migrated to the deep femoral artery was successfully retieved through the contralateral femoral artery.Outcomes:The patient was discharged 2 days later, after an uneventful hospital stay.Lessons:Stent deformation after postdilation is a possible causes of stent migration

Clinical and procedural outcomes of 5-French versus 6-French sheaths in transradial coronary interventions

The radial artery has been increasingly used for its favorable safety profile. However, no conclusive data are available on the optimal sheath size. In particular, it is seemingly difficult to weight both advantages and disadvantages of narrower versus larger sheaths size. Despite several studies were performed to compare the use of 6-Fr to the smaller 5-Fr sheaths, these were mostly small, single center-studies, yielding various results. We performed a comprehensive meta-analysis of all available studies comparing the use of 5-Fr versus 6-Fr sheaths in coronary procedures through the TRA. Studies comparing a 5-Fr versus a 6-Fr sheaths were searched for in PubMed, the Cochrane Library, and ISI Web of Knowledge databases. Studies were deemed eligible if they only included patients undergoing transradial cardiac catheterization with 5-Fr or 6-Fr system and reported at least one of these parameters: contrast dye volume, procedural success, procedural time, access complications, radial artery occlusion, and bleedings. Odds ratio (OR) and the mean difference (MD) were respectively used for dichotomous and continuous variables as summary measures. Both the random-effects model and the fixed effect models were used for computation of meta-analyses. Heterogeneity was assessed by means of the Cochrane Q test. Metaregression was calculated using the unrestricted maximal likelihood random effects model. The use of a 5-Fr system is associated with a significant lower contrast medium administration (MD=-22.20 [-36.43 to-7.96], P<0.01) and significantly reduces bleedings (OR=0.58 [0.38- 0.90], P=0.02), without compromising procedural success (OR=0.95 [0.53-1.69], P=0.86) or procedure length (OR=0.55 [-2.58 to 3.69], P=0.73), compared to the 6-Fr system. Despite no significant difference was observed between the groups (OR=0.88 [0.50-1.56], P=0.67), at metaregression RAO incidence in the 5-Fr group was increasingly lower as the percentage of women included into the study increased (P=0.02). Some potentially interesting technical details, such as sheath length, hydrophilic coating, or periprocedural anticoagulation, were not homogeneously reported in individual studies. Results of the present meta-analysis confirm the excellent safety profile of transradial procedures both with 5-Fr and 6-Fr system. A 5-Fr system could be preferred in patients with a higher bleeding propensity or kidney injury

ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement

Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient's survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task

Pathophysiology of aortic stenosis and approach to treatment with percutaneous valve implantation

Aortic stenosis (AS) is the most commonly acquired valvular heart disease in the Western world (2-7% of the population aged >65 years) and the mortality for untreated symptomatic severe AS is up to 50-60% at 2 years in high-risk patients. This review summarizes laboratory and recent clinical investigations concerning AS and current best treatment. Particular emphasis will be placed on pathophysiology and on the concept of afterload mismatch and preload reserve in which left ventricular function is proportionately matched to level of left ventricular pressure, mainly because such studies carry important implications for both treatment with transcatheter aortic valve implantation (TAVI) and prognosis. Surgical aortic valve replacement is currently the gold-standard treatment for patients with severe symptomatic AS. Without surgery, the prognosis is extremely poor, with a 3-year survival rate 75 years with severe AS are declined for surgery. TAVI was recently introduced as a new therapeutic option for patients with AS, so the current indications, the technical differences between 2 different transcatheter aortic valves and the clinical available data will be also examined in detail