The trans-subclavian retrograde approach for transcatheter aortic valve replacement: Single-center experience

ObjectiveAortic valve disease is the most common acquired valvular heart disease in adults. With the increasing elderly population, the proportion of patients with symptomatic aortic stenosis who are unsuitable for conventional surgery is increasing. Transcatheter aortic valve implantation has rapidly gained credibility as a valuable alternative to surgery to treat these patients; however, they often have severe iliac-femoral arteriopathy, which renders the transfemoral approach unusable. We report our experience with the trans-subclavian approach for transcatheter aortic valve implantation using the CoreValve (Medtronic CV Luxembourg S.a.r.l.) in 6 patients.MethodsIn May 2008 to September 2009, 6 patients (mean age of 82 ± 5 years), with symptomatic aortic stenosis and no reasonable surgical option because of excessive risk, were excluded from percutaneous femoral CoreValve implantation because of iliac-femoral arteriopathy. These patients underwent transcatheter aortic valve implantation via the axillary artery. Procedures were performed by a combined team of cardiologists, cardiac surgeons, and anesthetists in the catheterization laboratory. The CoreValve 18F delivery system was introduced via the left subclavian artery in 6 patients, 1 with a patent left internal thoracic to left anterior descending artery graft.ResultsProcedural success was obtained in all patients, and the mean aortic gradient decreased 5 mm Hg or less immediately after valve deployment. One patient required implantation of a permanent pacemaker. One patient required a subclavian covered stent implantation to treat a postimplant artery dissection associated with difficult surgical hemostasis. One patient was discharged in good condition but died of pneumonia 40 days after the procedure. All patients were asymptomatic on discharge, with good mid-term prosthesis performance.ConclusionsTranscatheter aortic valve implantation via a surgical subclavian approach seems safe and feasible, offering a new option to treat select, inoperable, and high-risk patients with severe aortic stenosis and peripheral vasculopathy

Direct Aortic CoreValve Implantation via Right Anterior Thoracotomy in a Patient with Patent Bilateral Mammary Artery Grafts and Aortic Arch Chronic Dissection

Direct aortic trans-catheter aortic valve implantation is an alternative approach to treat high risk for surgery patients affected by severe aortic stenosis and concomitant peripheral vascular disease. We describe a case of direct aortic CoreValve implantation made via a right anterior thoracotomy in a 78-year-old male affected by severe aortic stenosis and severe peripheral vasculopathy, who previously underwent coronary artery bypass grafting, with patent bilateral mammary artery grafts and chronic aortic arch dissection

Redox Proteomics Identification of Oxidatively Modified Myocardial Proteins in Human Heart Failure: Implications for Protein Function

<div><p>Increased oxidative stress in a failing heart may contribute to the pathogenesis of heart failure (HF). The aim of this study was to identify the oxidised proteins in the myocardium of HF patients and analyse the consequences of oxidation on protein function. The carbonylated proteins in left ventricular tissue from failing (n = 14) and non-failing human hearts (n = 13) were measured by immunoassay and identified by proteomics. HL-1 cardiomyocytes were incubated in the presence of stimuli relevant for HF in order to assess the generation of reactive oxygen species (ROS), the induction of protein carbonylation, and its consequences on protein function. The levels of carbonylated proteins were significantly higher in the HF patients than in the controls (p<0.01). We identified two proteins that mainly underwent carbonylation: M-type creatine kinase (M-CK), whose activity is impaired, and, to a lesser extent, α-cardiac actin. Exposure of cardiomyocytes to angiotensin II and norepinephrine led to ROS generation and M-CK carbonylation with loss of its enzymatic activity. Our findings indicate that protein carbonylation is increased in the myocardium during HF and that these oxidative changes may help to explain the decreased CK activity and consequent defects in energy metabolism observed in HF.</p> </div

Direct Aortic CoreValve implantation via right anterior thoracotomy in a patient with patent bilateral mammary artery grafts and aortic arch chronic dissection

Direct aortic trans-catheter aortic valve implantation is an alternative approach to treat high risk for surgery patients affected by severe aortic stenosis and concomitant peripheral vascular disease. We describe a case of direct aortic CoreValve implantation made via a right anterior thoracotomy in a 78-year-old male affected by severe aortic stenosis and severe peripheral vasculopathy, who previously underwent coronary artery bypass grafting, with patent bilateral mammary artery grafts and chronic aortic arch dissection

Intracellular generation of ROS in cardiomyocytes exposed to various compounds.

<p>(<b>A</b>) Relative DCF fluorescence of ROS generation. (<b>B</b>) Percentage increase in ROS generation vs control cells after 5 min. *p<0.01 vs control cells; n = 5. PE, phenylephrine; ISO, isoprotenerol; NE, norepinephrine; AngII, angiotensin II; ET-1, endothelin-1, TNFα, tumor necrosis factor α.</p

Immunofluorescence analysis of carbonylated proteins in cardiomyocytes after treatment with angiotensin II (AngII) or phenylephrine (PE).

<p>The cells were stained with anti-DNP antibody and visualised by means of a secondary antibody conjugated with Alexa Fluor dye 488. Representative of three independent experiments.</p

CK activity in cardiomyocytes.

<p>(<b>A</b>) CK activity in cell lysate measured after pretreatment with NAC (N-acetyl-l-cysteine) for 1 h, and then with angiotensin II (AngII) or phenylephrine (PE) for 4 h in the absence or presence of NAC. (<b>B</b>) Oxidative modification of CK activity <i>in vitro</i>. Purified human M-CK (30 units/mL) was incubated for 1 h at 25°C with H₂O₂ (1 mmol/L) in 25 mmol/L Tris-HCl (pH 7.4) in the absence or presence of 100 units/mL of catalase before measurement of CK activity. *p<0.05 <i>vs</i> CK alone. (<b>C</b>) CK activity in cells lysate measured after pretreatment with different ROS inhibitors for 1 h, and then with phenylephrine (PE) for 4 h. *p<0.05 <i>vs c</i>ontrol; ^#p<0.05 <i>vs</i> PE-treated cells, ^§p<0.05 <i>vs</i> AngII-treated cells (n = 5).</p

ELISA-measured protein carbonyl levels in the myocardium of 14 HF patients and 13 controls.

<p>*p<0.01 <i>vs</i> controls.</p