Coronary Angiography After Transcatheter Aortic Valve Replacement (TAVR) to Evaluate the Risk of Coronary Access Impairment After TAVR‐in‐TAVR

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[High-risk ST-elevation acute coronary syndrome in a patient with multivessel coronary artery disease complicated by refractory cardiogenic shock undergoing complex percutaneous coronary revascularization: role and timing of mechanical circulatory support devices]

Cardiogenic shock (CS) following acute myocardial infarction complicated by severe ventricular dysfunction remains the leading cause of death despite customized pharmacological therapy and optimal revascularization. The use of temporary mechanical circulatory support (MCS) devices during refractory CS might represent the only chance of survival to address the underlying systemic inflammatory response preventing the development of multiorgan failure. We report the case of a patient with a very-high-risk non-ST-elevation acute coronary syndrome and multivessel calcific coronary artery disease complicated by refractory CS undergoing complex percutaneous coronary revascularization. We show a gradual and complementary use of MCS devices tailored on hemodynamic monitoring, clinical and laboratory variables and multidisciplinary collaboration to early recognize the downward spiral that may ensue with multiorgan dysfunction or potential complications leading to death

Ruolo della risonanza magnetica cardiaca nella stratificazione prognostica dei pazienti con cardiomiopatia ipertrofica

Introduzione. La risonanza magnetica cardiaca (CMR) con gadolinio fornisce informazioni di tipo morfologico, dinamico, di perfusione e di caratterizzazione tissutale. Nella cardiomiopatia ipertrofica (CMI) tramite CMR \ue8 possibile identificare la presenza di edema miocardico e di difetti di perfusione, segni di ischemia acuta, cos\uec come di aree di fibrosi, rappresentate dalla presenza di late-enhancement (LE). Tali reperti possono assumere un significato prognostico ai fini della stratificazione del rischio di morte improvvisa o di evoluzione verso lo scompenso cardiaco. Scopo. Lo scopo del presente studio \ue8 valutare la presenza di segni di edema miocardico, di ipoperfusione e di LE in pazienti con CMI e correlare la presenza di tali reperti con l\u2019evoluzione clinica. Metodi. 44 pazienti con CMI sono stati sottoposti a CMR con acquisizione di sequenze per la valutazione della cinetica, sequenze T2-pesate per l\u2019identificazione dell\u2019edema e immagini dopo somministrazione di mezzo di contrasto (gadolinio) per lo studio della perfusione (in 37 pazienti) e l\u2019identificazione del LE. 41 dei 44 pazienti arruolati sono stati seguiti per un follow-up clinico medio di 31 \ub1 12 mesi comprendente visita cardiologica, ecocardiogramma, Holter o interrogazione dell\u2019ICD ogni 6 mesi. Risultati. In 24/44 pazienti (54%) \ue8 stato riscontrato aumento del segnale nelle sequenze T2-pesate, indicativo di edema ed in 17/37 pazienti (46%) difetti di perfusione. In 39/44 pazienti (89%) era presente LE: in 35 (80%) in forma localizzata, in 4 (9%) interessava diffusamente il ventricolo sinistro. Vi era una correlazione statisticamente significativa tra la contemporanea presenza di focolai di LE, edema ed ipoperfusione e segni clinici di ischemia acuta o subacuta (p = 0,02; RR 1,99, 95% C.I. 0,77-5,02), mentre la presenza di LE diffuso associato a difetti di perfusione in assenza di edema \ue8 risultata correlare con i parametri clinici di evoluzione della CMI in fase end-stage (p <0,001; RR 13,7, 95% C.I. 1,83-102,05). Durante il periodo di follow-up 2 pazienti sono deceduti per morte improvvisa, in 2 si sono verificati episodi di tachicardia ventricolare (TV) sostenuta a cui \ue8 seguito l\u2019impianto di defibrillatore (ICD) per prevenzione secondaria e 9 pazienti sono stati sottoposti ad impianto di ICD in prevenzione primaria, per la presenza di uno o pi\uf9 fattori di rischio per morte improvvisa. All\u2019Holter o all\u2019interrogazione dell\u2019ICD sono state registrate TV sostenute o non sostenute in 20 pazienti. Due pazienti sono stati sottoposti con successo a trapianto cardiaco per scompenso refrattario. In un paziente deceduto improvvisamente vi era presenza di un grosso focolaio intramurale di LE a livello del setto medio, mentre nell\u2019altra il LE era in forma diffusa. In tutti i 20 pazienti in cui sono stati riscontrati episodi di TV era presente LE, con caratteristiche ed estensione variabile (da un singolo focolaio a forme diffuse) ed in 14 pazienti era presente anche edema. Gli eventi aritmici sono risultati essere pi\uf9 frequenti nei pazienti con LE, rispetto a quelli senza riscontro di LE (20/39, 54% vs 0/5, 0%; p = 0,039) cos\uec come nei pazienti con edema (14/24, 58% vs 6/20, 30%; p = 0,05). Da notare come 2 pazienti con TV sostenuta fossero ambedue in fase end-stage di malattia e presentassero entrambi forme diffuse di LE. Conclusioni. Il riscontro di edema e LE alla CMR identifica pazienti con CMI ad aumentato rischio aritmico ed il LE risulta un segno ad alta sensibilit\ue0 (100%), ma a bassa specificit\ue0 (21%) nell\u2019identificare i soggetti a rischio di aritmie, con un basso potere predittivo positivo (51%), ma con un potere predittivo negativo del 100%. Forme estese di LE caratterizzano l\u2019evoluzione verso la fase end-stage di malattia oltre a predisporre l\u2019insorgenza di aritmie minacciose per la vita

Cardiovascular magnetic resonance signs of ischemia in hypertrophic cardiomyopathy.

Abstract Background: Recurrent myocardial ischemia has been recognized as playing an important role in the pathophysiology of hypertrophic cardiomyopathy (HCM) and cardiovascular magnetic resonance (CMR), with or without gadolinium, is a promising method of evaluating fibrosis, edema and hypoperfusion. The aim of this study is to evaluate the interrelationship between late enhancement (LE) and other signs of ischemia, such as edema and perfusion defects, and to relate them to clinical data in order to describe the stage of the disease. Methods: Forty-four patients were evaluated by CMR cine images, T2-weighted sequences for edema and LE sequences. First-pass perfusion studywas obtained in 37 patients. Acute-subacute ischemic eventswere clinically defined as the presence of chest pain or new onset of ST-segment depression, end-stage phase by left ventricular ejection fraction b50% and maximal left ventricular wall thickness b25 mm. Results: Intramural patchy LE was found in 35/44 (80%) patients; extensive LE in 4/44 (9%). Edema was present in 24/44 (54%) patients and perfusion defects in 17/37 (46%). Simultaneous presence of patchy LE, edema and hypoperfusion in corresponding segments, was significantly associated to acute\u2013subacute ischemic-phase parameters (p=0.02; RR 1.99, 95% C.I. 0.77\u20135.02). Extensive LE and perfusion defects in the absence of edema were significantly related to end-stage HCM (pb0.001; RR 13.7, 95% C.I. 1.83\u2013102.05). Conclusions: Using CMR in patients with HCM, we found focal tissue abnormalities consistent with regional ischemia at various stages. CMR provides important, clinically relevant information on the acuity, extent and functional relevance of ischemic injuries in HCM. \ua9 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Hypertrophic cardiomyopathy; Myocardial ischemia; Magnetic resonance imagin

Role of \u201cIschemia Modified Albumin\u201d in detecting myocardial ischemia in hypertrophic cardiomyopathy.

Background. Myocardial ischemic events are well known to occur in patients with hypertrophic cardiomyopathy (HCM) as a consequence of small vessel disease and mismatch between left ventricular hypertrophy and coronary flow. Ischemia modified albumin (IMA) has been recently suggested as an early marker of reversible myocardial ischemia in acute coronary syndromes. Aim of this study is to evaluate the role of IMA in detecting myocardial ischemia in HCM patients. Methods. IMA, cTnI, cTnT and high sensitivity C reactive protein (hs CRP) concentrations were measured in 42 HCM pts, 15 female (36%) and 27 male (64%), aged from 13 to 76 years (mean age 42,4\ub116.8). Peripheral venous blood samples were taken after 30 minutes supine position. IMA was measured by the Albumin Cobalt Binding test (Ischemia Technologies, USA). IMA values 65100 KU/L (mean value in 107 controls), were considered positive for ischemia. Clinical data, ST depression, and maximal left ventricular wall thickness (MLVWT) were collected. Cardiac Magnetic Resonance (CMR) acquiring cine images, T2- weighted sequences for edema and late-enhancement (LE) sequences was performed in 24 pts and coronary angiography in 10 pts. Results. Conclusions. IMA levels are elevated in 50% of HCM patients. Therapy with Verapamil is significantly associated to normal levels of IMA but this interesting result needs be confirmed in a larger HCM population

The use of a mobile application to support physical activity and lifestyle changes in persons living with HIV: the smartapp study

INTRODUCTION: Although physical activity has been shown to improve fitness, metabolic and inflammatory parameters in people living with HIV, adherence to exercise programs is usually low when not strictly supervised. Therefore, the aim of this study was to assess if the use of a mobile application will favor engagement to exercise by providing motivational inputs, and therefore adherence to training. We hypothesized, as a consequence an improvement of physical fitness, and therefore of health status. METHODS: This pilot study was a two-armed, parallel group, randomized controlled trials in which HIV-infected subjects were enrolled and assigned to either an experimental group (EG), which trained with a smartphone application, or a control group (CG), which trained with a hard copy training program. Physical activity program included an initial coach-supervised period of 4 weeks, followed by 12 weeks where participants were instructed to train independently. The program consisted of walking or jogging three times/week for 60 minutes. At baseline (BL) and after 16-weeks (W16), patients underwent measurement of CRF by peak oxygen consumption (VO2peak), body composition (body mass, body mass index-BMI, waist, hip circumferences, %fat mass and %fat free mass by bioimpedentiometry), and metabolic parameters (total-, HDL-, LDL-cholesterol). Results are given as number (%) or median (IQR) values. Intention-to-treat analysis regarding an improvement of the 15% of VO2peak was performed with a Chi-Square test. Percentage changes between BL and W16 regarding EG and CG were assessed by Wilcoxon matched-pairs signed rank test. RESULTS: Thirty-seven subjects were screened and 28 were eligible and divided in EG [n=13, age: 52 (36-56) y-o, height: 176 (170-180) cm, BMI: 24.4 (22.1-27.1) kg/m2, CD4+: 648 (439-762)], and CG [n=15, age: 50 (36-56) y-o, height: 172 (170-180) cm, BMI: 24.8 (22.1-27.1) kg/m2, CD4+: 619 (439-762)]. During training we had 1 and 2 drop-outs for EG and CG, respectively. Median training adherence was 100% (IQR 91-100%) during the initial coach supervised period, and 70% (IQR 41-91%) during the independently training period, with 15/28 (54%) who trained for at least 50% of the sessions. Intention-to-treat analysis showed post-intervention improvement in VO2peak (+ 15%, p=0.005), % fat mass (-10%, p=0.014); %fat free mass (+ 8%, p=0.008), total cholesterol (- 6%, p=0.016) between EG and CG were observed. CONCLUSION: Adherence to training is fundamental, but seems to be low when not strictly supervised in HIV infected patients. The preliminary results from this pilot study showed that patients trained using a smartphone application were more adherent and as consequence improved physical fitness, body composition and metabolic parameters

The use of mobile application to support physical activity and lifestyle changes in persons living with HIV: the smart app study

INTRODUCTION: Although physical activity has been shown to improve fitness, metabolic and inflammatory parameters in people living with HIV, adherence to exercise programs is usually low when not strictly supervised. Therefore, the aim of this study was to assess if the use of a mobile application will favor engagement to exercise by providing motivational inputs, and therefore adherence to training. We hypothesized, as a consequence an improvement of physical fitness, and therefore of health status. METHODS: This pilot study was a two-armed, parallel group, randomized controlled trials in which HIV-infected subjects were enrolled and assigned to either an experimental group (EG), which trained with a smartphone application, or a control group (CG), which trained with a hard copy training program. Physical activity program included an initial coach-supervised period of 4 weeks, followed by 12 weeks where participants were instructed to train independently. The program consisted of walking or jogging three times/week for 60 minutes. At baseline (BL) and after 16-weeks (W16), patients underwent measurement of CRF by peak oxygen consumption (VO2peak), body composition (body mass, body mass index-BMI, waist, hip circumferences, %fat mass and %fat free mass by bioimpedentiometry), and metabolic parameters (total-, HDL-, LDL-cholesterol). Results are given as number (%) or median (IQR) values. Intention-to-treat analysis regarding an improvement of the 15% of VO2peak was performed with a Chi-Square test. Percentage changes between BL and W16 regarding EG and CG were assessed by Wilcoxon matched-pairs signed rank test. RESULTS: Thirty-seven subjects were screened and 28 were eligible and divided in EG [n=13, age: 52 (36-56) y-o, height: 176 (170-180) cm, BMI: 24.4 (22.1-27.1) kg/m2, CD4+: 648 (439-762)], and CG [n=15, age: 50 (36-56) y-o, height: 172 (170-180) cm, BMI: 24.8 (22.1-27.1) kg/m2, CD4+: 619 (439-762)]. During training we had 1 and 2 drop-outs for EG and CG, respectively. Median training adherence was 100% (IQR 91-100%) during the initial coach supervised period, and 70% (IQR 41-91%) during the independently training period, with 15/28 (54%) who trained for at least 50% of the sessions. Intention-to-treat analysis showed post-intervention improvement in VO2peak (+ 15%, p=0.005), % fat mass (-10%, p=0.014); %fat free mass (+ 8%, p=0.008), total cholesterol (- 6%, p=0.016) between EG and CG were observed. CONCLUSION: Adherence to training is fundamental, but seems to be low when not strictly supervised in HIV infected patients. The preliminary results from this pilot study showed that patients trained using a smartphone application were more adherent and as consequence improved physical fitness, body composition and metabolic parameters

ROLE OF "ISCHEMIA MODIFIED ALBUMIN" IN DETECTING MYOCARDIAL ISCHEMIA IN HYPERTROPHIC CARDIOMYOPATHY

Purpose: Myocardial ischemic events are well known to occur in patients with Hypertrophic Cardiomyopathy (HCM) as a consequence of small vessel disease and mismatch between left ventricular hypertrophy and coronary flow. Myocardial ischemia plays a major role in the course of the disease leading to progressive left ventricular fibrosis which represents the electrophysiological substrate of life-threatening arrhythmias. Ischemia modified albumin (IMA) has been recently suggested as an early marker of reversible myocardial ischemia in acute coronary syndromes. Aim of this study is to evaluate the role of IMA in detecting myocardial ischemia in HCM patients. Methods: IMA testing was performed in 51 consecutive HCM patients, 17 female (33%) and 34 male (67%), aged from 15 to 76 years (mean age 44 \ub116.1), after 30 minutes supine position. IMA concentration was measured by the Albumin Cobalt Binding test (Ischemia Technologies, USA). Clinical data, 12-lead electrocardiogram and echocardiogram (2D, M-mode, CW and PW Doppler) were collected in all patients. Cardiac Magnetic Resonance (CMR) acquiring cine images, T2-weighted sequences for edema and late-enhancement (LE) sequences was performed in 22 patients. Results: Mean IMA levels were higher in patients with maximal left ventricular wall thickness (MLVWT) 65 25 mm compared with those with MLVWT 1 had a mean IMA value lower than patients with Doppler E/A 50%) (101.28\ub18.32 KU/L) and those with FE 64 50% (94.7\ub1 7.13 KU/L; p = 0.02). The presence of Q waves at the 12-lead electrocardiogram was associated with higher mean IMA levels if compared with the absence of Q waves (104.2\ub17.04 KU/L vs 99.3\ub18,39 KU/L; p = 0.03). Finally therapy with Verapamil was associated with mean IMA values lower than \u3b2-blockers therapy (96.8\ub14,20 KU/L vs 103.3\ub17.90 KU/L; p = 0.03). Conclusions: Higher levels of IMA were observed in HCM patients withsevere or massive myocardial hypertrophy as well as in patients with diastolic dysfunction. Therapy with Verapamil seems to be protective for ischemic events, nevertheless further studies are necessary to assess the usefulness of this marker in clinical practice. Pubblicato in Eur Heart J. 2007;28 Abstract Suppl: 47

Coronary Access After Transcatheter Aortic Valve Replacement With Commissural Alignment: The ALIGN-ACCESS Study

Background: Coronary access (CA) after transcatheter aortic valve replacement (TAVR) with supra-annular transcatheter heart valves (THV) can be challenging. Specific Evolut R/Pro and Acurate Neo THVs orientations are associated with reduced neo-commissure overlap with coronary ostia, while SAPIEN 3 THV cannot be oriented. With the ALIGN-ACCESS study (TAVR With Commissural Alignment Followed by Coronary Access), we investigated the impact of commissural alignment on the feasibility of CA after TAVR. Methods: We performed coronary angiography after TAVR with intra-annular SAPIEN 3, supra-annular Evolut R/Pro, and Acurate Neo THVs in 206 patients. Evolut THVs were implanted aiming for commissure alignment. Alignment of Acurate Neo was retrospectively assessed in 36, intentionally attempted in 26 cases. The primary end point was the rate of unfeasible and nonselective CA after TAVR. Results: Thirty-eight percent of patients received SAPIEN 3, 31.1% Evolut Pro/R, 30.1% Acurate Neo THV. Final valve orientation was favorable to commissural alignment in 85.9% of Evolut and 69.4% of Acurate Neo cases (with intentional alignment successful in 88.5%). Selective CA was higher for SAPIEN 3 than for aligned and misaligned supra-annular THVs (95% versus 71% versus 46%, P<0.001). Cannulation of at least one coronary was unfeasible with 11% misaligned supra-annular, 3% aligned supra-annular, and 0% SAPIEN 3 THVs. Independent predictors of unfeasible/nonselective CA were implantation of a misaligned supra-annular THV (odds ratio, 4.59 [95% CI, 1.81-11.61]; P<0.01), sinus of Valsalva height (odds ratio, 0.83 [95% CI, 0.7-0.98]; P=0.03), and THV-sinus of Valsalva relation (odds ratio, 1.06 [95% CI, 1.02-1.1]; P<0.01). Conclusions: Commissural alignment improves the rate of selective CA after TAVR with supra-annular THVs. Nevertheless, aligned supra-annular THVs carry higher risk of unfeasible/nonselective CA than SAPIEN 3. Patients with a misaligned supra-annular THV, low sinus of Valsalva, and higher THV-sinus of Valsalva relation are at highest risk of impaired CA after TAVR

Real-World Experience With a Large Bore Vascular Closure Device During TAVI Procedure: Features and Predictors of Access-Site Vascular Complications

Backgrounds: Among vascular closure devices (VCDs), the novel collagen plug-based MANTA VCD is the first designed for large bore percutaneous access. We aimed to assess the features and predictors of access-site vascular complications in an unselected trans-femoral transcatheter aortic valve replacement (TF-TAVR) population. Methods: Patients undergoing large bore arteriotomy closure with 18F MANTA VCD following TF-TAVR at a large tertiary care center from September 2019 to January 2021 were prospectively analyzed. Primary Outcome was the MANTA VCD access-site-related complications according to Valve Academic Research Consortium-3 (VARC) definitions. Its incidence and predictors were evaluated. Results: Eighty-eight patients (median age 82 years, 48% male, 3.3 median Society of Thoracic Surgeons score) undergoing TF-TAVR were included, mostly (63%) treated with a self-expandable device and with outer diameter sizes varied from 18F to 24-F. MANTA VCD technical success rate was 98%, while 10 patients (11%) experienced MANTA VCD access-site vascular complications which included 8% of minor complications and only to 2% of major events resulting in VARC type ≥2 bleeding. Vessel occlusion/stenosis (60%), perforation (20%), and pseudoaneurysm/dissection/hematoma (20%) occurred, but all were managed without surgical treatment. Independent predictors of failure were age (p = 0.04), minimum common femoral artery diameter (CFA) (p < 0.01), sheath-to-femoral-artery ratio (SFAR) (p < 0.01), and a lower puncture height (p = 0.03). A CFA diameter <7.1 mm with a SFAR threshold of 1.01 were associated with VCD failure. Conclusions: In a more comers TF-TAVR population, MANTA VCD was associated with reassuring rates of technical success and major access-site vascular complications. Avoiding lower vessel size and less puncture site distance to CFA bifurcation might further improve outcomes