Heterotopic Transcatheter Tricuspid Valve Implantation: A Useful Bailout Strategy After Failed Transcatheter Tricuspid Valve Repair?

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Impact of design characteristics among studies comparing coronary computed tomography angiography to noninvasive functional testing in chronic coronary syndromes.

BACKGROUND Coronary computed tomography angiography (CCTA) is widely adopted to detect obstructive coronary artery disease (CAD) in patients with chronic coronary syndromes (CCS). However, it is unknown to which extent study-specific characteristics yield different conclusions. METHODS We summarized non-randomized and randomized studies comparing CCTA and noninvasive functional testing for CCS with information on the outcome of myocardial infarction (MI). We evaluated the differential effect according to study characteristics using random-effect meta-analysis with Hartung-Knapp-Sidik-Jonkman adjustments. RESULTS Fifteen studies (8 non-randomized, 7 randomized) were included. CCTA was associated with decrease in relative (odds ratio (OR) 0.54, 95%CI 0.47 to 0.62, p<0.001) and absolute MI risk (risk difference (RD) -0.4%, 95%CI -0.6 to -0.1, p=0.005). The results remained consistent among the non-randomized (RD -0.4%, 95%CI -0.7 to -0.1, p=0.029), but not among the randomized trials where there was no difference in the observed risk (RD 0.2%, 95%CI -0.6 to 0.1, p=0.158). CCTA was not associated with MI reduction in studies with clinical outcome definition (OR 0.77, 95%CI 0.41 to 1.44, p=0.212), research driven follow-up (OR 0.54, 95%CI 0.24 to 1.21, p=0.090), central event assessment (OR 0.63, 95%CI 0.21 to 1.86, p=0.207), outcome adjudication (OR 0.74, 95%CI 0.24 to 2.23, p=0.178), or at low-risk of bias (OR 0.74, 95%CI 0.24 to 2.23, p=0.178). CONCLUSIONS Among studies of any design, CCTA was associated with lower risk of MI in CCS compared to noninvasive functional testing. This benefit was diminished among studies with clinical outcome definition, central outcome assessment/adjudication or at low-risk of bias

Retrograde Retrieval of a Novel Large Mitral Clip After Embolization Into the Left Ventricle.

We describe the successful retrieval of a novel large mitral clip, which embolized in a patient with severe secondary mitral regurgitation and left ventricular dysfunction, dilated left ventricle, and severely tethered mitral valve leaflets in the setting of a challenging anatomy for transcatheter edge-to-edge repair. The description highlights planning, technical issues, and possible adverse events of this bailout procedure. (Level of Difficulty: Intermediate.)

Subclinical atrial fibrillation: when to give NAO?

Atrial fibrillation is defined as subclinical (SAF) when occurs without symptoms and is discovered only during the interrogation of permanent or temporary cardiac implant-able devices. The significant interest in this condition derives from the fact that could easily be otherwise undiagnosed, portending to a potential serious neurological and cardiovascular consequences. The diagnosis of SAF is important for both the primary form and for patients after a stroke, and an appropriate management of antithrombotic treatment becomes a central instrument of prevention. Atrial fibrillation carries a five times increase in the thromboembolic risk. The subclinical asymptomatic forms of atrial tachyarrhythmias and fibrillation, diagnosed by interrogation of implantable cardiac devices, foretell a non-irrelevant risk of stroke, significantly higher than the one for patients without rhythm disturbances. Regardless the cause, the long-lasting asymptomatic arrhythmias, in patients with a significant risk profile, predict more important consequences and can justify anticoagulant treatment, also in primary prevention settings

Vascular approaches and its potential implications in transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has become in the last years a primary therapeutic tool in order to treat percutaneously severe aortic stenosis in frail patients with multiple comorbidity and a high surgical risk. In almost all cases, the complexity of patients who are candidates for TAVI is also reflected in challenging access sites. This vascular issue addresses the invasive play of constantly evolving devices and resulting complications have a considerable impact on patient morbidity and mortality. For this reason, the study and the choice of the different access site require the attention and experience of the operators to reach the most reliable and feasible vascular approach for a real procedural success