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

[Figure: see text

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.)

Long Stent Implantation on the Left Anterior Descending Coronary Artery at a Follow-Up of More Than Five Years

Background: Stent implantation represents the standard of care in coronary intervention. While a short stent implanted on a focal lesion located on the left anterior descending artery (LAD) seems a reasonable alternative to an internal mammary implant, the same for long stents is still debated. Methods: We reported the long-term data of 531 consecutive patients who underwent Percutaneous Coronary Intervention (PCI) with long stents in two highly specialized centres. The main inclusion criteria were the implantation of stents longer than 30 mm on the LAD and a minimum follow-up (FU) of five years. The primary endpoint was mortality, and the secondary endpoints were any myocardial infarction (MI), target vessel and lesion revascularization (TVR and TLR, respectively), and stent thrombosis (ST) observed as definite, probable, or possible. Results: In this selected population with characteristics of complex PCI (99.1%), the long-term follow-up (mean 92.18 ± 35.5 months) estimates of all-cause death, cardiovascular death, and any myocardial infarction were 18.3%, 10.5%, and 9.3%, respectively. Both all-cause and cardiovascular deaths are significantly associated with three-vessel disease (HR 6.8; confidence of interval (CI) 95% 3.844–11.934; p &lt; 0.001, and HR 4.7; CI 95% 2.265–9.835; p &lt; 0.001, respectively). Target lesion (TLR) and target vessel revascularization (TVR) are associated with the presence of three-lesion disease on the LAD (HR 3.4; CI 95% 1.984–5.781; p &lt; 0.001; HR 3.9 CI 95% 2.323–6.442; p &lt; 0.001, respectively). Re-PCI for any cause occurred in 31.5% of patients and shows an increased risk for three-lesion stenting (HR 4.3; CI 95% 2.873–6.376; p &lt; 0.001) and the treatment of bifurcation with two stents (HR 1.6; 95% CI 1.051–2.414; p = 0.028). Stent thrombosis rate at the 5-year FU was 4.4% (1.3% definite; 0.9% probable; 2.1% possible), including a 1.7% rate of very-late thrombosis. The stent length superior to 40 mm was not associated with poor outcomes (all-cause death p = 0.349; cardiovascular death p = 0.855; MI p = 0.691; re-PCI p = 0.234; TLR p = 0.805; TVR p = 0.087; ST p = 0.189). Conclusion: At an FU of longer than five years, patients treated with stents longer than 30 mm in their LAD showed acceptable procedural results but poor outcomes.</p

Long Stent Implantation on the Left Anterior Descending Coronary Artery at a Follow-Up of More Than Five Years

Background: Stent implantation represents the standard of care in coronary intervention. While a short stent implanted on a focal lesion located on the left anterior descending artery (LAD) seems a reasonable alternative to an internal mammary implant, the same for long stents is still debated. Methods: We reported the long-term data of 531 consecutive patients who underwent Percutaneous Coronary Intervention (PCI) with long stents in two highly specialized centres. The main inclusion criteria were the implantation of stents longer than 30 mm on the LAD and a minimum follow-up (FU) of five years. The primary endpoint was mortality, and the secondary endpoints were any myocardial infarction (MI), target vessel and lesion revascularization (TVR and TLR, respectively), and stent thrombosis (ST) observed as definite, probable, or possible. Results: In this selected population with characteristics of complex PCI (99.1%), the long-term follow-up (mean 92.18 ± 35.5 months) estimates of all-cause death, cardiovascular death, and any myocardial infarction were 18.3%, 10.5%, and 9.3%, respectively. Both all-cause and cardiovascular deaths are significantly associated with three-vessel disease (HR 6.8; confidence of interval (CI) 95% 3.844–11.934; p &lt; 0.001, and HR 4.7; CI 95% 2.265–9.835; p &lt; 0.001, respectively). Target lesion (TLR) and target vessel revascularization (TVR) are associated with the presence of three-lesion disease on the LAD (HR 3.4; CI 95% 1.984–5.781; p &lt; 0.001; HR 3.9 CI 95% 2.323–6.442; p &lt; 0.001, respectively). Re-PCI for any cause occurred in 31.5% of patients and shows an increased risk for three-lesion stenting (HR 4.3; CI 95% 2.873–6.376; p &lt; 0.001) and the treatment of bifurcation with two stents (HR 1.6; 95% CI 1.051–2.414; p = 0.028). Stent thrombosis rate at the 5-year FU was 4.4% (1.3% definite; 0.9% probable; 2.1% possible), including a 1.7% rate of very-late thrombosis. The stent length superior to 40 mm was not associated with poor outcomes (all-cause death p = 0.349; cardiovascular death p = 0.855; MI p = 0.691; re-PCI p = 0.234; TLR p = 0.805; TVR p = 0.087; ST p = 0.189). Conclusion: At an FU of longer than five years, patients treated with stents longer than 30 mm in their LAD showed acceptable procedural results but poor outcomes.</p

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