1 Transcatheter aortic valve implantation in symptomatic severe aortic stenosis: where do we stand? Aortic stenosis occurs in 2%-9% of patients over the age of 65, the most common cause being degenerative.^([1,2]) The...1 Transcatheter aortic valve implantation in symptomatic severe aortic stenosis: where do we stand? Aortic stenosis occurs in 2%-9% of patients over the age of 65, the most common cause being degenerative.^([1,2]) The preferred treatment in symptomatic severe aortic stenosis(SAS) is surgical aortic valve replacement(SAVR), but in the elderly, the surgical risk can be greater than the benefit.([3]).展开更多
BACKGROUND Although transcatheter aortic valve implantation(TAVI)is a safe and effective treatment for aortic stenosis,it still carries some risks,such as valve leaks,stroke,and even death.The left ventricular global ...BACKGROUND Although transcatheter aortic valve implantation(TAVI)is a safe and effective treatment for aortic stenosis,it still carries some risks,such as valve leaks,stroke,and even death.The left ventricular global longitudinal strain(LVGLS)measurement may be useful for the prediction of adverse events during this operation.AIM To explore the change of LVGLS during TAVI procedure and the relationship between LVGLS and perioperative adverse events.METHODS In this study,61 patients who had undergone percutaneous transfemoral TAVI were evaluated by transthoracic echocardiography.Before surgery,data on left ventricular ejection fraction(LVEF)and LVGLS were collected separately following balloon expansion and stent implantation.Difference in values of LVGLS and LVEF during preoperative balloon expansion(pre-ex),preoperative stent implantation(pre-im)and balloon expansion-stent implantation(ex-im)were also examined.Adverse events were defined as perioperative death,cardiac rupture,heart arrest,moderate or severe perivalvular leakage,significant mitral regurgitation during TAVI,perioperative moderate or severe mitral regurgitation,perioperative left ventricular outflow tract obstruction,reoperation,and acute heart failure.RESULTS The occurrence of perioperative adverse events was associated with differences in pre-ex LVGLS,but not with difference in pre-ex LVEF.There were significant differences between pre-LVGLS and ex-LVGLS,and between pre-LVGLS and im-LVGLS(P=0.037 and P=0.020,respectively).However,differences in LVEF were not significant(P=0.358,P=0.254);however differences in pre-ex LVGLS were associated with pre-LVGLS(P=0.045).Compared to LVEF,LVGLS is more sensitive as a measure of left heart function during TAVI and the perioperative period.Moreover,the differences in LVGLS were associated with the occurrence of perioperative adverse events,and changes in LVGLS were apparent in patients with undesirable LVGLS before the surgery.Furthermore,LVGLS is useful to predict changes in cardiac function during TAVI.CONCLUSION Greater attention should be paid to the patients who plan to undergo TAVI with normal LVEF but poor LVGLS.展开更多
BACKGROUND Aortic stenosis is the most common valve disease in adults.Transcatheter aortic valve implantation(TAVI)is being increasingly applied for intermediate-to lowrisk patients.Here,we describe an uncommon compli...BACKGROUND Aortic stenosis is the most common valve disease in adults.Transcatheter aortic valve implantation(TAVI)is being increasingly applied for intermediate-to lowrisk patients.Here,we describe an uncommon complication of delayed right coronary obstruction in a transapical TAVI case.CASE SUMMARY A 73-year-old woman with a EuroSCORE II of 1.21%underwent transapical TAVI because of severe aortic stenosis.The surgical procedure was uneventful.However,during routine monitoring after valve placement,the patient had a sudden onset of slow heart rate,the systolic blood pressure dropped sharply from 115 to 60 mmHg,and the central venous pressure abruptly increased from 10 to 33 cmH2O.The patient had a poor response to vasoactive agents.Transesophageal echocardiography revealed poor myocardial contractility,and electrocardiography showed a significant depression of ST-segment.Another angiography was performed immediately,which suggested complete obstruction of the right coronary artery.An emergency protocol was initiated.Cardiopulmonary bypass was established immediately.An aortic biological valve replacement under cardiopulmonary bypass was performed.CONCLUSION Perioperative monitoring,early recognition,and diagnosis of obstruction of coronary arteries in TAVI are important.Transesophageal echocardiography is a useful diagnostic and monitoring tool in this situation.Emergency protocols should be established during TAVI.展开更多
Paravalvular Leakage(PVL)has been recognized as one of the most dangerous complications in relation to Transcathether Aortic Valve Implantation(TAVI)activities.However,data available in the literature about Fluid Str...Paravalvular Leakage(PVL)has been recognized as one of the most dangerous complications in relation to Transcathether Aortic Valve Implantation(TAVI)activities.However,data available in the literature about Fluid Structure Interaction(FSI)for this specific problem are relatively limited.In the present study,the fluid and structure responses of the hemodynamics along the patient aorta model and the aortic wall deformation are studied with the aid of numerical simulation taking into account PVL and 100%TAVI valve opening.In particular,the aorta without valve(AWoV)is assumed as the normal condition,whereas an aorta with TAVI 26 mm for 100%Geometrical Orifice Area(GOA)is considered as the patient aorta with PVL complication.A 3D patient-specific aorta model is elaborated using the MIMICS software.Implantation of the identical TAVI valve of Edward SAPIEN XT 26(Edwards Lifes ciences,Irvine,California)is considered.An undersized 26 mm TAVI valve with 100%valve opening is selected to mimic the presence of PVL at the aortic annulus.The present research indicates that the existence of PVL can increase the blood velocity,pressure drop and WSS in comparison to normal conditions,thereby paving the way to the development of recirculation flow,thrombus formation,aorta wall collapse,aortic rupture and damage of endothelium.展开更多
BACKGROUND Complications of transcatheter aortic valve implantation(TAVI)procedures include bleeding,vascular complications,and strokes.These complications are often associated with the type of access used.The two typ...BACKGROUND Complications of transcatheter aortic valve implantation(TAVI)procedures include bleeding,vascular complications,and strokes.These complications are often associated with the type of access used.The two types of access in TAVI procedures are primary and secondary.The main use of the primary access is for valve delivery,while secondary access is used for angiography and hemodynamic monitoring.While there are many options for primary access,those for secondary access are transfemoral and transradial.AIM To compare outcomes between transradial vs transfemoral secondary access(TFSA).METHODS A systematic search was conducted using major databases(EMBASE,PubMed,Cochrane Central,Google Scholar),which resulted in 5 studies that met the criteria for study selection.Outcomes of interest were 30-d rates each of major/life-threatening bleeding,vascular complications,strokes,and mortality.All 5 studies were observational.Only adjusted or matched data were used when available in this meta-analysis.RESULTS A total of 5065 patients underwent TAVI,with 1453 patients(28.7%)having undergone transradial secondary access(TRSA)and 3612 patients(71.3%)TFSA.Irrespective of the site of primary access,the odds of having major or lifethreatening bleeding were 60%lower in the TRSA group than the TFSA group(P<0.00001).The odds of having major vascular complications were 52%lower in the TRSA group(P<0.0001)with no difference in minor vascular complications between the 2 groups.Similarly,the odds of mortality in 30-d after the procedure were 41%lower(P=0.006)and the odds of stroke were 54%lower(P=0.001)in the TRSA group than the TFSA group.CONCLUSION The transradial secondary approach appears to be a safer alternative to the transfemoral secondary approach in TAVI procedures.展开更多
BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated w...BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.展开更多
Patients experiencing severe aortic stenosis with acute decompensation often face elevated surgical aortic valve replacement risks,leading to high postoperative mortality rates.However,for some patients eligible for t...Patients experiencing severe aortic stenosis with acute decompensation often face elevated surgical aortic valve replacement risks,leading to high postoperative mortality rates.However,for some patients eligible for transcatheter aortic valve implantation(TAVI),computed tomography angiography for assessing the aortic root and coronary artery might be challenging before the TAVI procedure.This case highlights a patient who underwent emergency TAVI guided by coplane view generated using J-tipped wires fluoroscopy without computed tomography evaluation before the TAVl.This approach reduces contrast usage during the TAVI procedure,significantly mitigating the risks of renal injury and heart function deterioration.展开更多
Background The effective orifice area(EOA)is utilized to characterize the hemodynamic performance of the transcatheter heart valve(THV).However,there is no consensus on EOA measurement of self-expanding THV.We aimed t...Background The effective orifice area(EOA)is utilized to characterize the hemodynamic performance of the transcatheter heart valve(THV).However,there is no consensus on EOA measurement of self-expanding THV.We aimed to compare two echocardiographic methods for EOA measurement following transcatheter self-expanding aortic valve implantation.Methods EOA was calculated according to the continuity equation.Two methods were constructed.In Method 1 and Method 2,the left ventricular outflow tract diameter(LVOTd)was measured at the entry of the prosthesis(from trailing-to-leading edge)and proximal to the prosthetic valve leaflets(from trailing-toleading edge),respectively.The velocity-time integral(VTI)of the LVOT(VTILVOT)was recorded by pulsed-wave Doppler(PW)from apical windows.The region of the PW sampling should match that of the LVOTd measurement with precise localization.The mean transvalvular pressure gradient(MG)and VTI of THV was measured by Continuous wave Doppler.Results A total of 113 consecutive patients were recruited.The mean age was 77.2±5.5 years,and 72 patients(63.7%)were male.EOA1 with the use of Method 1 was larger than EOA2(1.56±0.39 cm2 vs.1.48±0.41 cm2,P=0.001).MG correlated better with the indexed EOA1(EOAI1)(r=-0.701,P<0.001)than EOAI2(r=-0.645,P<0.001).According to EOAI(EOAI≤0.65 cm2/m2,respectively),the proportion of sever prosthesis-patient mismatch with the use of EOA1 was lower than EOA2(12.4%vs.21.2%,P<0.05).Compared with EOA2,EOA1 had lower interobserver and intra-observer variability(intra:0.5%±17%vs.3.8%±22%,P<0.001;inter:1.0%±9%vs.3.5%±11%,P<0.001).Conclusions For transcatheter self-expanding valve EOA measurement,LVOTd should be measured in the entry of the prosthesis stent(from trailing-to-leading edge),and VTILVOT should match that of the LVOTd measurement with precise localization.展开更多
BACKGROUND: This study aims to investigate whether small balloon aortic valvuloplasty(BAV) reduces the need for permanent pacemaker implantation (PPMI) after transcatheter aortic valveimplantation (TAVI).METHODS: This...BACKGROUND: This study aims to investigate whether small balloon aortic valvuloplasty(BAV) reduces the need for permanent pacemaker implantation (PPMI) after transcatheter aortic valveimplantation (TAVI).METHODS: This was a retrospective analysis using data from our local TAVI database. SmallBAV was defined as a small balloon size (=18 mm) pre-dilatation. Normal BAV was defined as aballoon size >18 mm. The primary endpoint was the incidence of new PPMI.RESULTS: Of 99 consecutive TAVI patients, five patients were excluded due to pre-existingpermanent pacemaker. Patients in the small BAV group (n=57) had a signifi cantly lower PPMI ratecompared with the normal BAV group (n=37) (3.5% vs. 18.9%, P=0.026). Moderate or severe aorticvalve regurgitation post-procedure was similar between the small BAV and normal BAV groups (5.3%vs. 8.1%, P=0.480);likewise, the mean aortic gradient post-procedure did not differ significantly(11.5±5.2 mmHg vs. 12.2±7.3 mmHg, 1 mmHg=0.133 kPa, P=0.580) between the groups. Devicesuccess rates were also similar (94.7% vs. 91.8%, P=0.680). In multivariable analysis, small BAV(P=0.027), the ratio of prosthesis diameter to annulus diameter (P=0.048), and mean aortic gradientby echo in the basement (P=0.021) were independent predictors of PPMI.CONCLUSIONS: The small BAV strategy is associated with a low rate of permanentpacemaker implantation after transcatheter self-expanding valve implantation in this single-centerobservational study.展开更多
Aortic arch aneurysms are rarely isolated entities, and most frequently associated with either ascending or descending aorta pathologies. Association with aortic valve stenosis is uncommon and traditional surgical tre...Aortic arch aneurysms are rarely isolated entities, and most frequently associated with either ascending or descending aorta pathologies. Association with aortic valve stenosis is uncommon and traditional surgical treatment is always challenging. Here we report a minimally invasive and endovascular management of these two pathologies in a 89-year-old man with LAD-stented ischemic cardiomyopathy. We describe our initial therapeutic strategy, per procedure difficulties and final management of this challenging case. Finally, we discuss the different therapeutic options for the endovascular treatment of aortic arch aneurysm associated with aortic valve stenosis.展开更多
Objective:Diverse antithrombotic strategies were applied to patients undergoing aortic valve replacement.However,the optimal therapeutic regimen for patients undergoing transcatheter aortic valve implantation/replacem...Objective:Diverse antithrombotic strategies were applied to patients undergoing aortic valve replacement.However,the optimal therapeutic regimen for patients undergoing transcatheter aortic valve implantation/replacement(TAVI/TAVR)remains unclear.The purpose of this study was to compare the efficacy and safety of various antithrombotic therapies following TAVI/TAVR.Methods:Relevant clinical trials evaluating the effect of anticoagulation or antiplatelet regimens on patients after TAVI/TAVR from inception to September 2020 were identified using the PubMed,EMBASE,and the Cochrane Library databases.The inclusion criteria including(1)all patients underwent TAVI/TAVR;(2)the interventions were antithrombotic strategies that prevent the occurrence of thrombotic events in patients;(3)randomized controlled trials or prospective observational studies;and(4)investigation of at least 1 outcome with a follow-up period of≥3 months.The exclusion criteria including(1)research content was identical or irrelevant to the purpose of the present study;(2)lack of the required outcome index or availability of fragmentary original information;and(3)the full text is not available.The major outcomes were all-cause mortality,thromboembolic complications,and bleeding events.The Cochrane Collaboration’s tool and the Newcastle-Ottawa Scale were used for assessing the risk of bias in included studies.Results:Thirteen studies(3 randomized controlled trials and 10 non-randomized studies)were identified,with a total of 23,497 patients.Four studies compared direct oral anticoagulants(DOACs)with warfarin,1 study compared aspirin with warfarin,6 studies compared aspirin plus clopidogrel(dual antiplatelet therapy(DAPT))with aspirin monotherapy,and 2 studies compared DAPT and aspirin monotherapy with warfarin concurrently.There were no significant differences found between the DOAC and warfarin groups regarding all-cause mortality(risk ratio(RR):1.03;95%confidence interval(CI):0.65–1.64;P=0.909;Phet=0.105),clinical adverse events(RR:1.59;95%CI:0.99–2.58;P=0.057;Phet=0.738),or bleeding events(RR:0.93;95%CI:0.78–1.11;P=0.437;Phet=0.338).The rates of all-cause mortality(RR:0.71;95%CI:0.54–0.93;P=0.012;Phet=0.845)and bleeding events(RR:0.43;95%CI:0.22–0.83;P=0.012;P_(het)=0.569)were lower in the aspirin group versus the warfarin group;however,there was no difference in the rate of clinical adverse events(RR:0.38;95%CI:0.14–1.07;P=0.068;Phet=0.593).The DAPT group had an advantage versus the aspirin group in all-cause mortality(RR:0.89;95%CI:0.82–0.98;P=0.013;Phet=0.299);however,the incidence of bleeding events(RR:2.06;95%CI:1.39–3.07;P<0.001;Phet=0.001)exhibited an increasing trend.Notably,there was a slight decrease in the incidence of clinical adverse events(RR:1.09;95%CI:0.94–1.26;P=0.268;Phet=0.554).Conclusion:The present meta-analysis integrates the latest published results on antithrombotic strategies in patients after TAVI/TAVR.Aspirin showed a favorable risk-benefit profile versus warfarin,with lower rates of all-cause mortality and bleeding events.Although DAPT was also associated with a significantly lower rate of all-cause mortality,it was linked to a higher incidence of bleeding events.The DOACs did not show significant benefits compared with warfarin.Some certain limitations should be noted,such as different types of trails produce heterogeneity and finite inclusion of TAVI/TAVR patients increased selection bias.展开更多
BACKGROUND The use of pre-closure suture-based devices represents a widely access-site hemostasis technique in percutaneous transfemoral transcatheter-aortic-valvereplacement(TF-TAVR);yet this technique is associated ...BACKGROUND The use of pre-closure suture-based devices represents a widely access-site hemostasis technique in percutaneous transfemoral transcatheter-aortic-valvereplacement(TF-TAVR);yet this technique is associated with the risk of a device failure that may result in clinically relevant residual bleeding.Thus,a bailout intervention is needed.So far,the best management of pre-closure device failure has not been recognized.AIM To report the first clinical results obtained using a novel bailout hemostasis technique for patients with double suture-based vascular closure device failure in the setting of TF-TAVR.METHODS We developed a“pledget-assisted hemostasis”technique to manage residual access-site bleeding.This consists of the insertion of a surgical,non-absorbable,polytetrafluoroethylene pledget over the sutures of the two ProGlide(Abbott Vascular,CA,United States).The ProGlide’s knot-pushers are used to push down the pledget and the hand-made slipknot to seal the femoral artery leak.This technique was used as a bailout strategy in patients undergoing TF-TAVR with a systematic double pre-closure technique.Post-procedural access-site angiography was systematically performed.In-hospital complications were systematically detected and classified according to Valve Academic Research Consortium-2 criteria.RESULTS Out of 136 consecutive patients who underwent TF-TAVR,15 patients(mean age 80.0±7.2 years,66.7%female)with access-site bleeding after double pre-closure technique failure were treated by pledget-assisted hemostasis.In the majority of patients,16F sheath was used(n=12;80%).In 2 cases(13%),a peripheral balloon was also inflated in the iliac artery to limit blood loss during pledget preparation.Angiography-confirmed hemostasis(primary efficacy endpoint)was achieved in all patients.After the procedure,1 patient required blood transfusion(2 units),and no other bleeding or major ischemic complication was noticed.CONCLUSION The“pledget assisted hemostasis”might be considered as a possible bailout technique to treat patients with residual access site bleeding.Further studies are needed to compare this approach with other bail-out techniques.展开更多
Bioprosthetic heart valves(BHVs)are important for transcatheter valve replacement.Current commercial BHVs on the market are basically porcine or bovine pericardium(BP)crosslinked with glutaraldehyde(GA).Simply applyin...Bioprosthetic heart valves(BHVs)are important for transcatheter valve replacement.Current commercial BHVs on the market are basically porcine or bovine pericardium(BP)crosslinked with glutaraldehyde(GA).Simply applying GA to BHVs can enhance mechanical stability,but cannot alleviate in vivo calcification.In this work,we developed a two-step decellularization(TSD)strategy to modify this biomacromolecular network,in which BP was post-treated,as the second step of decellularization,with a mild biosurfactant n-dodecyl-β-D-maltoside in a mixture of isopropanol and phosphate-buffered saline after the first step of traditional decellularization and GA cross-linking.The TSD-treated BP exhibited not only low cytotoxicity and excellent mechanical properties in vitro,but also low immune responses and significant anticalcification in vivo.After 60 days of subcutaneous implantation in the back of Wistar rats,the calcium content was,as quantified with an inductively coupled plasma optical emission spectrometer,only 1.1µg/mg compared to 138.6µg/mg in the control group without the post-treatment.In addition,collagen fibrils were observed with field emitting scanning electron microscopy(SEM),and the morphology and composition of the calcified sites resulting from in vivo biomineralization were studied with SEM with energy dispersive spectroscopy and also X-ray diffraction.This study proposes a facile yet effective anticalcification strategy for the modification of the bovine pericardial bioprosthetic heart valve,a natural biomacromolecular network.展开更多
Background:The donkey pericardium is considered a good candidate to manufacture percutaneous heart valves based upon its thinness,low cellularity and undulating collagen bundles and laminates.Decellularization represe...Background:The donkey pericardium is considered a good candidate to manufacture percutaneous heart valves based upon its thinness,low cellularity and undulating collagen bundles and laminates.Decellularization represents an avenue worth exploring,should its superiority to glutaraldehyde-treated pericardium be demonstrated.Materials and methods:Donkey pericardium was divided into two groups:regular glutaraldehyde fixation and mild decellularization.The treated pericardia were observed using scanning electron microscopy,histology and transmission electron microscopy.Tensile tests were performed along the axial and perpendicular directions,with the data fitted into both the Gasser–Ogden–Holzapfel(GOH)material model and the Fung’s anisotropic one.Results:The microstructures of the pericardia processed by the two protocols were similar,showing collagen bundles and laminates free of flaws.The decellularization eliminated most of the cells,however leaving the structure somehow compressed.The collagen filaments in bundles were slightly blurry.The anisotropy rates of the non-decellularized specimens were almost identical to the decellularized ones.The decellularized pericardium appeared stiffer.Conclusion:The decellularization proved to be effective.However,it makes the tissue stiffer,which may lead to higher shear concentration during cardiac cycles and reduce its wavy microstructure.Therefore,it appears premature to select decellularized donkey pericardium to manufacture heart valves.展开更多
文摘1 Transcatheter aortic valve implantation in symptomatic severe aortic stenosis: where do we stand? Aortic stenosis occurs in 2%-9% of patients over the age of 65, the most common cause being degenerative.^([1,2]) The preferred treatment in symptomatic severe aortic stenosis(SAS) is surgical aortic valve replacement(SAVR), but in the elderly, the surgical risk can be greater than the benefit.([3]).
文摘BACKGROUND Although transcatheter aortic valve implantation(TAVI)is a safe and effective treatment for aortic stenosis,it still carries some risks,such as valve leaks,stroke,and even death.The left ventricular global longitudinal strain(LVGLS)measurement may be useful for the prediction of adverse events during this operation.AIM To explore the change of LVGLS during TAVI procedure and the relationship between LVGLS and perioperative adverse events.METHODS In this study,61 patients who had undergone percutaneous transfemoral TAVI were evaluated by transthoracic echocardiography.Before surgery,data on left ventricular ejection fraction(LVEF)and LVGLS were collected separately following balloon expansion and stent implantation.Difference in values of LVGLS and LVEF during preoperative balloon expansion(pre-ex),preoperative stent implantation(pre-im)and balloon expansion-stent implantation(ex-im)were also examined.Adverse events were defined as perioperative death,cardiac rupture,heart arrest,moderate or severe perivalvular leakage,significant mitral regurgitation during TAVI,perioperative moderate or severe mitral regurgitation,perioperative left ventricular outflow tract obstruction,reoperation,and acute heart failure.RESULTS The occurrence of perioperative adverse events was associated with differences in pre-ex LVGLS,but not with difference in pre-ex LVEF.There were significant differences between pre-LVGLS and ex-LVGLS,and between pre-LVGLS and im-LVGLS(P=0.037 and P=0.020,respectively).However,differences in LVEF were not significant(P=0.358,P=0.254);however differences in pre-ex LVGLS were associated with pre-LVGLS(P=0.045).Compared to LVEF,LVGLS is more sensitive as a measure of left heart function during TAVI and the perioperative period.Moreover,the differences in LVGLS were associated with the occurrence of perioperative adverse events,and changes in LVGLS were apparent in patients with undesirable LVGLS before the surgery.Furthermore,LVGLS is useful to predict changes in cardiac function during TAVI.CONCLUSION Greater attention should be paid to the patients who plan to undergo TAVI with normal LVEF but poor LVGLS.
基金Supported by the National Natural Science Foundation of China,No.81600918
文摘BACKGROUND Aortic stenosis is the most common valve disease in adults.Transcatheter aortic valve implantation(TAVI)is being increasingly applied for intermediate-to lowrisk patients.Here,we describe an uncommon complication of delayed right coronary obstruction in a transapical TAVI case.CASE SUMMARY A 73-year-old woman with a EuroSCORE II of 1.21%underwent transapical TAVI because of severe aortic stenosis.The surgical procedure was uneventful.However,during routine monitoring after valve placement,the patient had a sudden onset of slow heart rate,the systolic blood pressure dropped sharply from 115 to 60 mmHg,and the central venous pressure abruptly increased from 10 to 33 cmH2O.The patient had a poor response to vasoactive agents.Transesophageal echocardiography revealed poor myocardial contractility,and electrocardiography showed a significant depression of ST-segment.Another angiography was performed immediately,which suggested complete obstruction of the right coronary artery.An emergency protocol was initiated.Cardiopulmonary bypass was established immediately.An aortic biological valve replacement under cardiopulmonary bypass was performed.CONCLUSION Perioperative monitoring,early recognition,and diagnosis of obstruction of coronary arteries in TAVI are important.Transesophageal echocardiography is a useful diagnostic and monitoring tool in this situation.Emergency protocols should be established during TAVI.
基金Universiti Putra Malaysia,for providing funds for this project through Grant UPM GP-IPM/2019/9675000.
文摘Paravalvular Leakage(PVL)has been recognized as one of the most dangerous complications in relation to Transcathether Aortic Valve Implantation(TAVI)activities.However,data available in the literature about Fluid Structure Interaction(FSI)for this specific problem are relatively limited.In the present study,the fluid and structure responses of the hemodynamics along the patient aorta model and the aortic wall deformation are studied with the aid of numerical simulation taking into account PVL and 100%TAVI valve opening.In particular,the aorta without valve(AWoV)is assumed as the normal condition,whereas an aorta with TAVI 26 mm for 100%Geometrical Orifice Area(GOA)is considered as the patient aorta with PVL complication.A 3D patient-specific aorta model is elaborated using the MIMICS software.Implantation of the identical TAVI valve of Edward SAPIEN XT 26(Edwards Lifes ciences,Irvine,California)is considered.An undersized 26 mm TAVI valve with 100%valve opening is selected to mimic the presence of PVL at the aortic annulus.The present research indicates that the existence of PVL can increase the blood velocity,pressure drop and WSS in comparison to normal conditions,thereby paving the way to the development of recirculation flow,thrombus formation,aorta wall collapse,aortic rupture and damage of endothelium.
文摘BACKGROUND Complications of transcatheter aortic valve implantation(TAVI)procedures include bleeding,vascular complications,and strokes.These complications are often associated with the type of access used.The two types of access in TAVI procedures are primary and secondary.The main use of the primary access is for valve delivery,while secondary access is used for angiography and hemodynamic monitoring.While there are many options for primary access,those for secondary access are transfemoral and transradial.AIM To compare outcomes between transradial vs transfemoral secondary access(TFSA).METHODS A systematic search was conducted using major databases(EMBASE,PubMed,Cochrane Central,Google Scholar),which resulted in 5 studies that met the criteria for study selection.Outcomes of interest were 30-d rates each of major/life-threatening bleeding,vascular complications,strokes,and mortality.All 5 studies were observational.Only adjusted or matched data were used when available in this meta-analysis.RESULTS A total of 5065 patients underwent TAVI,with 1453 patients(28.7%)having undergone transradial secondary access(TRSA)and 3612 patients(71.3%)TFSA.Irrespective of the site of primary access,the odds of having major or lifethreatening bleeding were 60%lower in the TRSA group than the TFSA group(P<0.00001).The odds of having major vascular complications were 52%lower in the TRSA group(P<0.0001)with no difference in minor vascular complications between the 2 groups.Similarly,the odds of mortality in 30-d after the procedure were 41%lower(P=0.006)and the odds of stroke were 54%lower(P=0.001)in the TRSA group than the TFSA group.CONCLUSION The transradial secondary approach appears to be a safer alternative to the transfemoral secondary approach in TAVI procedures.
文摘BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.
基金supported by the Liaoning Provincial Science and Technology Joint Project(2021JH2/10300104)National Key R&D Program of China(2020YFC2008100)。
文摘Patients experiencing severe aortic stenosis with acute decompensation often face elevated surgical aortic valve replacement risks,leading to high postoperative mortality rates.However,for some patients eligible for transcatheter aortic valve implantation(TAVI),computed tomography angiography for assessing the aortic root and coronary artery might be challenging before the TAVI procedure.This case highlights a patient who underwent emergency TAVI guided by coplane view generated using J-tipped wires fluoroscopy without computed tomography evaluation before the TAVl.This approach reduces contrast usage during the TAVI procedure,significantly mitigating the risks of renal injury and heart function deterioration.
文摘Background The effective orifice area(EOA)is utilized to characterize the hemodynamic performance of the transcatheter heart valve(THV).However,there is no consensus on EOA measurement of self-expanding THV.We aimed to compare two echocardiographic methods for EOA measurement following transcatheter self-expanding aortic valve implantation.Methods EOA was calculated according to the continuity equation.Two methods were constructed.In Method 1 and Method 2,the left ventricular outflow tract diameter(LVOTd)was measured at the entry of the prosthesis(from trailing-to-leading edge)and proximal to the prosthetic valve leaflets(from trailing-toleading edge),respectively.The velocity-time integral(VTI)of the LVOT(VTILVOT)was recorded by pulsed-wave Doppler(PW)from apical windows.The region of the PW sampling should match that of the LVOTd measurement with precise localization.The mean transvalvular pressure gradient(MG)and VTI of THV was measured by Continuous wave Doppler.Results A total of 113 consecutive patients were recruited.The mean age was 77.2±5.5 years,and 72 patients(63.7%)were male.EOA1 with the use of Method 1 was larger than EOA2(1.56±0.39 cm2 vs.1.48±0.41 cm2,P=0.001).MG correlated better with the indexed EOA1(EOAI1)(r=-0.701,P<0.001)than EOAI2(r=-0.645,P<0.001).According to EOAI(EOAI≤0.65 cm2/m2,respectively),the proportion of sever prosthesis-patient mismatch with the use of EOA1 was lower than EOA2(12.4%vs.21.2%,P<0.05).Compared with EOA2,EOA1 had lower interobserver and intra-observer variability(intra:0.5%±17%vs.3.8%±22%,P<0.001;inter:1.0%±9%vs.3.5%±11%,P<0.001).Conclusions For transcatheter self-expanding valve EOA measurement,LVOTd should be measured in the entry of the prosthesis stent(from trailing-to-leading edge),and VTILVOT should match that of the LVOTd measurement with precise localization.
基金supported by National Key R & D Plan(2017YFC1104202).
文摘BACKGROUND: This study aims to investigate whether small balloon aortic valvuloplasty(BAV) reduces the need for permanent pacemaker implantation (PPMI) after transcatheter aortic valveimplantation (TAVI).METHODS: This was a retrospective analysis using data from our local TAVI database. SmallBAV was defined as a small balloon size (=18 mm) pre-dilatation. Normal BAV was defined as aballoon size >18 mm. The primary endpoint was the incidence of new PPMI.RESULTS: Of 99 consecutive TAVI patients, five patients were excluded due to pre-existingpermanent pacemaker. Patients in the small BAV group (n=57) had a signifi cantly lower PPMI ratecompared with the normal BAV group (n=37) (3.5% vs. 18.9%, P=0.026). Moderate or severe aorticvalve regurgitation post-procedure was similar between the small BAV and normal BAV groups (5.3%vs. 8.1%, P=0.480);likewise, the mean aortic gradient post-procedure did not differ significantly(11.5±5.2 mmHg vs. 12.2±7.3 mmHg, 1 mmHg=0.133 kPa, P=0.580) between the groups. Devicesuccess rates were also similar (94.7% vs. 91.8%, P=0.680). In multivariable analysis, small BAV(P=0.027), the ratio of prosthesis diameter to annulus diameter (P=0.048), and mean aortic gradientby echo in the basement (P=0.021) were independent predictors of PPMI.CONCLUSIONS: The small BAV strategy is associated with a low rate of permanentpacemaker implantation after transcatheter self-expanding valve implantation in this single-centerobservational study.
文摘Aortic arch aneurysms are rarely isolated entities, and most frequently associated with either ascending or descending aorta pathologies. Association with aortic valve stenosis is uncommon and traditional surgical treatment is always challenging. Here we report a minimally invasive and endovascular management of these two pathologies in a 89-year-old man with LAD-stented ischemic cardiomyopathy. We describe our initial therapeutic strategy, per procedure difficulties and final management of this challenging case. Finally, we discuss the different therapeutic options for the endovascular treatment of aortic arch aneurysm associated with aortic valve stenosis.
基金supported by the Foundation for Talent in Clinical Research of The Army Medical University(No.2018XLC3021).
文摘Objective:Diverse antithrombotic strategies were applied to patients undergoing aortic valve replacement.However,the optimal therapeutic regimen for patients undergoing transcatheter aortic valve implantation/replacement(TAVI/TAVR)remains unclear.The purpose of this study was to compare the efficacy and safety of various antithrombotic therapies following TAVI/TAVR.Methods:Relevant clinical trials evaluating the effect of anticoagulation or antiplatelet regimens on patients after TAVI/TAVR from inception to September 2020 were identified using the PubMed,EMBASE,and the Cochrane Library databases.The inclusion criteria including(1)all patients underwent TAVI/TAVR;(2)the interventions were antithrombotic strategies that prevent the occurrence of thrombotic events in patients;(3)randomized controlled trials or prospective observational studies;and(4)investigation of at least 1 outcome with a follow-up period of≥3 months.The exclusion criteria including(1)research content was identical or irrelevant to the purpose of the present study;(2)lack of the required outcome index or availability of fragmentary original information;and(3)the full text is not available.The major outcomes were all-cause mortality,thromboembolic complications,and bleeding events.The Cochrane Collaboration’s tool and the Newcastle-Ottawa Scale were used for assessing the risk of bias in included studies.Results:Thirteen studies(3 randomized controlled trials and 10 non-randomized studies)were identified,with a total of 23,497 patients.Four studies compared direct oral anticoagulants(DOACs)with warfarin,1 study compared aspirin with warfarin,6 studies compared aspirin plus clopidogrel(dual antiplatelet therapy(DAPT))with aspirin monotherapy,and 2 studies compared DAPT and aspirin monotherapy with warfarin concurrently.There were no significant differences found between the DOAC and warfarin groups regarding all-cause mortality(risk ratio(RR):1.03;95%confidence interval(CI):0.65–1.64;P=0.909;Phet=0.105),clinical adverse events(RR:1.59;95%CI:0.99–2.58;P=0.057;Phet=0.738),or bleeding events(RR:0.93;95%CI:0.78–1.11;P=0.437;Phet=0.338).The rates of all-cause mortality(RR:0.71;95%CI:0.54–0.93;P=0.012;Phet=0.845)and bleeding events(RR:0.43;95%CI:0.22–0.83;P=0.012;P_(het)=0.569)were lower in the aspirin group versus the warfarin group;however,there was no difference in the rate of clinical adverse events(RR:0.38;95%CI:0.14–1.07;P=0.068;Phet=0.593).The DAPT group had an advantage versus the aspirin group in all-cause mortality(RR:0.89;95%CI:0.82–0.98;P=0.013;Phet=0.299);however,the incidence of bleeding events(RR:2.06;95%CI:1.39–3.07;P<0.001;Phet=0.001)exhibited an increasing trend.Notably,there was a slight decrease in the incidence of clinical adverse events(RR:1.09;95%CI:0.94–1.26;P=0.268;Phet=0.554).Conclusion:The present meta-analysis integrates the latest published results on antithrombotic strategies in patients after TAVI/TAVR.Aspirin showed a favorable risk-benefit profile versus warfarin,with lower rates of all-cause mortality and bleeding events.Although DAPT was also associated with a significantly lower rate of all-cause mortality,it was linked to a higher incidence of bleeding events.The DOACs did not show significant benefits compared with warfarin.Some certain limitations should be noted,such as different types of trails produce heterogeneity and finite inclusion of TAVI/TAVR patients increased selection bias.
文摘BACKGROUND The use of pre-closure suture-based devices represents a widely access-site hemostasis technique in percutaneous transfemoral transcatheter-aortic-valvereplacement(TF-TAVR);yet this technique is associated with the risk of a device failure that may result in clinically relevant residual bleeding.Thus,a bailout intervention is needed.So far,the best management of pre-closure device failure has not been recognized.AIM To report the first clinical results obtained using a novel bailout hemostasis technique for patients with double suture-based vascular closure device failure in the setting of TF-TAVR.METHODS We developed a“pledget-assisted hemostasis”technique to manage residual access-site bleeding.This consists of the insertion of a surgical,non-absorbable,polytetrafluoroethylene pledget over the sutures of the two ProGlide(Abbott Vascular,CA,United States).The ProGlide’s knot-pushers are used to push down the pledget and the hand-made slipknot to seal the femoral artery leak.This technique was used as a bailout strategy in patients undergoing TF-TAVR with a systematic double pre-closure technique.Post-procedural access-site angiography was systematically performed.In-hospital complications were systematically detected and classified according to Valve Academic Research Consortium-2 criteria.RESULTS Out of 136 consecutive patients who underwent TF-TAVR,15 patients(mean age 80.0±7.2 years,66.7%female)with access-site bleeding after double pre-closure technique failure were treated by pledget-assisted hemostasis.In the majority of patients,16F sheath was used(n=12;80%).In 2 cases(13%),a peripheral balloon was also inflated in the iliac artery to limit blood loss during pledget preparation.Angiography-confirmed hemostasis(primary efficacy endpoint)was achieved in all patients.After the procedure,1 patient required blood transfusion(2 units),and no other bleeding or major ischemic complication was noticed.CONCLUSION The“pledget assisted hemostasis”might be considered as a possible bailout technique to treat patients with residual access site bleeding.Further studies are needed to compare this approach with other bail-out techniques.
基金the National Natural Science Foundation of China(No.52130302).
文摘Bioprosthetic heart valves(BHVs)are important for transcatheter valve replacement.Current commercial BHVs on the market are basically porcine or bovine pericardium(BP)crosslinked with glutaraldehyde(GA).Simply applying GA to BHVs can enhance mechanical stability,but cannot alleviate in vivo calcification.In this work,we developed a two-step decellularization(TSD)strategy to modify this biomacromolecular network,in which BP was post-treated,as the second step of decellularization,with a mild biosurfactant n-dodecyl-β-D-maltoside in a mixture of isopropanol and phosphate-buffered saline after the first step of traditional decellularization and GA cross-linking.The TSD-treated BP exhibited not only low cytotoxicity and excellent mechanical properties in vitro,but also low immune responses and significant anticalcification in vivo.After 60 days of subcutaneous implantation in the back of Wistar rats,the calcium content was,as quantified with an inductively coupled plasma optical emission spectrometer,only 1.1µg/mg compared to 138.6µg/mg in the control group without the post-treatment.In addition,collagen fibrils were observed with field emitting scanning electron microscopy(SEM),and the morphology and composition of the calcified sites resulting from in vivo biomineralization were studied with SEM with energy dispersive spectroscopy and also X-ray diffraction.This study proposes a facile yet effective anticalcification strategy for the modification of the bovine pericardial bioprosthetic heart valve,a natural biomacromolecular network.
基金supported by the National Natural Science Foundation of China(grant 81770476)Shanghai Maritime University of China.through Key Discipline Construction Project(grant 2017ZZ02008)the Amirkabir University of Technology,Tehran,Iran,a Fonds de Recherche en Chirurgie Vasculaire from the CHU de Quebec and the Department of Surgery at Laval University,Quebec,Canada.
文摘Background:The donkey pericardium is considered a good candidate to manufacture percutaneous heart valves based upon its thinness,low cellularity and undulating collagen bundles and laminates.Decellularization represents an avenue worth exploring,should its superiority to glutaraldehyde-treated pericardium be demonstrated.Materials and methods:Donkey pericardium was divided into two groups:regular glutaraldehyde fixation and mild decellularization.The treated pericardia were observed using scanning electron microscopy,histology and transmission electron microscopy.Tensile tests were performed along the axial and perpendicular directions,with the data fitted into both the Gasser–Ogden–Holzapfel(GOH)material model and the Fung’s anisotropic one.Results:The microstructures of the pericardia processed by the two protocols were similar,showing collagen bundles and laminates free of flaws.The decellularization eliminated most of the cells,however leaving the structure somehow compressed.The collagen filaments in bundles were slightly blurry.The anisotropy rates of the non-decellularized specimens were almost identical to the decellularized ones.The decellularized pericardium appeared stiffer.Conclusion:The decellularization proved to be effective.However,it makes the tissue stiffer,which may lead to higher shear concentration during cardiac cycles and reduce its wavy microstructure.Therefore,it appears premature to select decellularized donkey pericardium to manufacture heart valves.
