Echocardiographic phenotype in severe aortic valve stenosis with and without cardiac amyloidosis: The AMY-TAVI trial

Background: Longitudinal Strain (LS) pattern in cardiac amyloidosis (CA) typically spares the apex of the heart, which is a sensitive and specific finding that can be used to distinguish CA from other causes of left ventricular (LV) hypertrophy. RELAPS >1 suggests with high specificity CA, and shows a bright red in the apical segments of the polar map. Purpose(s): To identify differential echocardiographic characteristics of aortic stenosis (AS) with concomitant TTR-CA (AS-CA) compared to AS alone. Method(s): Patients with severe symptomatic AS undergoing TAVI were prospectively and consecutively included between Jan-19 and Dec-20. Pre-procedure, a complete echocardiogram was performed that included deformation parameters using Speckle-Tracking. Strain derived Indices accepted for CA screening were calculated: RELAPS: Relative apical LS (average apical LS/average basal+mid LS);SAB: (apical-septal/basal-septal LS);EFSR: (LVEF/GLS). After TAVI, a 99Tc-DPD scintigraphy and a proteinogram were performed to screen for CA. Result(s): 324 patients were included. The mean age was 81 yo, 52% women. 39 (12%) patients presented cardiac uptake on scintigraphy: 14 (4.3%) grade 1;13 (4%) grade 2, and 11 (3.4%) grade 3. Strain analysis could be performed in 243 patients due to acoustic window and covid19 pandemic restrictions. Echocardiographic characteristics between AS alone and those with grade 1 (AS-DTD1) and grade 2/3 (AS-CA) are shown in Table 1. Compared with AS alone, patients with AS-CA had significantly lower transvalvular gradients, although similar AVA, and low flow-low gradient (LF-LG) AS was more prevalent. AS-CA exhibited slightly worse cardiac remodeling (LV mass ind: 202 g/m2 vs 176 g/m2, p=0.032), and worse diastolic dysfunction, but without significant differences in thickness, diameters or volumes, with similar relative wall thickness (RWT: 0.53 vs. 0.51 mm, p=0.52). LVEF was similar, however myocardial contraction fraction (MCF= stroke volume/myocardial volume) and MAPSE were worse in AS-CA. GLS, RELAPS, SAB and EFSR were not different, but RELAPS >1 pattern was more prevalent in AS-CA (74% vs 44%, p=0,006) (Figure 1). Mass/strain ratio (RMS) was similar. There were no differences in size and fractional emptying of left atrium, or atrial septum thickness. Right ventricle (RV) size was similar, as well as conventional function parameters (TAPSE and S'). However, RV LS was worse in AS-CA. Pericardial effusion was more prevalent in AS-CA (25% vs 7.4%, p=0.013). In the multivariate analysis, predictors of AS-CA were: Age (OR: 1,2, p=0,02), BG (OR: 0,2, p=0,01), E/A (OR: 4,7, p=0,02), LV Mass index (OR: 1,02, p=0,04) and RELAPS >1 (OR: 0,12, p=0,01). Conclusion(s): Dual pathology of AS-AC is common in older patients referred for TAVI. Although it is more prevalent in patients with AS-CA, RELAPS>1 pattern can be present in almost 50% of patients with severe AS alone, which reduces its value as screening tool for CA in this clinical setting respect to others. (Table Presented).

Echocardiographic phenotype and prognostic value of relative apical sparing of longitudinal strain pattern in severe aortic stenosis with and without cardiac amyloidosis. The AMYTAVI study

Introduction: It is estimated that 15% of patients with AS have concomitant cardiac amyloidosis (CA). Left ventricular (LV) longitudinal strain (LS) pattern with relative apical sparing (RELAPS>1), shown as bright red in the apical segments on the polar map, has been strongly associated with CA. Its presence and its significance in AS is yet to be determined. Purpose(s): To determine the prevalence of the RELAPS>1 pattern in patients with severe AS with and without concomitant CA, and to analyze the echocardiographic phenotype associated with this strain pattern and its prognostic value. Method(s): Patients with severe symptomatic AS undergoing TAVI were prospectively and consecutively included between Jan-19 and Dec-20. Pre-procedure, a complete echocardiogram was performed that included deformation parameters using Speckle-Tracking. Strain derived Indices accepted for CA screening were calculated: RELAPS: Relative apical LS (average apical LS/average basal+mid LS);SAB: (apical-septal/basal-septal LS);EFSR: (LVEF/GLS). After TAVI, a 99Tc-PYP scintigraphy and a proteinogram were performed to screen for CA. Result(s): 324 patients were included. The mean age was 81 yo, 52% women. Strain analysis could be performed in 243 patients due to acoustic window and covid19 pandemic restrictions. Among those, 111 (46%) presented relative apical sparing (RELAPS>1). There were no differences in clinical characteristics between patients with RELAPS <1 and >1: Similar age, sex, cardiovascular risk factors and funcional class, renal function or NT-proBNP. Among patients with RELAPS>1 there was more frecuently CA with uptake grade 2 and 3 on scintigraphy (15% vs. 4.5%, P=0.006) (Figure 1). RELAPS>1 group showed greater LV hypertrophic remodeling: Thicker myocardial wall with smaller ventricular cavity, especially concentric hypertrophy;LVEF and GLS was similar, however, MAPSE and myocardial contraction fraction (MCF) were worse in RELAPS >1 group, and EFSR was significantly higher (4.2 vs 3.9, p=0.002). RELAPS >1 group had smaller aortic valve area (AVA: 0.6 vs 0.7 cm2, p=0.045), but similar transvalvular gradients due to lower stroke volume. It had larger atria and less left atrial (LA) fractional emptying, as well as higher prevalence of atrial fibrillation (AF: 41% vs 27%, p=0.03). Right ventricle (RV) size were similar, however, RV function was worse in RELAPS >1 group (TAPSE: 19 vs 21 mm, p=0.003;free Wall LS: -24 vs -27%, p=0.008). There was no difference in all-cause mortality at 1 year of follow-up between groups (6.4% vs. 6.3%, p=1). Figure 2 represents the morphological characteristics according to the LS phenotype. Conclusion(s): In severe AS, RELAPS >1 is present in almost half of the patients. It is associated with worse cardiac remodeling, as well as higher prevalence of AF. However, it wasn't associated with higher mortality at 1 year. 1 in 7 patients with AS and RELAPS >1 have concomitant ATTR CA grade 2/3.

Trends and Predictors of Short Wait Time for Transcatheter Aortic Valve Replacement in a Rural Health Care Network

Background Prolonged wait times for Transcatheter Aortic Valve Replacement (TAVR) are associated with increased mortality. Rural health care systems may have challenges in efficiency due to travel related delays. We determined temporal trends and predictors of Short TAVR Wait Time (STWT: TAVR <=30 days from first referral). Methods We identified 918 consecutive patients with Aortic Stenosis (AS) undergoing TAVR from 1/1/19-6/30/22 at a rural tertiary care center. Patients with wait times?>90 days (N=87) were excluded due to patient preferences or treatment of comorbidities. We assessed TAVR wait times (means and STWT%) over time and determined the impact of COVID 19 onset (3/1/20) and driving distance on TAVR efficiency. Results Half of the cohort achieved STWT (51%). TAVR volumes, patient age, sex, and comorbidities were generally stable over time. Mean wait times decreased despite the onset of COVID 19: pre-COVID 36+/- 19 vs post-COVID 31+/- 19 days (p=0.003) (Figure). There was no interaction of travel distance and mean wait time: 33+/- 19 days <= 60 miles vs 32+/- 19 days?> 60 miles (P=NS). Conclusion TAVR efficiency improved over the past 4 years with one half of patients experiencing a STWT. Neither COVID 19 nor long travel distance negatively impacted TAVR efficiency in a rural health care network. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Prosthetic valve thrombosis: literature review and two case reports

Prosthetic heart valve thrombosis is one of the most dangerous prosthetic valve complications. Proper monitoring and management of these patients help to prevent this complication. Fluoroscopy is advantageous in cases of thrombosis to assess the function of the prosthetic valve by measuring opening and closing angles. We describe two cases of aortic mechanical valve thrombosis with different mechanisms of thrombus formation. The first case was a 48-year-old woman admitted to the hospital because of shortness of breath during minimal exertion and significantly reduced exercise tolerance. Due to rheumatic heart disease the patient underwent aortic and mitral mechanical prosthesis and has been using warfarin in therapeutic norms. During echocardioscopy aortic prosthesis obstruction and severe tricuspid valve regurgitation were observed. The patient was scheduled for aortic root and TV prosthesis surgery. The second patient also had aortic mechanical valve due to severe aortic stenosis caused by rheumatism and presented with organizing pneumonia and progressing respiratory failure as complications of the COVID-19 infection and was admitted with dyspnea, cough, and weakness. Aortic prosthetic valve thrombosis was diagnosed despite optimal treatment and therapeutic INR.Copyright © 2023, CKS.

Recurrent Embolic Strokes in a Young Patient - a Case of Late Tavr Thrombosis and Endocarditis

Background Late complications of transcatheter aortic valve replacement (TAVR) are uncommon. We present a patient two-years post TAVR with recurrent strokes. Case A 56-year-old male with history of TAVR and pacemaker first presented with left-sided weakness found to have acute right MCA strokes and COVID. TTE showed a non-thickened valve with normal gradients and device interrogation revealed no arrhythmias. Six months later, he presented with acute left MCA strokes as well as new murmur, leukocytosis, and splenic infarcts on CT. TTE demonstrated a prosthetic aortic valve mean gradient of 43mmHg. TEE confirmed leaflet thrombosis with severe prosthetic aortic stenosis and mobile thrombus (Figure 1). Multiple sets of blood cultures were negative. Decision-making He was first treated with therapeutic anticoagulation but switched to broad spectrum antibiotics with increasing evidence for infection. He underwent Ross procedure with intra-operative evidence of multiple aortic root abscesses (Figure 1). PCR sequencing of the vegetation revealed staphylococcus species related to S. Haemolyticus. His course may be best explained by embolic stroke caused by progressive TAVR thrombosis in the setting of COVID-associated coagulopathy and subsequent superinfection leading to endocarditis and septic emboli. Conclusion Late TAVR thrombosis and endocarditis are rare complications. TAVR patients presenting with stroke merit prompt evaluation with dedicated echocardiographic imaging. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Acute Transcatheter Aortic Valve Replacement Failure Secondary to Covid-19 Infection

Background Valve thrombosis is a documented cause of prosthetic valve failure. Common features include increased cusp thickness, reduced cusp mobility, and increased transvalvular gradient. Case reports have been published of prosthetic valve thrombosis secondary to COVID-19 infection, but this may represent the first documented case of bioprosthetic transcatheter aortic valve replacement (TAVR) thrombosis in the setting of COVID-19. Case A 90 year-old female with atrial fibrillation on apixaban and severe aortic stenosis status-post TAVR with normal valve function on recent echocardiogram presented in clinic with acute chest pain. She was found to have COVID-19 infection and severe bioprosthetic valvular regurgitation with leaflet thickening, abnormal cusp mobility, and elevated transvalvular gradient. [Formula presented] Decision-making Given the time course of valve failure, COVID-19 infection, and echocardiographic features, the patient was diagnosed with bioprosthetic valve thrombosis secondary to COVID-19. She was optimized with diuresis and continued on apixaban before undergoing valve-in-valve TAVR with resolution of valvular dysfunction. Conclusion This case contributes to a body of literature describing thrombotic complications in patients with valve replacement and COVID-19 infection despite concurrent anticoagulation. Increased vigilance and investigations are warranted to better characterize thrombotic risk and optimal antithrombotic strategies in this patient populace.Copyright © 2023 American College of Cardiology Foundation

Heyde Syndrome Complicated by Essential Thrombocythemia: A Case Report.

Heyde syndrome is a multisystem disorder characterized by the triad of aortic stenosis (AS), gastrointestinal bleeding, and acquired von Willebrand syndrome. Age-related degeneration is the most common cause of aortic stenosis and is frequently encountered in today's aging society. Approximately 20% of patients with severe aortic stenosis have Heyde syndrome. We encountered an older patient with primary thrombocytosis who was brought to a rural community hospital with bloody stools and was diagnosed with bleeding from an intestinal arteriovenous malformation. A final diagnosis of Heyde syndrome was made based on the presence of severe aortic stenosis and the presence of schistocytes in peripheral blood smears. Valvular diseases can complicate chronic hematological diseases. When the rapid progression of anemia and segmented red blood cells in the peripheral blood are observed in patients with severe aortic stenosis, Heyde syndrome should be considered based on peripheral blood smears and clinical course.

"Be Your Own Doctor" Experiences of Patients With Transcatheter Aortic Valve Implantation During the Pandemic: A Qualitative Study.

Background and Purpose: Although patients have had reduced access to healthcare institutions due to the COVID-19 pandemic and the related preventive measures, there is no current data on how the pandemic has affected patients who underwent transcatheter aortic valve implantation (TAVI), despite their need for close follow-up.This study investigated TAVI patients' experiences with self-care management during the pandemic. Methods: This study adopted a descriptive qualitative design. The sample consisted of 24 patients recruited using purposive sampling. Data were collected by telephone and analyzed using inductive content analysis. Results: The data were grouped under three themes: "vulnerability," "worsening of psychological condition," and "expectations." The most challenging self-care behaviors reported by TAVI patients were determined to be doing regular physical activity, managing their symptoms, complying with treatment, and attending regular check-ups. They also reported experiencing psychological problems such as fear, concern, and abandonment and stated a need for better communication and follow-up at home during the pandemic. Implications for Practice: The pandemic has more than ever demonstrated the importance of effective self-care for cardiovascular patients. Nurses should plan individualized interventions regarding the problems in self-care management that we identified in this study. In this regard, the use of secure digital applications such as telerehabilitation can be effective. Also, nurses should develop community-based and political initiatives to allow sustainable self-care management to be effectively implemented in special patient groups in extraordinary circumstances such as pandemics.

Coronary Artery Disease and Severe Aortic Stenosis in the Covid-19 Era: A Case Report

An 81-years-old with a history of hypertension, dyslipidemia, and chronic ischemic heart disease with prior stent implantation of right coronary artery in 2011. Due to its poor compliance, no recurrent symptoms, and, finally, the COVID-19 pandemic, the patient did not perform any cardiological follow-up during these years. Unfortunately, the last six months he has reported the onset of dyspnea and typical angina due to moderate efforts, undervalued by the patient. Because of the rapid worsening of dyspnea and typical angina in the last 5 days, he went to the local emergency department (ED). The role in/role out routine exams performed in the ED documented a COVID-19 infection. At the ED, his vital signs were normal, with a blood pressure of 135/75 mm Hg, heart rate of 74 regular beats/min, body temperature of 36.5 degreeC, oxygen saturation of 97% in ambient air, and respiratory rate of 16/ min. Of note, the chest x-ray was normal, as well as no alterations were documented at the CTscan performed a few hours later. First-line blood sample tests were within range except for Hb 10 mg/dl. Therefore, a cardiological evaluation was requested. Electrocardiogram (ECG) showed inverted T-waves in V1-4 leads, and echocardiography showed normal left ventricular ejection fraction (FE 55% Simpson), left ventricular anterolateral wall hypokinesia, and severe aortic stenosis (V max 4.78 m/ s, Gr max 4.78 m/s, Gr medium 59 mmHg). Since myocardial necrosis enzymes were increased (T-hs 118.7 ng/dl;CK-MB 6.3 ng/L;NT-ProBNP 761 ng/dl), leading to the suspicion of acute coronary syndrome the patient underwent coronary angiography, showing critical stenoses of the left descending artery (LAD), circumflex (LCX), I obtuse marginal (IOM), and patent stent of the right coronary artery. Therefore, the Heart team deemed the patient at high operatory risk choosing, in agreement with the patient, for a percutaneous coronary intervention (PCI) followed by TAVR. Accordingly, the patients underwent PCI of LAD with the implantation of a Xience-Serra 3.0x15 mm and PCI of LCX with the implantation of an Onyx 2.75x18 mm stent. After COVID -19 resolution, which happen 7 days later, the patient was moved to our cardiology department. Two days later in the same procedure, we performed the first PCI of I-OM with the implantation of a Xience Sierra 3.0x18 mm stent following a TAVI with the implantation of Evolute Pro valve 29 mm. The postprocedure echocardiogram showed an optimal valve position with a transvalvular mean pressure gradient of 4 mm Hg. After six days post-TAVI, for a complete atrioventricular block, the patient also underwent a pacemaker implantation. The patient was finally discharged after 10 from TAVI. Discussion(s): This case report offers several foods for thought. First, the COVID-19 pandemic has negatively affected primary and secondary prevention, even for patients affected by cardiovascular disease. Our patient has postponed clinical checks even when the symptoms reappeared, also because of the concerns lead by the COVID-19 pandemic. Second, completeness and timing of coronary disease revascularization, which in this case was staged and performed before TAVI. Finally, the late occurrence of advanced heart block requiring PM implantation. For instance, in an era of fast-track TAVI, more studies are warranted to identify patients who are at higher risk of late PM implantation.

The impact of COVID-19 in patients with severe aortic stenosis: Artificial intelligence research.

INTRODUCTION: Untreated, severe, symptomatic aortic stenosis is associated with an ominous diagnosis without intervention. This study aims to determine the impact of the COVID-19 pandemic on the mortality of patients with severe stenosis during the first wave and compare it with the same period last year. METHODS: All patients who went to the hospitals in a spanish region during the first wave, and in the same period of previous year, were analysed using Artificial Intelligence-based software, evaluating the mortality of patients with severe aortic stenosis with and without COVID-19 during the pandemic and the pre-COVID era. Mortality of the three groups were compared. Regarding cardiac surgeries was a tendency to decrease (p = .07) in patients without COVID-19 between the pandemic and the previous period was observed. A significant decrease of surgeries between patients with COVID-19 and without COVID-19 was shown. RESULTS: Data showed 13.82% less admitted patients during the first wave. 1112 of them, had aortic stenosis and 5.48% were COVID-19 positive. Mortality was higher (p = .01), in COVID-19 negative during the pandemic (4.37%) versus those in the pre-COVID19 era (2.57%); it was also in the COVID-19 positive group (11.47%), versus covid-19 negative (4.37%) during the first wave (p = .01). CONCLUSIONS: The study revealed a decrease in patients who went to the hospital and an excess of mortality in patients with severe AD without infection during the first wave, compared to the same period last year; and also, in COVID-19 positive patients versus COVID-19 negative.

Early Single-Center Experience With Meril's Myval Transcatheter Heart Valve

Background: TAVR has emerged as a revolutionary treatment for patients with symptomatic and severe AS, irrespective of surgical-risk profile. Novel transcatheter heart valves (THV) with a lower profile, ease of use and expected longer durability are being developed to target younger and low-risk population. Myval is a 14Fr-balloon expandable THV with a skirt to minimize the occurrence of paravalvular leak (PVL), and has been recently approved for commercial use in Brazil. We sought to report our initial experience with this novel device. Methods: Single-center, single arm, open label prospective registry encompassing all consecutive patients referred to TAVR in our Institution between December 2020 and November 2021. Indication for TAVR was according to current international guidelines. Clinical and echocardiographic outcomes were defined accordingly to VARC-III criteria. Results: A total of 39 patients were enrolled so far. Mean age was 79.5 years, 42% were female and mean STS score was 4%. Pre-procedures mean gradient and aortic valve area were 53.3 mmHg and 0.7cm2, respectively. All procedures were performed under minimalist approach using percutaneous, femoral access. Two patients were treated for bicuspid aortic stenosis and four patients underwent a valve-in-valve procedure. Procedure success was achieved in 100% of the cases, and post-procedure echocardiogram revealed a mean residual gradient of 5 mmHg, with PVL greater than mild in a single case. Permanent pacemaker was required in only 2 patients, and mean hospital stay was 3.1 days. At 30-days, there were two deaths, one due to COVID in a patient who presented major access bleeding requiring prolonged hospital stay, and another one a cardiovascular death. Conclusion: In our initial experience with the Myval THV, valve performance and 30-day clinical results were encouraging. Low rates of complications were observed, comparable to the best last-generation THV. At the time of the meeting, three-month clinical and echocardiographic FU will be available.

THE TRUTH THE TEETH TOLD: THE UNUSUAL CASE OF A SUBPHRENIC MASS

CASE: A 75-year-old man with a history of aortic stenosis status post transcatheter aortic valve replacement (TAVR), compensated cirrhosis in the setting of alcohol use disorder, and osteoarthritis presented with hyper-acute dyspnea and chest pain that awoke him from sleep. Three years prior to admission, an abdominal computed tomography (CT) for his TAVR evaluation revealed a 2 cm, irregular, peripherally-enhancing mass in the right subphrenic space, most concerning for malignancy but stable in size a year later. Further work-up was delayed due to the COVID-19 pandemic. One week prior to this presentation, he returned to care with 6 months of progressive right shoulder pain, pleuritic chest pain, and 5 kg of unintentional weight loss and was found to have growth of the right subphrenic mass to 4.9 cm, for which he underwent interventional radiology-guided aspiration and biopsy from a subxiphoid approach. Pathology on the core biopsy was inconclusive, revealing granulation tissue with chronic inflammatory changes and negative routine cultures. He was hemodynamically stable and discharged home. On admission, he was afebrile, tachypneic to 26, tachycardic to 120, hypotensive to 80/40, and saturating 94% on room air. He was found to have a large pericardial effusion with tamponade physiology, upon which 500 mL of serous fluid was drained via emergent pericardiocentesis. Laparoscopic biopsy of the subphrenic mass revealed a purulent fluid collection. 16S/18S sequencing and MALDI cultures were most consistent with Actinomyces spp. With further history-taking alongside an Italian language interpreter, he was found to have had prior dental abscesses, the likely origin of his Actinomyces infection, although the curious propensity for the subphrenic location remains unknown. Periodontal disease had been diagnosed but not fully treated given lack of insurance coverage and perceived importance. His pericarditis and ensuing tamponade was attributed to irritation and seeding from the subxiphoid approach for attempted fluid aspiration. IMPACT/DISCUSSION: Actinomyces spp. are a part of the normal human gut and oral cavity flora, but when pathogenic, they are often associated with dental, pulmonary, and urinary tract infections. In addition to periodontal disease, this patient's risk factors for Actinomyces abscess formation include cirrhosis (via transient gut translocation from elevated portal pressures) and alcohol use disorder (via increased aspiration risk). There have been several reports of Actinomyces spp. causing pericarditis and tamponade following seeding from liver, lung, and oral cavity abscesses- to our knowledge, however, none from subphrenic abscesses. CONCLUSION: This case highlights the importance of an oral health history in work-up of an indolent growing thoracic mass and the challenges in comprehensive history-taking in patients with limited English proficiency. Increasing coverage of dental services (e.g. a Medicare dental benefit) is key to health and health equity.

A clinical case of transapical aortic valve implantation for low-gradient stenosis in a comorbid patient with COVID-19-associated pneumonia

Aortic stenosis is the leading entity in the structure of valvular pathology in adult population with the frequency ranging from 2 to 4% in the general population. The distinct features of this defect include slow progression and frequent lack of correlation between the severity of stenosis according to clinical and instrumental data. The article presents the case of successful transcatheter aortic valve implantation by transapical access in a 71-year-old patient with symptomatic low-flow, low-gradient aortic stenosis, heart failure with preserved left ventricular ejection fraction, a history of coronary artery bypass grafting, severe concomitant pathology, and recent moderate COVID-19 coronavirus infection. The complexity of management of elderly patients with combined pathology is updated, and a multidisciplinary approach to clinical decision-making in a high-risk clinical situation is demonstrated. © 2022 Folia Medica. All rights reserved.

Intra vascular lithotripsy facilitated Transfemoral TAVR

Transcatheter aortic valve replacement (TAVR) is now the standard of therapy for elderly population with severe aortic stenosis. Several studies have established that the outcomes of TAVR are superior when compared with Surgical aortic valve replacement (SAVR), especially when the access route is transfemoral arterial approach. In the elderly population with advanced age and numerous comorbidities, iliofemoral arterial disease (IAD) is not uncommon and it precludes the use of this route for TAVR. Peripheral Intravascular lithotripsy (IVL) has been previously established as an excellent safe and efficient modality to treat symptomatic occlusive calcific iliofemoral artery disease. The same principle of IVL has been recently used successfully to modify the vascular compliance of heavily calcified iliofemoral arteries thereby enabling large bore sheath advancement and safe passage of TAVR delivery catheter systems. We report the first case of Intravascular lithotripsy facilitated Transfemoral TAVR (TF-TAVR) in India. This case was done in December 2020 by the “femoral route” in order to keep the TAVR procedure simple straightforward and discharge the patient back home quickly in Covid times. The use of Intravascular Lithotripsy (IVL)was based on evidence of good outcomes in trials of peripheral vascular disease of lower limbs as well as from the good outcomes of few registries on IVL facilitated TAVR.1,2,3,4,5,6,8 The second case was done in August 2021 by us for another patient successfully.

British Cardiovascular Society Annual Conference, '100 years of Cardiology'

The proceedings contain 226 papers. The topics discussed include: mitral valve abnormalities in decedents of sudden cardiac death due to hypertrophic cardiomyopathy and idiopathic left ventricular hypertrophy;prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players;clinical outcomes and myocardial recovery in energetics, perfusion and contractile function after valve replacement surgery in severe aortic stenosis patients with diabetes comorbidity;brain phenotype of takotsubo syndrome;improving the diagnostic accuracy of apical hypertrophic cardiomyopathy;investigating a novel role for nesprin-1 and the linc complex in cardiomyocyte mechanotransduction;transcatheter aortic valve implantation in patients with right bundle branch block: should prophylactic pacing be undertaken?;and disease penetrance in asymptomatic carriers of familial cardiomyopathy variants.

Cerebral Infarction Following Correction of Aortic Coarctation Surgery in Children

Background: Coarctation of the aorta (CoA) is a congenital heart defect. Due to the narrowing of the descending aorta, blood flow mainly reduces after the stenosis, and CoA can occur at any region in the thoracic and abdominal aorta. Cardiac surgeons and cardiologists are familiar with postoperative complications of CoA;however, there are also some other complications that have not been reported to date. Case Presentation: The present study investigated three cases of CoA undergoing reconstructive surgery. Nevertheless, a couple of days after the surgery, they manifested symptoms suspected of cerebral infarction. Ischemic infarction was observed after performing brain computed tomography. Additionally, we discuss possible pathophysiology and reasons that can lead to this problem. Conclusions: In this case report, we presented three cases of CoA patients who underwent reconstructive surgery and manifested cerebral infarction as an adverse effect of the reconstructive surgery.

Current lipid-lowering approach and LDL target achievement in very high-risk patients: in-hospital results of a high-volume primary percutaneous coronary intervention tertiary center

Background: Low-density lipoprotein-cholesterol (LDL-C) is a well-accepted causal risk factor for atherothrombotic cardiovascular disease. Several randomized controlled trials and meta-analyses have shown that lipid-lowering therapies reduce cardiovascular events and have a positive effect in reducing vulnerable plaques. In particular, the recommended target for LDL-C has become more and more stringent, moving to 1.4 mmol/l (55 mg/dl) for very high-risk patients. According to the 2019 ESC/EAS Guidelines, the current paradigm for lipid management favors a stepwise approach consisting of early initiation of high-intensity statin, followed by subsequent addition of ezetimibe, and ultimately a consideration of PCSK9 inhibitor treatment if LDL-C levels remain elevated. Methods: We recruited 307 patients admitted for acute coronary syndrome (ACS) during the COVID-19 pandemic from March 2020 to December 2020. Baseline LDL-C concentration and prescribed hypolipemiant treatment at hospital admission and discharge were registered. Therefore, we included all consecutive patients identified as very-high cardiovascular risk, according to 2019 ESC guidelines. We stratified our population through variables independently associated with non-attainment of LDL-cholesterol such as hypertension, diabetes, peripheral arterial disease, clinical manifestations of ACS, number of main vessels treated, and complexity of the atherosclerotic disease. Results: 274 patients were included. Mean age was 69,9 years (SD 11,4), 20,8%were women, 23,7%had diabetes, 16,4%had PAD and 32,1 % suffered from valvular disease, mainly with mitral regurgitation or aortic stenosis no more than mild or moderate. Of 25.1% with a previous history of acute myocardial infarction, the 33,3% of whom didn't have statin therapy pre-ACS index (p =0,001). At admission, medium cholesterol levels of patients that underwent previous coronary revascularization (25,5% of the total population) were 84,21 ± 31,2 mg/dL, not in range according to both 2016 and 2019 ESC guidelines. At discharge, 77,37 % of all the patients included received only statin therapy VS 22,63% with statin plus ezetimibe. In the subpopulation of patients with recurring ACS events with LDL pre-admission > 100 mg/dL,despite high dose statin, only 25% of this population were discharged adding ezetimibe (VS 75% who kept on the treatment of high dose statin without up-titration). Conclusions: Management of dyslipidemia is frequently suboptimal and the gap between guidelines and clinical practice for lipid management across Europe has been exacerbated by the 2019 guidelines. A greater utilization of non-statin lipid-lowering therapies is likely needed to reach the LDL-C optimal target. A correct stratification of the risk class would help to identify, in a personalized perspective of treatment, patients at very high risk that would take advantage of more aggressive therapy to reach the lowest target of LDL-C ('the lower is better'). (Figure Presented).