Complexity assessment and technical aspect of coronary angiogram and percutaneous coronary intervention following transcatheter aortic valve implantation.

BACKGROUND: Performing selective coronary angiogram (CA) and percutaneous coronary intervention (PCI) post transcatheter aortic valve implantation (TAVI) may be challenging with various success rates of coronary ostia engagement. METHODS: Among all patients who underwent CA and/or PCI after TAVI from our single center TAVI registry, ostia cannulation success was reported according to the quality of ostia engagement and artery opacification, and was classified as either selective, partially selective or non-selective but sufficient for diagnosis. RESULTS: Among the 424 consecutive TAVI procedures performed at the aforementioned institution, 20 (4.7%) CA were performed in 19 (4.5%) patients at a median time of 464 days post TAVI (25-75% IQ: 213-634 days). CA were performed in 7 CoreValve, 9 Evolut R, 1 Evolut PRO and 2 Edwards Sapien 3 devices. Transradial vascular approach was attempted in 9 procedures (45%, right n = 6 and left n = 3) and was successful in 8 (40%) patients. A total of 20 left main artery ostium cannulation were attempted leading to a diagnostic CA in all of them with selective engagement in 65%. Engagement of the right coronary artery in 2 out of 15 attempted cases failed due to a low ostium in conjunction with a high implantation of a CoreValve prosthesis. 11 PCI (55% of CA) including 2 left main lesions were performed. In 4 patients (36.4% of the PCI), an extension catheter was required to engage the left main. All planned PCI were successful. CONCLUSIONS: Post TAVI CA and PCI are challenging but feasible even after supra-annular self-expandable valve implantation.

Left Posterior Thoracic Acoustic Window: A Forgotten Approach for Aortic Stenosis Assessment.

Accurate diagnosis of severe aortic stenosis is important for timely valve replacement. Peak aortic velocity and gradient recordings require optimal aortic jet-ultrasound beam alignment, which may be challenging in patients with poor acoustic windows due to obesity, lung disease, chest deformities, skin lesions, or surgical scars. In these clinical settings, alternative acoustic windows, notably the posterior thoracic window, can be helpful. However, in order to use the posterior thoracic window, some degree of left pleural effusion must be present.

Le diagnostic précis de la sténose aortique sévère est important pour procéder au remplacement de la valve dans un délai approprié. Les enregistrements du gradient et de la vélocité aortique maximale exigent un alignement optimal entre le flux aortique et le faisceau d'ultrasons, mais il peut s'avérer difficile chez les patients dont les fenêtres acoustiques sont mauvaises en raison de l'obésité, d'une pneumopathie, de déformations thoraciques, de lésions cutanées ou de cicatrices chirurgicales. Dans ces contextes cliniques, d'autres fenêtres acoustiques, notamment la fenêtre thoracique postérieure, peuvent être utiles. Toutefois, pour utiliser la fenêtre thoracique postérieure, un certain degré d'épanchement pleural gauche doit être présent.

Improved Exercise Tolerance, Oxygen Delivery, and Oxygen Utilization After Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) represents an effective therapeutic procedure, particularly in patients with severe aortic stenosis. We hypothesized that the decreased afterload induced by TAVI would improve exercise capacity by enhancing oxygen uptake in working muscles. METHODS: A standardized exercise test was performed in patients with severe aortic stenosis the day before TAVI and within 5 days thereafter. The main study endpoint was the workload achieved during a 5-minute standardized exercise test. Using electrical cardiometry and near-infrared spectroscopy, we explored and compared the changes in cardiac index (CI), as well as muscular and cerebral tissue oximetry, during the 2 exercise tests. RESULTS: Thirty patients completed the study protocol. Compared with the pre-TAVI period, patients achieved a higher median workload after TAVI (316 Joules [interquartile range {IQR}: 169-494] vs 190 Joules [IQR: 131-301], P = 0.002). Baseline CI increased from 2.5 l/min per m2 (IQR: 2.1-2.9) to 2.9 l/min per m2 (IQR: 2.5-3.2; P = 0.009), whereas CI at the end of the exercise test increased from 4.5 l/min per m2 (IQR: 3.4-5.3) to 4.7 l/min per m2 (3.4-6.4; P = 0.019). At the end of the exercise test, cerebral tissue oximetry increased from 70% (IQR: 65-72) to 74% (IQR: 66-78), and muscle tissue oximetry increased from 62% (IQR: 58-65) to 71% (65-74; P = 0.046 and P < 0.001, respectively). CONCLUSIONS: Early improvement of exercise capacity after TAVI is associated with increased CI and better oxygen utilization in the brain and skeletal muscles.

CONTEXTE: Le remplacement valvulaire aortique par cathéter (TAVI) représente une procédure thérapeutique efficace, en particulier chez les patients présentant une sténose aortique sévère. Nous avons émis l'hypothèse que la diminution de la postcharge induite par le TAVI améliorerait la capacité à l'effort en favorisant la consommation d'oxygène des muscles travaillant. MÉTHODES: Un test d'effort standardisé a été réalisé chez des patients souffrant de sténose aortique sévère la veille de l'intervention TAVI et dans les 5 jours qui ont suivi. Le principal critère d'évaluation de l'étude était la charge de travail atteinte lors d'un test d'effort standardisé de 5 minutes. En utilisant la cardiométrie électrique et la spectroscopie proche infrarouge, nous avons exploré et comparé les changements de l'index cardiaque (IC), ainsi que l'oxymétrie des tissus musculaires et cérébraux, pendant les 2 tests d'effort. RÉSULTATS: Trente patients ont terminé le protocole d'étude. Par rapport à la période pré-TAVI, les patients ont atteint une charge de travail médiane plus élevée après le TAVI (316 Joules [intervalle interquartile (IIQ) : 169-494] contre 190 Joules [IIQ : 131-301], p = 0.002). L'IC de base est passé de 2,5 l/min par m2 (IIQ : 2,1-2,9) à 2,9 l/min par m2 (IIQ : 2,5-3,2 ; p = 0.009), tandis que l'IC à la fin du test d'effort est passé de 4,5 l/min par m2 (IIQ : 3.4-5.3) à 4,7 l/min par m2 (3,4-6,4 ; p = 0,019). À la fin du test d'effort, l'oxymétrie du tissu cérébral est passée de 70 % (IIQ : 65-72) à 74 % (IIQ : 66-78), et l'oxymétrie du tissu musculaire est passée de 62 % (IIQ : 58-65) à 71 % (65-74; p = 0,046 et p < 0,001, respectivement). CONCLUSIONS: L'amélioration précoce de la capacité d'exercice après le TAVI est associée à un IC accru et à une meilleure utilisation de l'oxygène au niveau du cerveau et des muscles squelettiques.

Five-Year Follow-up After Percutaneous Management of a 40-Year-Old Man in Shock Treated by Percutaneous Coronary Intervention and MitraClip.

Acute coronary syndromes complicated by cardiogenic shock are associated with high mortality, and patients are definitely considered at high procedural risk. We present here the 5-year success of full percutaneous management of a young patient in cardiogenic shock with acute and chronic coronary artery disease as well as significant mitral regurgitation. Whereas the benefit of culprit lesion coronary revascularization is well established, evidence supporting chronic total occlusion revascularization in the acute setting remains poor. Percutaneous management of acute mitral regurgitation with cardiogenic shock is a viable option in patients with recurrent pulmonary edema.

Les syndromes coronariens aigus compliqués d'un choc cardiogéne sont associés à une mortalité élevée, et les patients sont clairement considérés comme présentant un risque interventionnel élevé. Nous présentons ici un cas de succès à 5 ans, de la prise en charge percutanée complète d'un jeune patient en état de choc cardiogéne avec une coronaropathie aiguë et chronique ainsi qu'une régurgitation mitrale sévère. Alors que le bénéfice de la revascularisation coronarienne de la lésion coupable est reconnu, l'évidence en faveur d'une revascularisation de l'occlusion totale chronique en phase aigue reste à établir. L'approche percutanée de la régurgitation mitrale aiguë avec choc cardiogéne est une option viable chez les patients présentant un œdème pulmonaire récurrent.

Determinants of hospital length of stay after transcatheter aortic valve implantation with self-expanding prostheses: a prospective, single centre observational study.

INTRODUCTION: We sought to identify baseline and periprocedural variables affecting hospital length of stay (LoS) in patients undergoing transcatheter aortic valve implantation (TAVI). METHODS: Data on 304 consecutive patients undergoing TAVI at a single centre between August 2008 and December 2017 were collected prospectively. All patients underwent a complete clinical, echocardiographic and laboratory evaluation including a comprehensive frailty assessment at baseline. LoS was defined as the number of in-hospital days after the TAVI procedure during the index hospitalisation until the time the patient left the hospital for home or a rehabilitation clinic. RESULTS: The mean LoS was 10.4 ± 7.1 days (median 8, interquartile range 5–12) with a significant trend towards shorter LoS over time (p <0.001). Patients discharged directly home were more likely to have shorter LoS (p = 0.007). All periprocedural complications were significantly associated with prolonged LoS (p <0.05 for all). Multivariate analysis showed an independent association between LoS and emergency admission (beta 3.24 ± 1.56, p = 0.039), baseline gait speed (beta: 0.39 ± 0.16, p = 0.018), baseline serum C-reactive protein (CRP, beta 0.14 ± 0.04, p = 0.001) and subclavian access (beta 8.27 ± 2 .9, p = 0.005). Gait speed and serum CRP remained significant determinants of LoS even after adjustment for periprocedural complications and patients’ discharge destination. CONCLUSION: Baseline gait speed and serum CRP are significant independent determinants of LoS after TAVI.

Transcatheter aortic valve implantation: Update in 2018.

During the last 15 years, transcatheter aortic valve implantation (TAVI) has gained wide acceptance with good reproducible clinical and safety outcomes. Today, TAVI has not only overtaken conventional surgery as the standard of care for the treatment of patients with symptomatic aortic stenosis at high surgical risk, but can also be considered in selected intermediate-risk patients. This follows technological improvements, better patient assessment and increased operator experience leading to a significant reduction in most procedure-related complications and long-term mortality. In this review, we provide internists, on the one hand with current data in the TAVI field including clinical outcomes from the most recent, major trials and on the other hand, highlight the remaining pitfalls of this treatment and the gaps in evidence that need to be addressed in order to further improve clinical practice and expand its indication.

Prognostic value of revascularising viable myocardium in elderly patients with stable coronary artery disease and left ventricular dysfunction: a PET/CT study.

Sparse information is available on the role of cardiac viability imaging in elderly patients. We aimed at evaluating the prognostic value of FDG-PET/CT in elderly patients with stable coronary artery disease (CAD) and reduced left ventricular ejection fraction (rLVEF) before revascularisation. Elderly patients (> 65 years old, mean 74 ± 7 years old) with CAD and rLVEF were followed after cardiac FDG-PET/CT and stratified according to presence/absence of viable myocardium and subsequent revascularisation. Fatal events of any cause as well as hospitalisations related to acute cardiac conditions were reported as clinical end-points. Predictors of fatal events in patients with viable myocardium (> 1 myocardium segment/20) were analysed. A total of 89 patients were followed (64 viable myocardia; 37 and 27 patients with and without subsequent revascularisation, respectively). The change in LVEF during follow-up (2.1 ± 1.6 years) was 3.8 ± 6.6% (P = 0.013) and - 0.75 ± 2.6% (P = 0.170) in patients with and without revascularisation, respectively. Log-rank (P = 0.037) and multivariate analysis (Wald: 6.305, P = 0.012) showed viable myocardium to be significantly associated with fatal events if not revascularised. Elderly patients with viable myocardium might potentially benefit from revascularisation procedures as improved left ventricular ejection fraction and survival were observed in our retrospective study as compared to patients in whom a revascularisation procedure was denied. Viable myocardium as detected by cardiac FDG PET/CT was associated with better clinical outcomes in elderly patients when revascularised.

Conduction disorders using the Evolut R prosthesis compared with the CoreValve: has anything changed?

Aim: We compared early postprocedural and midterm evolution of atrioventricular and intraventricular conduction disorders following implantation of the new generation Evolut R (ER) prosthesis in comparison with the previous generation CoreValve (CV) system using routinely recorded ECG up to 6-month follow-up. Methods: All consecutive patients treated by transcathether aortic valve implantation (TAVI) using the Medtronic self-expanding devices for symptomatic severe aortic stenosis in a single centre between October 2011 and February 2016 were considered for inclusion. ECGs recorded at baseline, day 1 after TAVI, discharge and 6 months were retrospectively analysed. At each time-point, intrinsic rhythm, PR interval, QRS axis and duration, and atrioventricular and intraventricular conduction were analysed. Atrioventricular and intraventricular conduction following TAVI at discharge and at 6 months were compared intrasubject at the different time intervals and between patients receiving the ER versus the CV prosthesis. Results: Among the 113 patients included in the analysis (51% female, 83.3±6.2 years), 60 (53%) patients received the CV and 53 (47%) patients received the ER. Compared with patients in the CV group, those in the ER group had a lower Society of Thoracic Surgeons score (6.3±3.1vs 4.8±3.6, P=0.02). Patients in the ER group in comparison with those in the CV group more frequently had postprocedural PR interval (57%vs23%, respectively, P=0.004) and QRS prolongation (76%vs50%, P=0.03) at discharge. Incidence of complete atrioventricular block was similar between both groups (9%vs18%, P=0.3) up to 6-month follow-up. No difference in term of new left bundle branch block (LBBB) (34%vs28%, P=0.8) or permanent pacemaker implantation rates (32.1%vs31.7%, P=1.0) was reported. Conclusions: Patients with the ER had greater postprocedural atrioventricular and intraventricular conduction delays than those with the CV at discharge, with however similar incidence of high-degree atrioventricular block, new LBBB and permanent pacemaker implantation up to 6-month follow-up.

Seguimiento a 30 días tras el implante percutáneo de válvula aórtica CoreValve Evolut R: estudio prospectivo de pacientes no seleccionados / Thirty-day outcome following CoreValve Evolut R Transcatheter aortic valve implantation: an all-comers prospective study

Introducción y objetivos: La información clínica de la nueva generación de CoreValve Evolut R recapturable y reposicionable es escasa. Métodos: Se recopiló prospectivamente, entre febrero de 2015 y abril de 2016, la información clínica de todos los pacientes sometidos a implante percutáneo de válvula aórtica (TAVI) con la Evolut R por estenosis aórtica sintomática. El objetivo primario fue el compuesto de seguridad y éxito del implante a los 30 días. También se indicó la incidencia de nuevos implantes de marcapasos. Resultados: Entre los 83 pacientes sometidos a TAVI durante el periodo de estudio, 71 (el 85,5% de la población; media de edad, 83 [intervalo intercuartílico, 80-87] años; puntuación de la Society of Thoracic Surgeons del 4,8% ± 3,5%) eran susceptibles de implante de la Evolut R y se los incluyó en el análisis. Fue necesario reposicionar la válvula en el 26,8% de los procedimientos. El objetivo de seguridad compuesto se observó en el 11,3% de los pacientes a los 30 días, con una mortalidad por todas las causas del 2,8%. Se logró el éxito del implante en el 90,1% de los pacientes. La fuga paravalvular fue de grado < II en el 98,4% de los pacientes. Se redujo el gradiente aórtico transvalvular medio del basal de 42,5 ± 14,5 a 7,7 ± 4,0 mmHg al alta (p < 0,0001). Fue necesario implantar nuevos marcapasos en el 23,9% de los pacientes. Conclusiones: La nueva generación de Evolut R es adecuada para la mayoría de los pacientes y muestra una tasa de éxito del implante alta y una mortalidad aceptable en una población sin sesgos, consecutiva y sin exclusiones, de un único hospital que realiza los TAVI exclusivamente con válvulas de la casa comercial Medtroni (AU)

Introduction and objectives: There are scarce clinical outcomes data on the new generation recapturable and repositionable CoreValve Evolut R. Methods: Data on all-comer patients undergoing transcatheter aortic valve implantation (TAVI) with the Evolut R for severe symptomatic aortic stenosis at a single center were prospectively collected between February 2015 and April 2016. Clinical endpoints were independently adjudicated according to the Valve Academic Research Consortium-2 criteria. Primary outcomes consisted of early safety composite endpoints and 30-day device success. The incidence of new permanent pacemaker implantation was recorded. Results: Among the 83 patients undergoing TAVI during this period, 71 (85.5% of the population; median age, 83.0 [interquartile range, 80.0-87.0] years; Society of Thoracic Surgeons scores, 4.8 3.5%) were suitable for Evolut R implantation and were included in the analysis. Repositioning was performed in 26.8% of the procedures. The early safety composite endpoint was observed in 11.3% of patients at 30 days, with 2.8% all-cause mortality. Device success was documented in 90.1% of patients. Paravalvular leakage was less than grade II in 98.4% of patients. The mean transvalvular aortic gradient was reduced from 42.5 14.5 mmHg at baseline to 7.7 4.0 mmHg at discharge (P < .0001 vs baseline). New permanent pacemaker implantation was required in 23.9% of patients. Conclusions: The new generation Evolut R is suitable for most patients and shows high device success and acceptable mortality in an unbiased, consecutive, all-comer population at a single center performing TAVI exclusively with Medtronic valves (AU)

Downstream indication to revascularization following hybrid cardiac PET/MRI: preliminary results.

BACKGROUND: Hybrid PET/MRI allows the acquisition of both fluorine-18-fluorodeoxyglucose (F-FDG) PET and cardiac magnetic resonance (CMR) during one session. Whether this will result in different referral to coronary revascularization (CR) is unknown. We compared this new hybrid method with all-nuclear/all-CMR methods in the assessment of viable myocardium and in downstream referral to CR. PATIENTS AND METHODS: Overall, 12 patients with rest perfusion defects on a single photon emission computed tomography (SPECT) were recruited for cardiac viability assessment using a PET/MRI device. Perfusion (SPECT and CMR), metabolism, late gadolinium enhancement (LGE), and contractility were compared using a 20-segments bull's eye for agreement. The patterns of ischemia/viability were compared between all-nuclear, all-CMR, and hybrid methods. Downstream CR was proposed after correlating findings to coronary angiography. RESULTS: The SPECT and CMR perfusion denoted poor agreement [agreement rate (AR): 60%; κ: 0.191, P<0.004]. The added PET metabolism concurred in reclassifying 19.2% of segments with intermediate or unassessable LGE using the hybrid method. Overall, the all-CMR method showed better agreement with the hybrid method than the all-nuclear method for findings of normal (AR: 100%, κ: 1.00 vs. 65.8% %; κ: 0.347, respectively; P<0.001), scar (AR: 85%; κ: 0.675 vs. 80.8%; κ: 0.596, respectively; P<0.001), and ischemic segments (AR: 95.8%; κ: 0.881 vs. 75.8%; κ: 0.168, respectively; P<0.001). Downstream CR was proposed in four, 11, and 12 vessels by the all-nuclear, all-CMR, or hybrid methods, respectively. CONCLUSION: Compared with all-CMR, the hybrid method allowed the reclassification of 19.2% segments. Using CMR perfusion instead of SPECT perfusion had a significant impact on downstream target vessel revascularization.

Thirty-day Outcome Following CoreValve Evolut R Transcatheter Aortic Valve Implantation: An All-comers Prospective Study.

INTRODUCTION AND OBJECTIVES: There are scarce clinical outcomes data on the new generation recapturable and repositionable CoreValve Evolut R. METHODS: Data on all-comer patients undergoing transcatheter aortic valve implantation (TAVI) with the Evolut R for severe symptomatic aortic stenosis at a single center were prospectively collected between February 2015 and April 2016. Clinical endpoints were independently adjudicated according to the Valve Academic Research Consortium-2 criteria. Primary outcomes consisted of early safety composite endpoints and 30-day device success. The incidence of new permanent pacemaker implantation was recorded. RESULTS: Among the 83 patients undergoing TAVI during this period, 71 (85.5% of the population; median age, 83.0 [interquartile range, 80.0-87.0] years; Society of Thoracic Surgeons scores, 4.8±3.5%) were suitable for Evolut R implantation and were included in the analysis. Repositioning was performed in 26.8% of the procedures. The early safety composite endpoint was observed in 11.3% of patients at 30 days, with 2.8% all-cause mortality. Device success was documented in 90.1% of patients. Paravalvular leakage was less than grade II in 98.4% of patients. The mean transvalvular aortic gradient was reduced from 42.5±14.5mmHg at baseline to 7.7±4.0mmHg at discharge (P<.0001 vs baseline). New permanent pacemaker implantation was required in 23.9% of patients. CONCLUSIONS: The new generation Evolut R is suitable for most patients and shows high device success and acceptable mortality in an unbiased, consecutive, all-comer population at a single center performing TAVI exclusively with Medtronic valves.

Extra-cardiac stimulators: what do cardiologists need to know?

For several decades, treating patients with pacemakers has been the privilege of cardiologists. However, in the last 30 years, researchers have found new targets for electrical stimulation in different clinical subspecialities, such as deep brain stimulation (for the treatment of Parkinson's disease, essential tremor, dystonia, and some psychiatric illnesses); spinal cord stimulation (for refractory angina, chronic pain, and peripheral artery disease); and sacral (for diverse urologic and proctologic conditions), vagal (for epilepsy), and phrenic nerve stimulation (for sleep apnoea). The purpose of this article is to familiarize cardiologists with these 'extra-cardiac pacemakers' and to discuss potential issues that must be addressed when these patients undergo cardiac procedures.

Impact of early haemodynamic goal-directed therapy in patients undergoing emergency surgery: an open prospective, randomised trial.

Haemodynamic goal-directed therapies (GDT) may improve outcome following elective major surgery. So far, few data exist regarding haemodynamic optimization during emergency surgery. In this randomized, controlled trial, 50 surgical patients with hypovolemic or septic conditions were enrolled and we compared two algorithms of GDTs based either on conventional parameters and pressure pulse variation (control group) or on cardiac index, global end-diastolic volume index and stroke volume variation as derived from the PiCCO monitoring system (optimized group). Postoperative outcome was estimated by a composite index including major complications and by the Sequential Organ Failure Assessment (SOFA) Score within the first 3 days after surgery (POD1, POD2 and POD3). Data from 43 patients were analyzed (control group, N = 23; optimized group, N = 20). Similar amounts of fluid were given in the two groups. Intraoperatively, dobutamine was given in 45 % optimized patients but in no control patients. Major complications occurred more frequently in the optimized group [19 (95 %) versus 10 (40 %) in the control group, P < 0.001]. Likewise, SOFA scores were higher in the optimized group on POD1 (10.2 ± 2.5 versus 6.6 ± 2.2 in the control group, P = 0.001), POD2 (8.4 ± 2.6 vs 5.0 ± 2.4 in the control group, P = 0.002) and POD 3 (5.2 ± 3.6 and 2.2 ± 1.3 in the control group, P = 0.01). There was no significant difference in hospital mortality (13 % in the control group and 25 % in the optimized group). Haemodynamic optimization based on volumetric and flow PiCCO-derived parameters was associated with a less favorable postoperative outcome compared with a conventional GDT protocol during emergency surgery.

Management of vascular complications following transcatheter aortic valve implantation.

BACKGROUND: Vascular complications (VCs) after transcatheter aortic valve implantation (TAVI) are frequent and their management is challenging. AIM: To report the incidence, predictors and management of VCs following percutaneous transfemoral TAVI (TF-TAVI) at a single centre. METHODS: We analyzed 102 consecutive patients who underwent percutaneous TF-TAVI between August 2008 and December 2013. All endpoints were evaluated at 30 days and 6 months according to Valve Academic Research Consortium-2 criteria. VC percutaneous treatment success was defined as residual stenosis<30%, absence of blood extravasation and absence of surgical or repeat endovascular intervention at 30 days. RESULTS: Twenty-two patients (22%) experienced VCs, including five patients (5%) with major VCs. Mortality at 30 days was significantly higher in patients with major VCs than in patients without major VCs (60% vs 3%; P=0.001). Patients with VCs had more life-threatening or major bleeding (23% vs 5%; P=0.02), but no difference in terms of need for blood transfusion was observed. Endovascular treatment was used in 13 of 22 patients with VCs (59%) and was successful in 11 of these 13 patients (85%). Primary surgical repair was necessary in only 1/22 (5%) patients, for a common femoral artery pseudoaneurysm 2 weeks after the TAVI procedure. CONCLUSIONS: VCs following TF-TAVI are frequent. Major but not minor VCs are associated with increased mortality. Percutaneous management of VCs is feasible and safe, and surgery is rarely needed.

Goal-directed hemostatic therapy using the rotational thromboelastometry in patients requiring emergent cardiovascular surgery.

AIMS AND OBJECTIVES: We assessed the clinical impact of goal-directed coagulation management based on rotational thromboelastometry (ROTEM) in patients undergoing emergent cardiovascular surgical procedures. MATERIALS AND METHODS: Over a 2-year period, data from 71 patients were collected prospectively and blood samples were obtained for coagulation testing. Administration of packed red blood cells (PRBC) and hemostatic products were guided by an algorithm using ROTEM-derived information and hemoglobin level. Based on the amount of PRBC transfused, two groups were considered: High bleeders (≥5 PRBC; HB) and low bleeders (<5 PRBC; LB). Data were analyzed using Chi-square test, unpaired t-test and analysis of variance as appropriate. RESULTS: Pre-operatively, the HB group (n = 31) was characterized by lower blood fibrinogen and decreased clot amplitude at ROTEM compared with the LB group (n = 40). Intraoperatively, larger amounts of fibrinogen, fresh frozen plasma and platelets were required to normalize the coagulation parameters in the HB group. Post-operatively, the incidence of major thromboembolic and ischemic events did not differ between the two groups (<10%) and the observed in-hospital mortality was significantly less than expected by the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM score, 22% vs. 35% in HB and 5% vs. 13% in LB group). CONCLUSIONS: ROTEM-derived information is helpful to detect early coagulation abnormalities and to monitor the response to hemostatic therapy. Early goal-directed management of coagulopathy may improve outcome after cardiovascular surgery.

Transcatheter aortic valve implantation in nonagenarians: effective and safe.

BACKGROUND: The number of nonagenarians is rising dramatically. These patients often develop severe aortic stenosis for which transcatheter aortic valve implantation (TAVI) is an attractive option. The aim of this study was to analyze the outcome of TAVI performed in a cohort of nonagenarian patients. METHODS: Between August 2008 and November 2012, 23 consecutive patients in their 90th year of age or older underwent TAVI in our institution after having been assessed by the local heart team. Data concerning baseline characteristics, procedural details and outcome were prospectively entered into a dedicated database. Transthoracic echocardiography and clinical follow-up were performed pre-procedure, at discharge, at 6 and 12 months and then annually post TAVI. RESULTS: Patients were male in 52% with a mean age of 90.3 ± 2.3 years. Mean logistic EuroSCORE and STS score were 26.6 ± 14.5% and 8.7 ± 2.9%, respectively. Transcatheter heart valve (THV) could be implanted in all but one patient. Mortality at 30 days was 8.7% overall and 4.8% for transfemoral approach. At 30 days the rate of stroke was 4.3%, paravalvular leak grade ≥ 2 was 8.7%, life-threatening bleeding was 13.0% and pacemaker implantation was 13%. Device success was 73.9%. The rate of all-cause mortality increased to 27.3% at one-year follow-up and 42.8% at a median follow-up of 417 days. CONCLUSIONS: TAVI is safe and effective even in a selected population of nonagenarians. Consequently, these patients should not be refused such a procedure based only on their age. Multi-disciplinary assessment is essential in order to properly select candidates.