Clinical and neurocognitive outcomes after transcatheter aortic valve implantation (TAVI) with cerebral protection: initial experience with a novel dual-filter device in Southeast Asia.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is increasingly performed in patients with severe aortic stenosis. A novel dual-filter system to reduce cerebral embolism during TAVI recently became available. We aimed to assess the feasibility, safety, and clinical and neurocognitive outcomes of TAVI with cerebral protection in Asian patients. METHODS: 40 consecutive patients undergoing TAVI with cerebral protection were enrolled. All procedures were performed via femoral access using the self-expanding Evolut R/PRO or Portico, or the balloon-expandable SAPIEN 3 bioprostheses. Baseline characteristics, procedural and clinical outcomes were recorded. Cognition was assessed at baseline and 30 days using the abbreviated mental test (AMT). RESULTS: The mean age of the patients (75% male) was 76.4 ± 8.4 years. TAVI was uncomplicated in all patients. The filter device was successfully deployed in 38 (95.0%) patients without safety issues. There was no stroke or death at 30 days, and the survival rate at nine months was 95.0%. There was no overall cognitive change (baseline vs. 30-day AMT: 9.2 ± 1.1 vs. 9.0 ± 1.5, p = 0.12), and only 1 (2.5%) patient developed impaired cognition at 30 days. Patients with a decreased AMT score at 30 days were significantly older than those without (82.1 ± 4.5 vs. 74.4 ± 7.7 years, p = 0.019). All patients with decreased AMT scores were aged ≥ 76 years. CONCLUSION: In this early Asian experience of TAVI under cerebral protection, the filter device was successfully deployed in 95% of patients, with 100% procedural success. There were no filter-related complications and no stroke or mortality at 30 days. Overall cognition was preserved, although increased age was associated with a decline in AMT score.

Primary percutaneous coronary intervention for acute myocardial infarction secondary to acute left main coronary occlusion in an institution without on-site cardiothoracic surgical support.

AIMS: There is no consensus on the optimal management of acute myocardial infarction due to acute left main coronary occlusion (LMCO). We evaluated the feasibility of primary percutaneous coronary intervention (PCI) for acute LMCO in an institution without on-site cardiothoracic surgical (CTS) support. METHODS AND RESULTS: We retrospectively identified 20 patients, median age 67 years (range 38 to 81). Sixteen patients presented with cardiogenic shock. All patients required intra-aortic balloon pump counterpulsation and inotropic support. Sixteen patients underwent stenting and four had balloon angioplasty only. Thrombolysis In Myocardial Infarction 3 flow was restored in 13 patients. Post-PCI, six patients were transferred to a tertiary institution for further care: three underwent extracorporeal membrane oxygenation (ECMO), one underwent both ECMO and coronary artery bypass grafting (CABG), one died before ECMO initiation and one stabilised without further intervention. Thirteen patients died in-hospital. There was one subsequent death out of the seven hospital survivors, with median follow-up 390 days (range 60 to 660 days). There was a trend towards survival with a shorter door-to-balloon time (p = 0.07). CONCLUSIONS: Primary PCI may be a feasible initial revascularisation strategy for acute LMCO in centres without on-site CTS support.