The use of vascular closure devices and impact on major bleeding and net adverse clinical events (NACEs) in balloon aortic valvuloplasty: a sub-analysis of the BRAVO study.

OBJECTIVE: To determine the impact of suture-mediated vascular closure devices (VCDs) on net adverse clinical events (NACEs) after balloon aortic valvuloplasty (BAV). BACKGROUND: Ischemic and bleeding complications are common following transfemoral BAV; however, previous studies have been single center and limited by varying definitions of major bleeding. METHODS: The Effect of Bivalirudin on Aortic Valve Intervention Outcomes (BRAVOs) study was a retrospective observational study conducted at two high-volume academic centers over a 6-year period designed to compare the effect of bivalirudin versus unfractionated heparin. This is a subanalysis of 428 consecutive patients who underwent BAV (with 10-13 French sheaths) to compare the effect of hemostasis with VCDs versus manual compression utilizing standardized definitions. NACE was defined as the composite of major bleeding and major adverse clinical events (MACEs). All events were adjudicated by an independent clinical events committee who were blinded to antithrombin use. RESULTS: Preclosure was performed in 269 (62.8%) of patients. While bivalirudin was used more frequently in those with pre-closure (60.6% vs. 37.7%, P < 0.001), a history of prior BAV (11.1% vs. 3.6%, P = 0.04) and peripheral vascular disease (30.7% vs. 19.7%, P = 0.01) was more common in those not undergoing preclosure (n = 159, 37%). Other clinical and demographic features were well balanced between groups. Vascular closure was associated with a significant reduction in NACE (24.5% vs. 10.0% P < 0.001). Results remained significant after adjusting for baseline differences and bivalirudin use (OR 0.38, 95% CI: 0.21-0.68; P = 0.001). CONCLUSIONS: Our study suggests that suture-mediated vascular closure is associated with a substantial reduction in NACE after transfemoral BAV. Large randomized clinical trials should be conducted to confirm our results.

Transseptal antegrade transcatheter aortic valve replacement for patients with no other access approach - a contemporary experience.

OBJECTIVE: To assess the feasibility and outcomes in patients undergoing transvenous transseptal (TS) transcatheter aortic valve replacement (TAVR). BACKGROUND: TS approach for TAVR was abandoned in favor of retrograde transfemoral, transaortic, or transapical approaches. TS TAVR may still be warranted in patients for whom no other approach is feasible. METHODS: Observational consecutive case series at a single center, to evaluate technical outcomes in inoperable patients with aortic stenosis who had contraindications for other approaches and who underwent TAVR via a transvenous TS antegrade approach using the Edwards-Sapien (ES) valve. RESULTS: Over a 4-month period, 9 patients underwent TS TAVR with 26 mm (n = 4) and 23 mm (n = 5) ES valves. Mean age was 84.5 ± 6.6 years and Society of Thoracic Surgeons predicted risk of mortality was 7.8 ± 2.8%. Specific contraindications for other access included iliofemoral arterial diameter <7 mm in 9 (100%), porcelain aorta in 6 (66%) patients, multiple (≥2) sternotomies in 2 (22%) patients, severe pulmonary disease in 3 (33%), extreme frailty in 1 (11%), spinal stenosis with impaired ability to rehabilitate postsurgery in 1 (11%) and apical left ventricular thrombus in 1 (11%) patient. Antegrade deployment of the ES prosthetic valve was technically feasible in 8 patients. Major bleeding occurred in 4 patients, two patients suffered acute kidney injury without need for dialysis and one patient required a permanent pacemaker. The median (25th, 75th percentiles) fluoroscopy time was 49 (34, 81) minutes and contrast volume was 150 (120, 225) ml. No patient had hemodynamically significant post-TAVR aortic insufficiency nor damage to the mitral valve. At 6 months follow-up, there were no cerebrovascular events or rehospitalizations and mean NYHA Class improved from 3.4 to 1.7. CONCLUSIONS: The antegrade TS approach to TAVR is a technically feasible option for "no-access" patients. Prospective assessment of the safety and efficacy of this approach in the current era warrants further study.

Cardiac biomarkers - the old and the new: a review.

Biomarkers are biological parameters that can be objectively measured and quantified as indicators of normal biologic processes, pathogenic processes, or responses to a therapeutic intervention. Typically thought of as disease process screening, diagnosing, or monitoring tools, biomarkers may also be used to determine disease susceptibility and eligibility for specific therapies. Cardiac biomarkers are protein components of cell structures that are released into circulation when myocardial injury occurs. They play a pivotal role in the diagnosis, risk stratification, and treatment of patients with chest pain and suspected acute coronary syndrome and those with acute exacerbations of heart failure. Cardiac markers are central to the new definition of acute myocardial infarction put forward by the American College of Cardiology and the European Society of Cardiology. Active investigation has brought forward an increasingly large number of novel candidate markers but few have withstood the test of time and become integrated into contemporary clinical care because of their readily apparent diagnostic, prognostic, or therapeutic utility.

Very late (10-year-old) bare metal stent thrombosis.

We present findings from a 59-year-old male patient who presented with coronary artery disease and refractory angina. Ten years prior, the patient had been implanted with 5 bare metal stents (BMS); he arrived with non-specific ST-T wave abnormalities. Angiographic data revealed a totally occluded right coronary artery at the level of the previously placed BMS, consistent with an acute occlusion and a significant thrombus. Our findings revealed that BMS thrombosis can occur as late as 10 years after implantation. Further data through clinical trials are warranted to look at this rare, but serious, complication.

Delayed-enhancement cardiovascular magnetic resonance coronary artery wall imaging: comparison with multislice computed tomography and quantitative coronary angiography.

OBJECTIVES: We examined whether delayed-enhancement cardiovascular magnetic resonance (DE-CMR) coronary artery wall imaging correlated with atherosclerosis detected by using multislice computed tomography (MSCT) and quantitative coronary angiography (QCA). BACKGROUND: The use of DE-CMR coronary vessel wall imaging may provide a noninvasive method to assess diseased coronary vessel walls. METHODS: We performed DE-CMR coronary artery wall imaging in 14 patients with cardiovascular risk factors and 6 healthy subjects without risk factors. RESULTS: A greater prevalence of strong DE was noted with greater MSCT evidence of disease, with DE in 2 (7%) of 30 coronary segments with no plaque by MSCT, in 1 (10%) of 10 segments with noncalcified plaque on MSCT, and in 16 (36%) of 44 segments with calcifications by MSCT (p = 0.009, adjusted p = 0.035). Delayed enhancement was observed in 8 (53%) of 15 segments with >20% coronary artery stenosis by QCA but also in 12 (15%) of 80 segments without angiographically apparent coronary disease (p = 0.004, adjusted p = 0.01). CONCLUSIONS: The use of DE-CMR allowed us to identify areas of DE that correlate with severity of atherosclerosis by MSCT and QCA. This novel approach may be useful for the assessment of coronary vessel wall in patients with suspected coronary artery disease.

Adherence to American College of Cardiology/American Heart Association guidelines for the management of anticoagulation in patients with mechanical valves undergoing elective outpatient procedures.

This study sought to establish the practice patterns of a diverse group of academic physicians, in the management of periprocedural anticoagulation for patients with mechanical heart valves, to study adherence to American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Physicians (n = 140) were surveyed to assess strategies for the periprocedural anticoagulation of patients with bileaflet mechanical heart valves undergoing 2 common outpatient procedures. Six patient scenarios with graded risk profiles were presented for each valve location (mitral and aortic). In >90% of high-risk patient scenarios, for which the ACC/AHA guidelines recommend periprocedural anticoagulation, anticoagulation was recommended, with minimal differences between physician specialties. However, periprocedural anticoagulation was also recommended in >70% of non-high-risk scenarios, for which the ACC/AHA guidelines recommend no periprocedural anticoagulation. Noncardiologists recommended anticoagulation more often in non-high-risk patients (p <0.01), especially for patients with aortic valve prostheses. Thus, academic physicians appropriately recommend periprocedural anticoagulation for high-risk patients with mechanical heart valves who undergo elective procedures. However, these data specifically suggest variability in practice for non-high-risk patients that are discordant with current ACC/AHA guidelines, with differences by treating specialty especially notable in this risk subset.