Outcome of transcatheter aortic valve replacement in Israeli Jews and Arabs.

Background: Ethnic minorities may face disparities in access to health care and clinical outcomes. Transcatheter aortic valve replacement (TAVR) has an established role in treatment of patients with severe symptomatic aortic stenosis, however outcome of these procedures among different demographics within the multi-ethnic Israeli society is unknown. We sought to compare mortality following TAVR between Jewish and Arab patients in Israel. Methods: A prospective single-center TAVR registry in northern Israel was analyzed. We compared post-procedural survival among Arab and Jewish patients who underwent TAVR, presenting the estimated hazard ratio (HR) using Cox regression. Results: Of 923 subjects who underwent TAVR between 2010-2021, 172 (19%) were Arab and 751 (81%) were Jewish. The Arab patient population was younger (mean 77 vs. 81 years, P<0.001), had lower prevalence of coronary artery disease (34%, vs. 43%, P=0.02), hypertension (80% vs. 88%, P<0.01) and calculated procedural mortality (EuroScore II: mean 4.6 vs. 4.9, P=0.02), and higher percentage of females (65% vs. 53%, P=0.01), body mass index (mean 30 vs. 28, P<0.001) and creatinine clearance (mean 67 vs. 59 mL/min, P<0.001). Arab patients had similar post-procedural mortality compared to Jewish patients [7-day mortality: adjusted HR 1.51, 95% confidence interval (CI): 0.39-5.77, P=0.55; 30-day mortality: adjusted HR 1.79, 95% CI: 0.62-5.18, P=0.29; 1-year mortality: adjusted HR 1.24, 95% CI: 0.72-2.12, P=0.43]. Conclusions: Arab patients undergoing TAVR were younger and had lower predicted mortality than Jewish counterparts, however, these characteristics did not translate into improved post-procedural survival.

Strategy for Totally Percutaneous Management of Vascular Injury in Combined Transfemoral Transcatheter Aortic Valve Replacement and Endovascular Aortic Aneurysm Repair Procedures.

Minimally invasive treatment of severe aortic stenosis by transcatheter aortic valve replacement (TAVR) and infrarenal abdominal aortic aneurysm by endovascular aortic aneurysm repair (EVAR) requires large-bore vascular access. These percutaneous transfemoral interventions may be performed as a combined procedure, however, vascular injury may necessitate surgical vascular repair. We implemented a strategy designed to enable percutaneous vascular repair, with stent-graft implantation, if necessary, after these combined procedures. We identified all combined percutaneous TAVR and EVAR procedures which were performed at our institution. Patient and procedural characteristics and clinical outcomes were analyzed. Six consecutive patients underwent total percutaneous combined TAVR and EVAR procedures. In all cases, TAVR was performed first and was followed by EVAR. Both common femoral arteries served as primary access sites for delivery of the implanted devices and hemostasis was achieved by deployment of vascular closure devices. Secondary access sites included the right brachial artery in all patients and superficial femoral arteries in 50% of the patients. In all cases an "0.014" 300-cm length "safety" wire was delivered to the common femoral artery or descending aorta by way of a secondary access site to facilitate stent graft delivery. Successful device implantation was achieved in all cases. Vascular closure device failure occurred in 2 patients and was treated by stent graft implantation by way of the brachial and superficial femoral arteries, without need for surgical vascular repair. A strategy designed to facilitate percutaneous vascular repair after combined EVAR and TAVR procedures may enable a truly minimally invasive procedure.

Recurrent Valve Migration During TAVR: Using One Valve to Anchor Another Valve.

This case describes management of recurrent valve migration during a TAVR procedure in a patient with a hypertrophic and hyperdynamic left ventricle. Since anchoring a valve in an optimal position within the aortic annulus was not possible, a valve was intentionally deployed deep within the left ventricular outflow tract. This valve was used as an anchoring site for an additional valve, which achieved an optimal hemodynamic result and clinical outcome outcome.

Strategies for Facilitating Totally Percutaneous Transfemoral TAVR Procedures.

Transcatheter aortic valve replacement (TAVR) has transformed the treatment of aortic stenosis and should ideally be performed as a totally percutaneous procedure via the transfemoral (TF) approach. Peripheral vascular disease may impede valve delivery, and vascular access site complications are associated with adverse clinical outcome and increased mortality. We review strategies aimed to facilitate TF valve delivery in patients with hostile vascular anatomy and achieve percutaneous management of vascular complications.

Transbrachial Secondary Vascular Access in Transcatheter Aortic Valve Replacement Procedures: A Single-Centre Retrospective Analysis.

BACKGROUND: Transfemoral transcatheter aortic valve replacement (TAVR) procedures require secondary vascular access for inserting accessory catheters and performing percutaneous repair of femoral artery injury. Use of the transbrachial approach for secondary vascular access in TAVR procedures has not been reported. METHODS: This study identified 48 patients at the current institution who had undergone transfemoral TAVR utilising transbrachial secondary vascular access. Efficacy and safety of this strategy for achieving a successful totally percutaneous procedure were examined. Study endpoints were occurrence of vascular complications and bleeding related to transbrachial access, as well as periprocedural and 1-year mortality. RESULTS: Mean patient age was 80±7 years and Society of Thoracic Surgeons Predicted Risk of Mortality score was 10.6±3.1. Sizes of sheaths inserted into the brachial artery were 6 Fr (85%), 8 Fr (2%), and 9 Fr (13%). Transbrachial access was used for delivering stent grafts to the femoral artery in 13% of the patients, inflation of an occlusive balloon within the iliac artery in 10%, and treatment of iatrogenic femoral artery stenosis in 2%. Successful valve replacement was achieved in all cases. Brachial sheaths were removed by manual compression following administration of protamine sulfate. There were no major access site complications or VARC-3 type ≥2 bleeding related to the brachial vascular access. Brachial artery occlusion occurred in two patients (4%) who underwent surgical vascular repair. Two (2) additional patients developed mild arm ischaemia, which was treated conservatively. Periprocedural mortality was 0% and early mortality was 8%. CONCLUSIONS: Transbrachial secondary access in TAVR procedures was feasible and enabled percutaneous vascular repair in cases of femoral artery injury.

Totally Percutaneous Transfemoral Transcatheter Aortic Valve Replacement Despite Failure to Deploy a Vascular Closure Device: A Single-Centre Case Series.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is preferably performed as a completely percutaneous procedure via transfemoral access. Suture-mediated vascular closure devices are deployed prior to sheath insertion (pre-closure). Inability to perform pre-closure may necessitate surgical vascular repair of the femoral artery. Patients at increased risk of vascular surgery complications may benefit from a percutaneous method for achieving access site haemostasis. Stent graft implantation is commonly used for treating access site injury following TAVR. This study assessed the feasibility of a strategy of planned stent graft implantation within the femoral artery for achieving access site haemostasis in patients undergoing transfemoral TAVR and in whom vascular pre-closure was not possible. METHODS: A prospective institutional TAVR registry was retrospectively analysed and a cohort of patients were identified who were selected for transfemoral valve delivery and in whom pre-closure failed and access site haemostasis was achieved by stent graft implantation. RESULTS: This strategy was used for achieving access site haemostasis in 11 patients (1.5% of 744 patients undergoing transfemoral TAVR). These patients were considered to be at increased risk of vascular surgery complications due to advanced age, frailty, comorbidities, or immobility. Stent graft implantation achieved access site haemostasis in all patients. During follow-up, 30-day mortality was zero, 1-year mortality was 27%, and none of the patients required additional vascular interventions. CONCLUSION: The preliminary data suggest that planned stent graft implantation within the femoral artery may achieve access site haemostasis and enable a totally percutaneous TAVR procedure, despite failure to perform pre-closure with a suture-based vascular closure device.

Pericardial constriction with calcified cystic mass compressing the right ventricle and right coronary artery.

Constrictive pericarditis is characterized by fibrosis and calcification of the pericardium that progressively impair the diastolic filling of the heart, causing heart failure. Uncommonly, pericardial constriction may be localized leading to a focal cystic mass formation that may compress nearby cardiac structures. We describe a unique case of a patient presenting with right heart failure due to idiopathic calcific constrictive pericarditis that was associated with a large pericardial cystic mass compressing the right ventricular free wall. This led to reduced cardiac output and possibly severe focal stenosis of the proximal right coronary artery that was resolved after pericardiectomy, the only definitive treatment for chronic progressive constrictive pericarditis. .

Five Hours of Resuscitation With 150 Electrical Shocks and Complete Recovery.

BACKGROUND: Myocardial ischemia may lead to lethal arrhythmias. Treatment of these arrhythmias without addressing the cause of ischemia may be futile. The length of resuscitation is an important parameter for determining when to stop resuscitation but with shockable rhythms and reversible cause of the cardiac arrest, the decision to terminate resuscitation is complex.  Case Summary: A patient with a three-month history of shortness of breath with effort developed pulseless ventricular tachycardia (VT) at the early stages of a stress test. In coronary angiography, a critical lesion in the right coronary artery (RCA) was observed and treated with two stents. During the procedure and for a total of five hours, the patient had more than 100 separate episodes of VT and ventricular fibrillation (VF) that were treated by 150 defibrillations, artificial ventilation, intra-aortic counter-pulsation balloon insertion, and multiple drugs. One hour after the initial stenting procedure, thrombosis of the RCA was demonstrated and treated successfully with angioplasty. Use of procainamide resolved the arrhythmias and the patient recovered completely without neurological deficit, ejection fraction of 45%, and is asymptomatic at one year following the event. DISCUSSION: Our case shows that with a revisable cause of cardiac arrest, resuscitation should be directed at maintaining perfusion of essential organs and treating the reversible cause. Without re-opening the RCA, we could not have saved the patient's life. The use of an extracorporeal membrane oxygenator, if available, should be considered in similar cases. Finally, the quality of cardiopulmonary resuscitation determines the neurological outcome regardless of the length of resuscitation, as was evident in our patient who recovered completely.

Survival of Patients with Chronic Total Occlusion of the Right Coronary Artery.

BACKGROUND: The impact of revascularization of coronary chronic total occlusion (CTO) on survival is unknown. Several studies, which included subjects with varied coronary anatomy, suggested that CTO revascularization improved survival. However, the contribution of CTO revascularization to improved outcome is unclear since it was more commonly achieved in subjects with fewer co-morbidities and less extensive coronary disease. OBJECTIVES: To study the association between CTO revascularization and survival in patients with uniform coronary anatomy consisting of isolated CTO of the right coronary artery (RCA). METHODS: A registry of 16,832 coronary angiograms was analyzed. We identified 278 patients (1.7%) with isolated CTO of the RCA who did not have lesions within the left coronary artery for which revascularization was indicated. Survival of 52 patients (19%) who underwent successful percutaneous coronary intervention was compared to those who did not receive revascularization. RESULTS: Revascularized patients were younger (60.2 vs. 66.3 years, P = 0.001), had higher creatinine clearance (106 vs. 83 ml/min, P < 0.0001), and had fewer co-morbidities than those who did not receive revascularization. Lack of CTO revascularization was a univariable predictor of mortality (hazard ratio [HR] = 2.65, 95% confidence interval [95%CI] 1.06-6.4) over 4.3 ± 2.5 years of follow-up. On multivariable analysis, the only predictors of mortality were increased age (HR 1.04, 95%CI 1.01-1.07), reduced creatinine clearance (HR 1.02, 95%CI 1.01-1.03), and ejection fraction below 55% (HR 2.24, 95%CI 1.22-4.11). CONCLUSIONS: Among patients with isolated RCA CTO who underwent extended follow-up, revascularization was not an independent predictor of increased survival.

Retrograde Femoral Artery Stent-Graft Implantation for Treatment of Access-site Bleeding Following Transcatheter Aortic Valve Implantation.

BACKGROUND: Access-site bleeding is a common complication of transfemoral transcatheter aortic valve implantation (TAVI). Percutaneous stent-graft implantation within the femoral artery may achieve hemostasis and avert the need for more invasive surgical vascular repair; however, failure to advance a guidewire antegradely via the injured vessel may preclude stent delivery. While retrograde stent-graft delivery from the distal vasculature may potentially enable percutaneous control of bleeding, this approach has not been reported. OBJECTIVES: To assess the feasibility of a retrograde approach for stent-graft implantation in the treatment of access-site bleeding following transfemoral TAVI. METHODS: A prospective TAVI registry was analyzed. Of 349 patients who underwent TAVI, transfemoral access was used in 332 (95%). Access-site injury requiring stent-graft implantation occurred in 56 (17%). In four patients (7%), antegrade wiring across the site of vascular injury was not possible and a retrograde approach for stent delivery was used. RESULTS: Distal vascular access was achieved via the superficial femoral or profunda artery. Retrograde advancement of a polymer-coated 0.035" wire to the abdominal aorta, followed by stent-graft delivery to the common femoral artery, achieved hemostasis in all cases. During a median (interquartile range) follow-up period of 198 (618) days (range 46-2455) there were no deaths and no patient required additional vascular interventions. CONCLUSIONS: A retrograde approach for stent-graft delivery is feasible and allows percutaneous treatment of a common femoral artery injury following TAVI in patients who are not suitable for the conventional antegrade approach.

Clinical features and outcomes of revascularization in very old patients with left main coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) is often more extensive in older adults and may involve multivessel and left main coronary artery (LMCA) disease. Elderly patients are commonly excluded from clinical trials, and limited real-world data exist on the management of LMCA disease in the very old. We aimed to investigate clinical features and outcomes of very old patients undergoing revascularization due to LMCA disease. PATIENTS AND METHODS: A retrospective single-center analysis of patients at least 80 years (n = 139) who underwent revascularization owing to CAD involving unprotected LMCA stenosis more than 50% was conducted. Subsequent major adverse cardiovascular events (MACE: myocardial infarction, stroke, and all-cause death) and repeat revascularizations were recorded, and their relation to revascularization procedure was studied. RESULTS: Percutaneous coronary intervention (PCI) was performed in 74 patients and coronary artery bypass surgery (CABG) in 65. Most patients (80%) had multivessel disease involving at least 2 additional coronary arteries. PCI was associated with older age, higher rates of baseline disability, previous revascularization, reduced ventricular function, significant aortic stenosis, and presentation with acute coronary syndrome, compared with CABG. Cumulative 3-year MACE rates were higher in patients undergoing PCI versus CABG (P = 0.009). After multivariable adjustment, predictors of MACE included presentation with ST-segment elevation myocardial infarction (STEMI) [hazard ratio (HR) = 2.39; 95% confidence interval: 1.24-4.63; P = 0.010], revascularization by PCI compared with CABG [HR = 2.21 (1.18-4.15); P = 0.013], baseline disability [HR = 2.17 (1.20-3.91); P = 0.010], and distal LMCA disease [HR = 1.87 (1.04-3.38); P = 0.038]. The difference in 3-year MACE between PCI and CABG was not observed in a propensity-score analysis of 90 patients matched 1: 1 for baseline disability, STEMI, and aortic stenosis (P = 0.797). CONCLUSION: In very old patients undergoing coronary revascularization owing to LMCA disease, PCI was associated with worse cardiovascular outcomes compared with CABG, influenced by a more severe and comorbid population selected for PCI. Baseline disability, presentation with STEMI, and distal LMCA bifurcation disease were additional independent outcome predictors.

Attainment of lipid goals and long-term mortality after coronary-artery bypass surgery.

INTRODUCTION: There is paucity of data regarding lipid goal attainment after coronary-artery bypass graft surgery (CABG) and its impact on adverse outcomes. We aimed to investigate the attainment of lipid goals and the association between plasma lipid levels achieved after CABG and mortality. METHODS: Retrospective analysis of 1230 patients undergoing CABG. Mortality was examined in relation to most-recent lipid levels attained, categorized by clinically-relevant thresholds, and according to the improvement from pre-operative levels. RESULTS: Low-density lipoprotein cholesterol (LDL-C) < 70 mg/dL was attained by 44% of the patients. After multivariable adjustment, the hazard ratio for long-term mortality was 1.33 (95% confidence interval, 1.05-1.67) and 1.97 (1.55-2.50) for patients attaining LDL-C 70-100 mg/dL and >100 mg/dL, respectively, compared with LDL-C < 70 mg/dL. The hazard ratio was 1.42 (1.07-1.88) and 1.73 (1.33-2.23) for patients attaining high-density lipoprotein cholesterol (HDL-C) 40-50 mg/dL and <40 mg/dL, respectively, compared with HDL-C > 50 mg/dL; and 1.11 (0.85-1.45) and 4.28 (1.89-9.68) for patients with triglycerides 200-500 mg/dL and >500 mg/dL compared with triglycerides <200 mg/dL. A progressive stepwise association was seen between the cumulative status of the lipid measures achieved and long-term mortality, with the lowest risk observed in those with optimal level of all lipid measures ( p < 0.0001). Improvement in any of the lipid measures from pre-operative to latest documented levels was associated with reduced mortality. CONCLUSIONS: Lack of attainment of optimal levels of routine lipid measures after CABG was common and associated both independently and additively with long-term mortality, emphasizing the importance of addressing plasma lipid profile as both a risk marker and a treatment target after CABG.