Comparative Outcomes of Transcarotid and Transsubclavian Transcatheter Aortic Valve Replacement.

BACKGROUND: Previous reports described successful use of transcarotid and transsubclavian approaches for the performance of transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis who cannot be treated with transfemoral access. The purpose of the present study was to compare these two alternative approaches with respect to safety, efficacy, and procedural efficiency. METHODS: A retrospective analysis of all TAVR procedures performed through either a transcarotid or a transsubclavian approach at a single tertiary care medical center between January 2016 and October 2018 was performed. Outcomes are reported in accordance with the Valve Academic Research Consortium definitions. RESULTS: During the study period, 33 patients had transcarotid TAVR and 38 patients had transsubclavian TAVR. Transcarotid patients were older (mean age, 82.9 ± 7.2 vs 78.1 ± 8.2 years; P = .012), but otherwise the two groups were not significantly different with respect to preoperative characteristics. Valve deployment was similar between the groups (100% vs 97%; P = .348). Procedure time was shorter with the transcarotid approach (110 ± 32 vs 134 ± 45 minutes; P = .014). There was a lower mean fluoroscopy air kerma in the transcarotid group (682.82 ± 713.48 mGy vs 2141 ± 2055 mGy; P < .001), although fluoroscopy dose-area product did not differ between the groups. There was no difference between the groups with respect to in-hospital or 30-day mortality (0% vs 3%; P = .355), stroke (3% vs 8%; P = .393), or vascular complication (3% vs 4%; P = .840). CONCLUSIONS: The transcarotid and the transsubclavian approaches have similar safety and efficacy outcomes. The transcarotid approach had a shorter procedure duration and a trend toward lower fluoroscopy duration and radiation exposure.

Advanced therapies for the management of adults with pulmonary arterial hypertension due to congenital heart disease: a systematic review.

Pulmonary arterial hypertension (PAH) secondary to congenital heart disease (CHD) is the third most common cause of PAH, and it is becoming increasingly common as improvements in the management of CHD have led to increased life expectancy for these patients. The medical management of PAH due to CHD (PAH-CHD) is largely the same as what has been used for the treatment of idiopathic PAH, though the body of literature supporting this management decision is very small. There are currently few studies available which specifically focus on the treatment of PAH-CHD. The purpose of this literature review is to compare the results of those studies that assessed the response to medical therapy among adults with PAH-CHD; studies were excluded if they focused on paediatric patients, did not include an assessment of 6 min walking distance or specifically assessed combination therapies. This review found that riociguat, bosentan, epoprostenol and sildenafil were all capable of improving functional capacity and haemodynamic parameters in patients with PAH-CHD, but whether this corresponds to an increase in mortality remains to be seen. Limitations of this review include the small sample size and variable duration of the included studies, which makes drawing direct comparisons between studies and the study drugs difficult. The lack of large, randomised double-blind clinical trials comparing different drugs head to head highlights an area that is ripe for ongoing medical research, the results of which may help shape future treatment algorithms tailored specifically for adults with PAH-CHD.

Spindle-cell sarcoma involving the major pulmonary arteries.

Primary pulmonary vasculature tumors are exceptionally rare, with only a few reported cases. Signs and symptoms of such neoplasms vary but include dyspnea, cough, and chest pain. This condition is associated with a high mortality rate and is easily misdiagnosed as a pulmonary artery embolism. We pre-sent a case of pulmonary artery sarcoma that demonstrates the value of cardiac magnetic resonance imaging for accurate diagnosis.

One-Year Survival is Not Affected by Gastrointestinal Bleeding After Percutaneous Coronary Interventions.

BACKGROUND: Percutaneous coronary intervention (PCI) has been the main therapy in acute coronary syndromes, and early antithrombotic agents as well as 1-year dual antiplatelet therapy are required for adjuvant therapy. However, the development of post-PCI gastrointestinal (GI) bleeding may increase all-cause mortality. We compared the characteristics and outcomes of patients with GI bleeding within 1 year after PCI to those who did not develop bleeding. METHODS: A retrospective cohort study was conducted using data from 384 PCI procedures performed between January 2011 and December 2013 at our hospital. End points were identified after 30 days, 90 days and 1 year postprocedure for evidence of GI bleeding or new onset anemia. Variables were compared between patients with and without GI bleeding using t test and Fisher exact test. Kaplan-Meier curve was constructed for estimating bleeding-free survival probability. RESULTS: In a more than 1-year follow-up period, there were 39 cases (10.2%, 95% CI: 0.073-0.136) of documented GI bleeds. Females were found to have a significantly higher frequency of GI bleeding than males (16.8% vs. 8.0%, P = 0.018), and Hispanics more than non-Hispanics (11.7% vs. 1.7%, P = 0.017). All patients with GI bleeding survived at 1 year. CONCLUSION: In our study of a predominantly Hispanic population, a high incidence of GI bleeding after PCI occurred. However, there was no association between the incidence of GI bleeding and all-cause mortality, whether PCI was performed in the setting of acute coronary syndrome or as an elective procedure. There is a need to conduct a larger prospective study to validate the findings of our study.

Contributors to and impact of residual shunting after device closure of atrial septal defects.

BACKGROUND: The prevalence of residual shunt in patients after device closure of atrial septal defect and its impact on long-term outcome has not been previously defined. METHODS: From a prospective, single-institution registry of 408 patients, we selected individuals with agitated saline studies performed 1 year after closure. Baseline echocardiographic, invasive hemodynamic, and comorbidity data were compared to identify contributors to residual shunt. Survival was determined by review of the medical records and the Social Security Death Index. Survival analysis according to shunt included construction of Kaplan-Meier curves and Cox proportional hazards modeling. RESULTS: Among 213 analyzed patients, 27% were men and age at repair was 47 ± 17 years. Thirty patients (14%) had residual shunt at 1 year. Residual shunt was more common with Helex (22%) and CardioSEAL/STARFlex (40%) occluder devices than Amplatzer devices (9%; P = .005). Residual shunts were more common in whites (79% vs 46%, P = .004). At 7.3 ± 3.3 years of follow-up, 13 (6%) of patients had died, including 8 (5%) with Amplatzer, 5 (25%) with CardioSEAL/STARFlex, and 0 with Helex devices. Patients with residual shunting had a higher hazard of death (20% vs 4%, P = .001; hazard ratio 4.95 [1.59-14.90]). In an exploratory multivariable analysis, residual shunting, age, hypertension, coronary artery disease, and diastolic dysfunction were associated with death. CONCLUSIONS: Residual shunt after atrial septal defect device closure is common and adversely impacts long-term survival.