Predictors of high-degree atrioventricular block in patients with new-onset left bundle branch block following transcatheter aortic valve replacement.

BACKGROUND: The development of new left bundle branch block (LBBB) is frequently seen post TAVR and is a known risk factor for progression to high degree AV block. The timing and likelihood of progression into complete heart block is variable and can develop after hospital discharge. We sought to determine predictors for the development of high degree AV block in patients who developed LBBB following TAVR. METHODS: All patients between 2014 and 2019 underwent electrophysiology study after developing LBBB post TAVR. Data on these patients including baseline characteristics, echo parameters, EKG variables, HV interval, and the need for subsequent pacemaker implantation were extracted. A prolonged HV interval was defined as ≥ 65 ms. Clinically significant conduction abnormality was defined as development of high-degree AV block or clinically significant complete heart block. RESULTS: Thirty-four patients were included in our study of which 10 (29.4%) developed clinically significant heart block, while 24 (70.6%) did not. The mean HV interval for patients with clinically significant heart block was 70.1 ms vs 57.8 ms for those who did not (p = 0.022). Pre-existing first-degree heart block prior to TAVR (p = 0.026), history of AFib (p = 0.05) in addition to STS score (p = 0.037) were predictors of development of high-degree AV block in our patient population. CONCLUSIONS: In patients who develop LBBB following TAVR, HV interval, pre-existing first-degree heart block, and STS score predict progression to high-degree AV block. Performance of a routine electrophysiology study should be considered for high-risk patients who develop LBBB following TAVR.

Integrating hemodynamics with ventricular and valvular remodeling in aortic stenosis. A paradigm shift in therapeutic decision making.

Aortic valve stenosis (AS) has traditionally been approached in hemodynamic terms. Although hemodynamics and symptoms have formed the basis of recommending interventional treatment in AS, other factors reflecting left ventricular and valvular and/or vascular remodeling are equally important for the prognosis and outcome of patients with AS. Left ventricular and valvular/vascular remodeling in AS do not consistently correlate with hemodynamic severity of AS. Those remodeling changes are reflected and can be detected by a variety of novel laboratory and imaging techniques, including biomarkers, echocardiography, cardiac magnetic resonance and gated Computer Tomography (CT) imaging. Taking all those elements into Heart Team therapeutic decision making in patients with AS, can significantly improve appropriate patient selection for interventional treatment and patient outcomes. We review this novel approach and propose a simple algorithm for decision making by the Heart Team, in patients with moderate or severe AS.

Successful epoprostenol withdrawal in pulmonary arterial hypertension: case report and literature review.

Pulmonary arterial hypertension is a rare and devastating disease characterized by vascular proliferation and remodeling. Epoprostenol, the drug counterpart of the eicosanoid prostacyclin, produced by the vascular endothelial cells, is the drug of choice for this disease. Its capacity to act rapidly and to significantly improve survival prospects in severe pulmonary hypertension patients has been supported by a wealth of evidence. Intravenous epoprostenol was believed to require therapy of indefinite duration. Since 2001, oral drugs have been approved for specific treatment. The availability of newer and less invasive drug therapies for pulmonary arterial hypertension led physicians to withdraw epoprostenol in carefully selected patients. We report a case of successful intravenous epoprostenol interruption in a patient with idiopathic disease. A literature review on epoprostenol withdrawal in pulmonary hypertension in adult patients is also provided.

Diabetes mellitus and unstable coronary artery disease: improved clinical outcome of coronary artery stenting in an era of glycoprotein IIb/IIIa inhibitors and lipid-lowering therapy.

OBJECTIVE: The short- and long-term clinical outcomes of coronary artery stenting in diabetic patients with unstable coronary artery disease were assessed and compared with a cohort of non-diabetic patients in the context of platelet glycoprotein IIb/IIIa inhibitors and lipid-lowering therapy. METHODS: The study population comprised 252 consecutive patients with unstable angina who underwent coronary artery stenting; of these 46 were diabetic and 206 were non-diabetic. In-hospital results and clinical outcome during follow-up (24 +/- 13 months, range 7-56 months) were obtained in all patients without major in-hospital complications. Survival curves and multivariate models for any late clinical event were reported. RESULTS: A high clinical success rate and no difference in in-hospital complications between the two groups of patients were observed. Complete revascularization rate was similar in diabetic and non-diabetic patients (48% compared with 52%). A greater proportion of diabetic than non-diabetic patients received IIb/IIIa inhibitors during the procedure and lipid-lowering drugs at hospital discharge (87% compared with 46%, P=0.001 and 83% compared with 61%, P=0.006 respectively). At 2-year clinical follow-up, the incidences of death and myocardial infarction were similar in both groups; the need for any revascularization was only slightly higher in diabetic patients (P=NS). Incomplete revascularization and multi-vessel disease were independent predictors of any revascularization. CONCLUSIONS: Coronary artery stenting combined with glycoprotein IIb/IIIa inhibitor infusion and long-term lipid-lowering therapy is an effective therapeutic strategy in diabetic patients with unstable coronary artery disease and is associated with good short- and long-term results, comparable to those observed in non-diabetic patients.

Long-term clinical outcome of coronary artery stenting in elderly patients.

BACKGROUND: The elderly constitute a rapidly expanding segment of our population and cardiovascular disease becomes more prevalent with increasing age. Existing data have shown that percutaneous coronary interventions in the elderly are associated with an increase risk of in-hospital complications compared to younger patients. In the present study we retrospectively assessed the long-term clinical outcome of coronary artery stenting in an elderly population and compared them with the cohort of younger patients. METHODS: The study population included 402 consecutive patients with coronary artery disease who underwent coronary artery stenting; of these 69 were elderly (age > 70 years, group I) and 333 were younger (age