Changing strategy for aortic stenosis with coronary artery disease by transcatheter aortic valve implantation

Transcatheter aortic valve implantation facilitated by right common carotid cut-down and innominate artery angioplasty with simultaneous right coronary artery vein graft percutaneous coronary intervention in a patient with mid aortic syndrome: a case report

Background

Transcatheter aortic valve implantation (TAVI) is most commonly performed via the femoral approach. Small caliber ilio-femoral arteries, severe calcification and tortuosity are often prohibitive reasons for TAVI via the femoral approach. Mid-aortic syndrome is a rare condition describing congenital or acquired coarctation of the abdominal aorta.

Case summary

To the best of our knowledge, this case report describes the world's first TAVI in a patient with mid-aortic syndrome with challenging vascular access that would preclude conventional TAVI access routes. A 76-year-old woman with intermittent claudication, underwent work-up for axillo-bifemoral bypass, underwent a TAVI for incidental severe asymptomatic severe aortic stenosis via right common carotid TAVI facilitated by innominate artery angioplasty achieved vascular access for TAVI. Percutaneous coronary intervention to a right coronary artery vein graft was simultaneously performed via a left brachial artery cut down.

Discussion

We demonstrate that complex angioplasty to coronary artery bypass grafts and the innominate artery alongside TAVI via a variety of arterial access sites is both safe and feasible.

Clinical impact of low-radiation computed tomography coronary angiography diagnosis for coronary artery stenosis: Study Protocol

BACKGROUND

The objective of this study aims to assess the clinic impact of low-radiation computed tomography coronary angiography (LR-CTCA) diagnosis for coronary artery stenosis (CAS).

METHODS

This study will comprehensively search the following electronic databases from inception to the present: PUBMED, EMBASE, Cochrane Library, PsycINFO, Web of Science, Google, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, VIP database, WANGFANG, and China National Knowledge Infrastructure. All these electronic databases will be searched without language restrictions. All case-controlled studies on assessing the clinical impact of LR-CTCA diagnosis for patients with CAS will be included. Quality Assessment of Diagnostic Accuracy Studies tool will be utilized to evaluate the methodological quality for each qualified studies.

RESULTS

We will assess the clinic impact of LR-CTCA diagnosis for CAS by measuring sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio.

CONCLUSION

The results of this study will summarize the latest evidence of LR-CTCA diagnosis for CAS.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019139336.

Timing and Outcomes of PCI in the TAVR Era

PURPOSE OF REVIEW

Transcatheter aortic valve replacement (TAVR) has become an established therapy for patients with symptomatic severe aortic stenosis (AS). As the number of patients referred for TAVR increases, so does the prevalence of untreated obstructive coronary artery disease (CAD) in the population under evaluation. Despite the high prevalence of CAD in patients treated with TAVR, the management strategy of concomitant CAD in these patients remains an area of considerable uncertainty.

RECENT FINDINGS

Percutaneous coronary intervention (PCI) in patients with CAD and severe AS has been shown to be feasible and safe. Whether revascularization before, during, or after TAVR is optimal remains a subject of debate. All three approaches represent valid strategies with advantages and disadvantages that need to be carefully weighed on an individual basis. Current expert opinions recommend that PCI should be performed before or at the time of TAVR as long as the risk of the procedure does not outweigh the potential benefits. The results of large clinical trials evaluating the optimal revascularization time are closely awaited.

The incidence and risk factors of coronary steal after ipsilateral AVF in patients with a coronary artery bypass graft

Objective

Ipsilateral arteriovenous fistula (AVF) may cause symptoms of coronary steal in patients who had undergone coronary artery bypass graft (CABG) using internal thoracic artery. The purpose of this study was to evaluate the adverse effects of ipsilateral AVF to CABG, including the incidence of coronary steal, and to analyze the risk factors for coronary steal.

Methods

Between 2000 and 2013, a total of 25 patients undergoing hemodialysis via upper extremity AVF, ipsilateral to the preexisting CABG, were reviewed retrospectively. Clinical assessment related to coronary steal, echocardiography before AVF, and coronary angiography after symptoms were assessed. The definition of coronary steal was the new development of one or more of the following symptoms within 12 weeks after AVF creation: chest pain, chest discomfort, and dyspnea.

Results

Three patients were clinically diagnosed as coronary steal. Left ventricular ejection fraction (LVEF) was statistically lower in coronary steal group compared to no-steal group (41.7% vs. 50.9%; p = 0.036). Patients with coronary steal were older at the age of CABG surgery and showed a higher incidence of regional wall motion abnormality.

Conclusions

Coronary steal after ipsilateral AVF creation in patients with CABG using in situ internal thoracic artery (ITA) developed in 12%, which can be related to low LVEF. In patients with CABG requiring AVF for hemodialysis, the ipsilateral fistula to the grafted ITA should be carefully selected and performed.

Specific changes in circulating cytokines and growth factors induced by exercise stress testing in asymptomatic aortic valve stenosis

Background

We evaluated exercise-induced changes in the profile of circulating cytokines and growth factors in patients with AS.

Methods

We studied 32 consecutive asymptomatic moderate-to-severe AS patients and 32 age and sex-matched controls. Plasma levels of interleukin (IL)-6, IL-10, hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF), and transforming growth factor (TGF)-β were measured at 4 time points, i.e. at rest, at peak bicycle exercise, one hour and 24 hours after a symptom-limited exercise.

Results

Exercise increased all the 5 markers in both groups (all p<0.0001). The maximum levels of all tested cytokines were higher in the AS group (all p<0.05) compared with controls. In AS patients the highest levels of VEGF, IL-6, and IL-10 were observed one hour after exercise, while in the control group at peak exercise. In both groups maximum TGF- β levels were observed one hour after exercise. HGF levels were higher at peak and one hour after test in the AS group (p = 0.0001), however the maximum value in AS was observed at peak while in controls after test. In both groups TGF-β was the only marker that remained increased 24 hours after exercise compared with the value at rest (p = 0.0001). The cytokines and growth factors showed no association with heart rate and the workload.

Conclusion

In asymptomatic patients with moderate-to-severe AS, exercise produces a different pattern of changes in circulating cytokines and growth factors, and maximum levels of all tested cytokines were significantly higher in AS patients compared with the control group.

Successful surgical aortic valve replacement for prosthetic valve infective endocarditis following transcatheter aortic valve implantation

An 80-year-old male underwent a transcatheter aortic valve implantation (TAVI) for severe senile aortic stenosis. Six weeks after the surgery, he was readmitted to our institution because of a high-grade fever. Transesophageal echocardiography revealed thickening of all three leaflets of the aortic prosthesis and mobile mass on the leaflet, and Streptococcus sanguis was identified from his blood culture. Therefore, he was diagnosed with prosthetic valve endocarditis (PVE) and received intensive intravenous antibiotic therapy. Because he did not respond to the pharmacological therapy, surgical aortic valve replacement (AVR) was indicated although it was considered a relatively high-risk procedure. Herein, we report on the successful surgical AVR in this patient using a pericardial valve after removal of the infected prosthetic valve, and discuss some issues related to this rare complication after TAVI. <Learning objective: Transcatheter aortic valve implantation (TAVI) is a highly effective procedure for patients with symptomatic severe aortic stenosis who are at high risk or deemed inoperable. Because it only requires limited surgical invasiveness, the risk of prosthetic valve endocarditis (PVE) after TAVI is thought to be low. However, PVE can occur even early after TAVI. We present our recent such case and discuss some issues related to this rare complication.>.

Initial experience with internal mammary artery harvesting with the da Vinci Surgical System for minimally invasive direct coronary artery bypass

PURPOSE

We evaluated the feasibility of off-pump minimally invasive direct coronary artery bypass (MIDCAB) in combination with robotic harvesting of the left internal mammary artery (LIMA).

METHODS

Since 2004, 33 patients [average age, 64 years; 27 males (82%)] have undergone MIDCAB with robotic LIMA harvesting performed through the fourth or fifth intercostal space with guidance by enhanced computed tomography (CT).

RESULTS

No deaths or major adverse cardiac events occurred. Robotic LIMA harvesting was completed in 30 cases (91%), while three cases (9%) required conversion to a median sternotomy due to bleeding. The risk of LIMA injury significantly increased with age (p = 0.0012). For the 30 successful cases, the average harvest time was 68 min, and the average intraoperative blood loss was 306 ml, with only three patients (9%) requiring a transfusion. The graft flow was measurable in all cases (average, 34 ml/minute). All grafts were shown to be patent in postoperative evaluations, although CT revealed that the LIMA in one patient was anastomosed to an untargeted artery.

CONCLUSIONS

Off-pump MIDCAB in combination with robotic harvesting of the LIMA is a reasonable and less invasive procedure than the standard procedures. Potential problems include difficulty controlling bleeding from the graft, especially in elderly patients, and proper identification of the target artery.