Peripartum Cardiogenic Shock and Mechanical Circulatory Support

Despite remarkable improvements in the past two decades, the annual cardiovascular mortality rate has remained higher for women than for men. Pregnant women represent an underinvestigated population in clinical research, and the mechanisms of long-term cardiovascular complications in women with obstetric complications remain to be elucidated. Regarding advanced heart failure during pregnancy, interventional approaches are effective but still underutilised. Percutaneous mechanical circulatory support is a valuable option for peripartum cardiogenic shock, although its use during pregnancy is still limited. Survival rates have improved in recent years, but further emphasis on the importance of early recognition and initiation of heart failure treatment in this patient group is warranted. The aims of this review are to summarise the current literature on the implementation of mechanical circulatory support in cardiogenic shock during pregnancy and delivery and to understand the role of percutaneous ventricular assist devices in the management of such conditions.

Incidence, Predictors, and Prognostic Impact of New Permanent Pacemaker Implantation After TAVR With Self-Expanding Valves

OBJECTIVES

The authors sought to evaluate the incidence, predictors, and outcomes of new permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) with contemporary self-expanding valves (SEV).

BACKGROUND

Need for PPI is frequent post-TAVR, but conflicting data exist on new-generation SEV and on the prognostic impact of PPI.

METHODS

This study included 3,211 patients enrolled in the multicenter NEOPRO (A Multicenter Comparison of Acurate NEO Versus Evolut PRO Transcatheter Heart Valves) and NEOPRO-2 (A Multicenter Comparison of ACURATE NEO2 Versus Evolut PRO/PRO+ Transcatheter Heart Valves 2) registries (January 2012 to December 2021) who underwent transfemoral TAVR with SEV. Implanted transcatheter heart valves (THV) were Acurate neo (n = 1,090), Acurate neo2 (n = 665), Evolut PRO (n = 1,312), and Evolut PRO+ (n = 144). Incidence and predictors of new PPI and 1-year outcomes were evaluated.

RESULTS

New PPI was needed in 362 patients (11.3%) within 30 days after TAVR (8.8%, 7.7%, 15.2%, and 10.4%, respectively, after Acurate neo, Acurate neo2, Evolut PRO, and Evolut PRO+). Independent predictors of new PPI were Society of Thoracic Surgeons Predicted Risk of Mortality score, baseline right bundle branch block and depth of THV implantation, both in patients treated with Acurate neo/neo2 and in those treated with Evolut PRO/PRO+. Predischarge reduction in ejection fraction (EF) was more frequent in patients requiring PPI (P = 0.014). New PPI was associated with higher 1-year mortality (16.9% vs 10.8%; adjusted HR: 1.66; 95% CI: 1.13-2.43; P = 0.010), particularly in patients with baseline EF <40% (P for interaction = 0.049).

CONCLUSIONS

New PPI was frequently needed after TAVR with SEV (11.3%) and was associated with higher 1-year mortality, particularly in patients with EF <40%. Baseline right bundle branch block and depth of THV implantation independently predicted the need of PPI.

Transcatheter aortic valve implantation with the Evolut platform for bicuspid aortic valve stenosis: the international, multicentre, prospective BIVOLUTX registry

BACKGROUND

Prospective data about transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve (BAV) patients are limited.

AIMS

We aimed to evaluate the clinical impact of the Evolut PRO and R (34 mm) self-expanding prostheses in BAV patients and explore the impact of different computed tomography (CT) sizing algorithms in a prospective registry.

METHODS

A total of 149 bicuspid patients were treated in 14 countries. The primary endpoint was the intended valve performance at 30 days. Secondary endpoints were 30-day and 1-year mortality, severe patient-prosthesis mismatch (PPM) and the ellipticity index at 30 days. All study endpoints were adjudicated according to Valve Academic Research Consortium 3 criteria.

RESULTS

The mean Society of Thoracic Surgeons score was 2.6% (1.7-4.2). Type I L-R BAV was observed in 72.5% of the patients. Evolut valve sizes 29 and 34 mm were utilised in 49.0% and 36.9% of the cases, respectively. The 30-day cardiac death rate was 2.6%; the 1-year cardiac death rate was 11.0%. Valve performance at 30 days was observed in 142/149 (95.3%) patients. The mean aortic valve area post-TAVI was 2.1 (1.8-2.6) cm2, and the mean aortic gradient was 7.2 (5.4-9.5) mmHg. No patient had more than moderate aortic regurgitation at 30 days. PPM was observed in 13/143 (9.1%) surviving patients and was severe in 2 patients (1.6%). Valve function was maintained at 1 year. The mean ellipticity index remained 1.3 (interquartile range 1.2-1.4). Overall, 30-day and 1-year clinical and echocardiography outcomes were similar between the two sizing strategies.

CONCLUSIONS

BIVOLUTX demonstrated a favourable bioprosthetic valve performance and good clinical outcomes after TAVI with the Evolut platform in patients with bicuspid aortic stenosis. No impact from the sizing methodology could be identified.

Temporal Trends and Contemporary Outcomes After Transcatheter Aortic Valve Replacement With Evolut PRO/PRO+ Self-Expanding Valves: Insights From the NEOPRO/NEOPRO-2 Registries

BACKGROUND

In recent years, transcatheter aortic valve replacement (TAVR) techniques and technology have continuously improved. Data regarding the impact of these advancements on outcomes in large real-world settings are still limited. The aim of this study was to investigate temporal trends and assess contemporary outcomes after TAVR with Evolut PRO/PRO+ supra-annular self-expanding valves.

METHODS

This study included patients enrolled in the multicenter NEOPRO (A Multicenter Comparison of Acurate NEO Versus Evolut PRO Transcatheter Heart Valves) and NEOPRO-2 (A Multicenter Comparison of ACURATE NEO2 Versus Evolut PRO/PRO+ Transcatheter Heart Valves 2) registries who underwent transfemoral TAVR with Evolut PRO/PRO+. Procedural dates (August 2017 through November 2021) were stratified in quartiles (Q) and used to investigate temporal trends in TAVR outcomes. Predischarge, 30-day Valve Academic Research Consortium-3 defined, and 1-year outcomes were evaluated.

RESULTS

In total, 1616 patients from 28 centers were included. Over time, patients had lower Society of Thoracic Surgeon-Predicted Risk of Mortality score (Q1-4, 4.1% [2.8-6.3%], 3.7% [2.6-5.3%], 3.3% [2.4-4.9%], 2.9% [2.2-4.3%]; P<0.001) and more moderate or heavy valve calcification (Q1-4, 80%, 80%, 82%, 88%; P=0.038). Overall Valve Academic Research Consortium-3 technical success was 94.1%, with 30-day and 1-year all-cause mortality of 2.4% and 10%, respectively. Throughout the study period, procedures were associated with higher rates of 30-day device success (Q1-4, 81.2%, 82.2%, 82.0%, 88.0%; Cochran-Armitage P=0.023) and early safety (Q1-4, 66.8%, 67.5%, 74.0%, 77.6%; Cochran-Armitage P<0.001), with fewer permanent pacemaker implantations (Q1-4: 15.3%, 20.0%, 12.1%, 11.6%; Cochran-Armitage P=0.023) and residual mild or greater paravalvular leaks (Q1-4, 50.4%, 42.1%, 36.5%, 35.8%; Cochran-Armitage P<0.001).

CONCLUSIONS

TAVR with Evolut PRO/PRO+ self-expanding valve is safe and effective. Despite the treatment of heavier calcified anatomies, procedural outcomes are improving over time with less need for pacemaker implantation and less significant paravalvular leaks.

P64 COVERED STENT IN A CHEST TRAUMA: CONGENITAL CORONARY ARTERIAL FISTULA OR TRAUMATIC CORONARY PERFORATION?

Coronary arterial fistula consists in a communication between a coronary artery and a cardiac cavity. It is tipically a congenital condition, but it can also be a result of invasive cardiac procedure. Although chest truama generally evolve to massive pericardial effusion, in some cases it can determine also a coronary perforation, with a consequent coronary arterial fistula. A 22–year–old male patient, with no cardiovascular history, was admitted after a road accident, reporting pelvis break, 17 costal break, and sternal break, with consequent chest pain. On admission the patient had a heart rate of 100 b.p.m. and a blood pressure of 130/80 mmHg. Elettrocardiogram (ECG) reported ST elevation in antero–septal derivations (V1–V4). Echocardiogram showed a global left ventricular (LV) ejection fraction of 55%, with an apical–septal akinesia, with a minimal anterior pericardial effusion, not emodinamically significant. So, an emergency coronary angiography was performed, showing a fistula of the distal segment of the left anterior discendent coronary (LAD). In this case there were two possible options, a previously unknown congenital coronary arterial fistula, or a traumatic coronary perforation, determining a coronary arterial fistula. Considering the possibility of a traumatic coronary perforation, with the consequent risk of rapid pericardial effusion worsening, the decision was to perform percutaneous coronary intervention (PCI) with a covered stent (Biotronik Papyrus 2.5 x 20 mm, 8 atm), with a good final result, with total occlusion of fistula. At 1 month follow up, the patient was asymptomatic for dyspnea or chest pain, with a heart rate of 70 b.p.m. and a blood pressure of 130/80 mmHg. ECG showed no anomalies in ST–T tract.

214 Covered stent in a chest trauma: congenital coronary arterial fistula or traumatic coronary perforation?

Aims

Coronary arterial fistula consists in a communication between a coronary artery and a cardiac cavity. It is tipically a congenital condition, but it can also be a result of invasive cardiac procedure. Although chest truama generally evolve to massive pericardial effusion, in some cases it can determine also a coronary perforation, with a consequent coronary arterial fistula.

Methods and results

A 22-year-old male patient, with no cardiovascular history, was admitted after a road accident, reporting pelvis break, 17 costal break, and sternal break, with consequent chest pain. On admission the patient had a heart rate of 100 b.p.m. and a blood pressure of 130/80 mmHg. Elettrocardiogram (ECG) reported ST elevation in antero-septal derivations (V1–V4). Echocardiogram showed a global left ventricular (LV) ejection fraction of 55%, with an apical-septal akinesia, with a minimal anterior pericardial effusion, not emodinamically significant. So, an emergency coronary angiography was performed, showing a fistula of the distal segment of the left anterior discendent coronary (LAD). In this case there were two possible options, a previously unknown congenital coronary arterial fistula, or a traumatic coronary perforation, determining a coronary arterial fistula. Considering the possibility of a traumatic coronary perforation, with the consequent risk of rapid pericardial effusion worsening, the decision was to perform percutaneous coronary intervention (PCI) with a covered stent (Biotronik Papyrus 2.5 × 20 mm, 8 atm), with a good final result, with total occlusion of fistula.

Conclusions

At 1 month follow-up, the patient was asymptomatic for dyspnoea or chest pain, with a heart rate of 70 b.p.m. and a blood pressure of 130/80 mmHg. ECG showed no anomalies in ST-T tract.

Contemporary management of severe symptomatic bicuspid aortic valve stenosis: the BiTri Registry

AIMS

A greater number of patients with bicuspid aortic valves (BAV) may be identified and treated as indications for transcatheter aortic valve implantation (TAVI) are expected to expand to younger patients. We evaluated the contemporary frequency and management of symptomatic patients with stenotic BAV in a multicenter European registry.

METHODS

Between November 2017 and February 2018, all consecutive patients admitted for symptomatic aortic stenosis across six high-volume European hospitals were prospectively enrolled in the BiTri registry.

RESULTS

Of the 832 patients, 17% (n = 138) had a BAV. The most frequent BAV phenotypes were type 1 (left--right coronary cusps fusion 64%) and type 1 (right-noncoronary cusps fusion 17%). Type 0 and type 2 accounted for 12 and 2%, respectively. When compared with tricuspid patients (n = 694), BAV patients were younger, with lower surgical risk. The transthoracic echocardiography (TTE) identified BAV in 64% of patients. Multisliced computed tomography (MSCT) additionally completed the diagnosis in 20% of patients. Surgical inspection finally identified the remaining undiagnosed 16% of BAV. A combination of TTE and MSCT was the most common diagnosis method for BAV. Surgical aortic valve replacement (SAVR) was the predominant therapeutic option for BAV (70%) whilst TAVI was performed in 26%.

CONCLUSION

BAV is frequently observed in symptomatic patients with aortic stenosis. These patients are younger, have a lower risk profile and are predominantly treated with SAVR as compared with tricuspid patients. However, TAVI is performed in almost one-third of BAV patients in contemporary European practice. TTE combined with MSCT identified 84% of BAV.

Clinical consequences of consecutive self-expanding transcatheter heart valve iterations

Objective

To compare early clinical outcomes after transcatheter aortic valve implantation (TAVI) with three consecutive generations of self-expanding valves (SEVs).

Methods

Clinical endpoints of consecutive patients who underwent TAVI with CoreValve, Evolut R or Evolut PRO were included in a prospective database.

Results

TAVI was performed with CoreValve (n = 116), Evolut R (n = 160) or Evolut PRO (n = 92). Evolut R and Evolut PRO showed a tendency towards lower permanent pacemaker implantation (PPI) rates compared to CoreValve (CoreValve 27% vs Evolut R 16% vs Evolut PRO 18%, p = 0.091). By multivariable regression analysis CoreValve had a significantly higher risk for PPI (odds ratio (OR) 2.79, 95% confidence interval (CI) 1.31–5.94, p = 0.008) compared to Evolut R, while Evolut R and PRO were similar. Severe paravalvular leakage (PVL) occurred only with CoreValve, but no significant difference was observed in moderate PVL (10% vs 8% vs 6%, p = 0.49). CoreValve had a tendency towards a higher risk for more-than-mild PVL as compared with the Evolut platform (R + PRO) (OR 2.46, 95% CI 0.98–6.16, p = 0.055). No significant differences in all-cause mortality (7% vs 4% vs 1%, p = 0.10), stroke (6% vs 3% vs 2%, p = 0.21) or major vascular complications (10% vs 12% vs 4%, p = 0.14) were observed.

Conclusions

TAVI with self-expanding valves was safe, and device iterations may result in a lower need for PPI. More-than-mild PVL seemed to occur less often with repositionable technology.

Supplementary Information

The online version of this article (10.1007/s12471-021-01568-5) contains supplementary material, which is available to authorized users.

Heterogeneity of debris captured by cerebral embolic protection filters during TAVI

AIMS

The aim of this study was to investigate the total amount, size and heterogeneity of debris captured among different transcatheter valve types and while repositioning.

METHODS AND RESULTS

A total of 328 patients who underwent transcatheter aortic valve implantation (TAVI) with the SENTINEL cerebral embolic protection (CEP) at our centre were eligible. Histopathological and semiquantitative analysis of captured debris was performed and data were entered into our prospective database. TAVI was performed with either the Evolut R/PRO (N=123), SAPIEN 3 (N=113) or Lotus valve (N=92). Capture of debris occurred in 98% of patients. Lotus TAVI resulted in more frequent foreign body material (62% vs 40% vs 47%, p=0.006), endothelium (49% vs 30% vs 16%, p<0.0005), calcified material (33% vs 12% vs 24%, p=0.001) and myocardial tissue (19% vs 11% vs 2%, p<0.0005) compared to SAPIEN 3 or Evolut R/PRO. Native (functional) bicuspid valves (OR 2.91, 95% CI: 1.20-7.03, p=0.02) and Lotus (OR 2.44, 95% CI: 1.14-5.24, p=0.02) were associated with the highest risk for dislodging particles ≥1,000 um. Valve repositioning was independently associated with larger amounts of debris (OR 2.96, 95% CI: 1.42-6.16, p=0.004).

CONCLUSIONS

All THV platforms had similar amounts of captured debris. THV repositioning seemed to be associated with a higher risk for dislodging greater amounts of debris to the brain.

ADDED Index or percentage diameter of residual coronary stenosis to risk-stratify patients presenting with STEMI

BACKGROUND

We compared the prognostic value of the ADDED Index with visually estimated diameter (DS) of residual coronary stenosis (RS) in STEMI patients after successful PCI of the culprit lesion. Even though associated with a positive outcome, the functional assessment of non-culprit stenosis remains largely underused, especially in STEMI patients. The Angiography-DeriveD hEmoDynamic index (ADDED index) showed high accuracy to predict FFR and it might be used to better guide the diagnostic and therapeutic work-up of such patients.

METHODS

We retrospectively included 596 patients grouped on the basis of either the ADDED Index (ADDED Negative (<2.23, n = 153) vs ADDED Positive (≥2.23, n = 129)) or the DS of the RS (RS Negative (<50%, n = 177) vs RS Positive (≥50%, n = 105)). Patients without any RS served as control (n = 314). Primary endpoints were: 1) major adverse cardiac events (MACE), composite of all-cause death, myocardial infarction (MI), clinically driven revascularizations (CDR); 2) non-culprit vessel oriented clinical events (VOCE), composite of all-cause death, non-culprit vessel related MI and CDR.

RESULTS

At 24 months the rate of both MACE and VOCE was significantly higher in both the ADDED Positive and RS Positive groups. However, differently from patients in whom complete revascularization was deferred on the basis of the angiography (RS Negative), no additional risk was found for patients in the ADDED Negative group.

CONCLUSIONS

In STEMI patients with MVD deferring treatment of RS on the basis of the ADDED index, rather than the visually estimated DS, is associated with a favorable clinical outcome.

Impact of baseline and newly acquired conduction disorders on need for permanent pacemakers with 3 consecutive generations of self-expanding transcatheter aortic heart valves

INTRODUCTIONS

We aimed to compare conduction dynamics and need for permanent pacemaker implantation (PPI) after CoreValve, Evolut R and PRO (transcatheter aortic valve replacement (TAVR)).

METHODS

Patients were stratified based on conduction at baseline; Cohort A had normal conduction, Cohort B had conduction abnormalities including atrioventricular (AV)-block, fascicular block or complete bundle branch block. Three different dynamic QRS-patterns were defined: stable QRS-duration, transient QRS-prolongation and persistent QRS-prolongation. We performed multivariable regression analysis to estimate the effect of the three separate transcatheter heart valves (THV's) on need for PPI at 30 days.

RESULTS

TAVR was performed with CoreValve (N = 113), Evolut R (N = 157) or Evolut PRO (N = 92). Conduction dynamics were similar between the different THVs. Overall, Evolut R and PRO showed a tendency towards less PPI compared to CoreValve (17% vs. 19% vs. 27%, P = 0.08), which was driven by a lower PPI rate in Cohort A (6% vs. 11% vs. 25%, P = 0.002). Need for PPI was restricted to patients with persistent QRS-prolongation in Cohort A (26/106) but did not correlate with conduction dynamics in Cohort B. In multivariable logistic regression analysis the use of Evolut R (OR 0.38, 95% CI 0.19-0.78, P = 0.008) and PRO (OR 0.41, 95% CI 0.19-0.91, P-value = 0.028) were independently associated with less need for PPI.

CONCLUSION

The newer generations Evolut R and PRO were associated with less PPI compared to CoreValve. Acquired persistent conduction abnormalities predicted PPI after TAVR only in patients with normal conduction at baseline. Our findings may help identify eligible patients for early discharge after Evolut R/PRO TAVR.

Suture- or Plug-Based Large-Bore Arteriotomy Closure: A Pilot Randomized Controlled Trial

OBJECTIVES

This study sought to test the superiority in terms of efficacy and safety of a dedicated plug-based vascular closure device (VCD) during transcatheter aortic valve replacement (TAVR) over a suture-based VCD.

BACKGROUND

Vascular complications after TAVR are relevant and often associated with VCD failure.

METHODS

The MASH (MANTA vs. Suture-based vascular closure after transcatHeter aortic valve replacement) trial is an international, 2-center pilot randomized controlled trial comparing the MANTA VCD (Teleflex, Wayne, Pennsylvania) versus 2 ProGlides (Abbott Vascular, Abbott Park, Illinois). The primary composite endpoint consisted of access site-related major or minor vascular complications at 30-days' follow-up. Secondary endpoints included clinically relevant access site bleeding, time to hemostasis, and modified VCD failure (defined as failure to achieve hemostasis within 5 min or requiring additional endovascular maneuvers such as endovascular stenting, surgical techniques, or additional closure devices). Adverse events were adjudicated by an independent clinical events committee according to the VARC-2 definitions.

RESULTS

A total of 210 TAVR patients were included between October 2018 and January 2020. Median age was 81 years, 54% were male, and the median STS score was 2.7%. There was no significant difference in the primary endpoint of access site-related vascular complications between MANTA and ProGlide (10% vs. 4%; p = 0.16). Clinically significant access site bleedings were similar with both closure techniques (9% vs. 6%; p = 0.57). Modified VCD failure occurred less frequently in MANTA versus ProGlide (20% vs. 40%; p < 0.01). Suture-based closure required more often additional closure devices, whereas MANTA numerically needed more covered stents and surgical bailouts.

CONCLUSIONS

Plug-based large-bore arteriotomy closure was not superior to suture-based closure. Plug-based closure required fewer, but a different kind of bailout maneuvers.

TAVI durability

Background

TAVI (Transcatheter aortic valve implantation) is now established as the preferred treatment option for patients with symptomatic severe aortic stenosis at prohibitive or high surgical risk and its application is increasingly supported by an accumulating evidence base in patients at intermediate and low risk, but the issue of valve durability are still unsettled.

Purpose

To evaluate long-term clinical outcomes and bioprosthesis valve dysfunction after TAVI.

Methods

All patients treated with transfemoral TAVI, from November 2007 to December 2014 were analyzed. Baseline clinical, procedural and in-hospital outcomes were collected and revised. Clinical and echocardiographic follow-up was conducted either by clinic visits or telephone consultations. All definitions of the clinical endpoints and bioprosthesis valve failure used were in concordance with the Valve Academic Research Consortium 2 and the European Society of Cardiology consensus, respectively.

Results

Four hundred and eight patients were included in the analysis. Median follow-up was 2.733 days (7.5 years), with the longest follow-up at 4.096 days (11.2 years). At 7.5 years (IQR 5.4–9.3 years), all-cause mortality was 64.5% (n=263), of these cardiovascular death was adjudicated in 33.6% (n=137), non-cardiovascular death in 30.9% (n=126) and valve-related death was 1.9% (n=8). Structural valve deterioration occurred in 2.9% (n=12), non-structural valve deterioration in 0.2% (n=1), thrombosis in 2.2% (n=9) and endocarditis in 3.2% of patients (n=13). Fourteen patients (3.4%) required surgical (1.2%) or percutaneous (2.2%) aortic valve re-intervention.

Conclusions

Percutaneous aortic bioprosthesis demonstrated a low bioprosthesis valve failure at a median of 7.5 years of clinical follow-up after implantation, with low rate of degeneration or need of re-intervention. Overall mortality was high with acceptable rates of cardiovascular mortality and low rates of valve-related deaths.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): EAPCI Education and Training Grants

Sex sub analysis from observational multicenter registry of patients treated with Impella mechanical circulatory support device in Italy: the IMP-IT women

Background

Women-specific data on safety, effectiveness, and outcomes for mechanical support in the setting of cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI) are still unsettled. The IMP-IT study was a multicenter observational national registry that enrolled all patients treated with Impella 2.5, Impella CP, Impella 5.0 and Impella RP, both for CS and HR-PCI indications, across 17 Italian centers from 2004 to June 2018

Purpose

To analyze the characteristics of female population enrolled in IMP-IT registry and to assess differences in presentation, timing to interventions and outcomes between men and women.

Methods

The Women-IMP-IT study is a multicenter observational national registry focusing on female population enrolled in IMP-IT study. Baseline, procedural and hemodynamics characteristics, such as outcome were collected. Differences between men and women were examined.

Results

Mean age of female population was 66.9±16.1 years, Body mass index was 26.3±5.5 kg/m2. There was a higher rate of cardiogenic shock (66.7% vs. 49.1%; p=0.06), NSTEMI (18% vs 9%, p=0.03) and acute myocarditis (9.6% vs 1.4%, p=0.01) in women vs men, associated with a lower rate of protected PCI (33.3% vs 50.9%, p=0.06). We did not observed a statistically difference in device related complications (27.4% vs 23.3%; p=0.50), respectively in women compared to men. In particular, no differences were observed in access site bleedings (10.8% vs 9%; p=0.70) and life threatening or severe bleeding (15.3% vs 11.4%; p=0.40). At one year, all-cause death rate was 45.1% in women vs 30.1% in men (p=0.016), and cardiac death rate was 42.5% in women and 27.5% in men (p=0.013). At 1-year no significant difference was observed in the rate of myocardial infarction (3.7% vs 2.3%; p=0.44), stroke (3.7% vs 2.6%; p=0.70), heat-failure hospitalization (7.7% vs 7.5%; p=1.0), need for left ventricular assist device or heart transplantation (1.3% vs 5.5%; p=0.21).

Conclusions

In our series, use of Impella is CS and HR-PCI is increasing in female population. Sex-differences in mortality are mostly explained by clinical differences at presentation.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): EAPCI Education and Training Grants

Comparison of the Sapien 3 versus the ACURATE neo valve system: A propensity score analysis

Objectives

To compare the outcomes of transfemoral ACURATE neo (NEO) and Sapien 3 (S3) patients in terms of device success and clinical safety outcomes using a propensity score analysis.

Background

Differences in clinical outcomes between the latest‐generation balloon‐expandable S3 and self‐expanding NEO in a “real‐world transfemoral TAVI population” are still unclear.

Methods

We compared up to 6 months clinical outcomes using a propensity score analysis (inverse probability of treatment weighting [IPTW]) to account for differences in baseline characteristics.

Results

A total of 345 patients underwent transfemoral transcatheter aortic valve implantation (TAVI) with either NEO or S3 at two centers in the Netherlands. Composite device success and early safety endpoints were comparable between NEO and S3 (Device success: IPTW‐adjusted OR: 0.35 [95% CI: 0.12–1.18], and early safety: IPTW‐adjusted OR: 0.51 [95% CI: 0.19–1.38]). Six‐months mortality was 5.3 versus 3.6%, stroke was 2.8 versus 3.3%, and pacemaker rate was 6.1 versus 8.6%, respectively with p = NS. Mean aortic gradient was lower in the NEO group (5.72 ± 2.47 vs. 9.05 ± 3.48; p = <.001), with a comparable rate of moderate or severe paravalvular leak (0 versus 2.1%; p = NS).

Conclusions

Device success and clinical safety outcomes were comparable for both valves. Up to 6‐months follow‐up clinical outcomes and mortality rate remained excellent. Mean aortic gradient was lower after ACURATE neo implantation.

Impact of drug-eluting stents on left ventricular wall motion after successful reperfusion of first anterior ST elevation myocardial infarction

BACKGROUND

Timely myocardial reperfusion by primary percutaneous coronary intervention (pPCI) prevents the development of left ventricular (LV) dysfunction after myocardial infarction (MI). We aimed to investigate whether bare-metal stents (BMS) and drug eluting stents (DES) differently affect the recovery of LV function in patients with ST-elevation MI (STEMI).

METHODS

Overall 103anterior STEMI patients were retrospectively analyzed. All patients had single vessel disease with culprit lesion at the left anterior descending coronary artery. Patients were categorized in DES group (N.=67) and BMS group (N.=36). Changes in LV contractility were assessed by trans-thoracic echocardiogram as Left Ventricular Wall Motion Score Index (LVWMSI). Follow-up visits were performed between 6 and 12 months after hospital discharge.

RESULTS

Compared to baseline, LV ejection fraction (EF) remained unchanged between the two groups at the follow-up; LVWMSI significantly improved in patients treated with DES (1.95±0.25 vs. 1.78±0.38, P<0.05), whereas did not change in those treated with BMS (2.09±0.21 vs. 1.98±0.33, P: not significant). At follow-up the LVWMSI was significantly higher in patients with DES than with BMS (P=0.048). LV end-systolic and end-diastolic volumes (LVESV, LVEDV) significantly increased in patients receiving a BMS, whereas it did not change in those receiving a DES (P<0.05). Multivariate analysis adjusted for age, gender, type of stent (DES or BMS), and type of revascularization (primary PCI or rescue PCI or thrombolysis + PCI) showed that DES implantation was an independent predictor of LVWMSI improvement (OR: 3.8 [1.143-12.969] P=0.03).

CONCLUSIONS

DES implantation is associated with a favorable impact on LV remodeling and regional contractility.

Impact of drug-eluting stents on left ventricular wall motion after successful reperfusion of first anterior ST elevation myocardial infarction

BACKGROUND

Timely myocardial reperfusion by primary percutaneous coronary intervention (pPCI) prevents the development of left ventricular (LV) dysfunction after myocardial infarction (MI). We aimed to investigate whether bare-metal stents (BMS) and drug eluting stents (DES) differently affect the recovery of LV function in patients with ST-elevation MI (STEMI).

METHODS

Overall 103anterior STEMI patients were retrospectively analyzed. All patients had single vessel disease with culprit lesion at the left anterior descending coronary artery. Patients were categorized in DES group (N.=67) and BMS group (N.=36). Changes in LV contractility were assessed by trans-thoracic echocardiogram as Left Ventricular Wall Motion Score Index (LVWMSI). Follow-up visits were performed between 6 and 12 months after hospital discharge.

RESULTS

Compared to baseline, LV ejection fraction (EF) remained unchanged between the two groups at the follow-up; LVWMSI significantly improved in patients treated with DES (1.95±0.25 vs. 1.78±0.38, P<0.05), whereas did not change in those treated with BMS (2.09±0.21 vs. 1.98±0.33, P: not significant). At follow-up the LVWMSI was significantly higher in patients with DES than with BMS (P=0.048). LV end-systolic and end-diastolic volumes (LVESV, LVEDV) significantly increased in patients receiving a BMS, whereas it did not change in those receiving a DES (P<0.05). Multivariate analysis adjusted for age, gender, type of stent (DES or BMS), and type of revascularization (primary PCI or rescue PCI or thrombolysis + PCI) showed that DES implantation was an independent predictor of LVWMSI improvement (OR: 3.8 [1.143-12.969] P=0.03).

CONCLUSIONS

DES implantation is associated with a favorable impact on LV remodeling and regional contractility.

Pregnancy-Associated Plasma Protein-A and its Role in Cardiovascular Disease. Biology, Experimental/Clinical Evidences and Potential Therapeutic Approaches

Pregnancy-Associated Plasma Protein-A (PAPP-A) is a zinc-binding metalloproteinase protein produced by placental syncytio-trophoblasts and secreted into the maternal circulation where its concentration progressively increases until term. In recent years, PAPP-A has been studied for its potential involvement in cardiovascular (CV) disease. However, all those studies did not provide a clear view to identify the pathophysiological links between PAPP-A plasma levels and the occurrence of CV events. In this review, starting from a complete description of PAPP-A structure and biology, we present an updated overview of experimental as well as clinical evidence on the role of this metalloproteinase in CV disease. Finally, we discuss possible therapeutic approaches to antagonize its potential detrimental CV effects.

Nobiletin inhibits oxidized-LDL mediated expression of Tissue Factor in human endothelial cells through inhibition of NF-κB

INTRODUCTION

Flavonoids are nutrients usually included in human diet with several significant biological activities. Nobiletin is a flavonoid that, besides having anti-inflammatory and anti-tumoral activity, seems to exert protective effects on cardiovascular system. Several studies investigated nobiletin as a natural drug to antagonize the atherosclerotic disease. On the contrary, literature about its potential role in modulating the main acute complication of atherosclerosis, thrombosis, is still scanty. Several studies have indicated that Tissue Factor (TF) plays a pivotal role in the pathophysiology of cardiovascular thrombotic events by triggering the formation of intracoronary thrombi. Oxidized-LDL have an important role in promoting athero-thrombotic events. This study investigates whether nobiletin might exert protective cardiovascular effects by preventing the oxidized-LDL mediated expression of TF in human endothelial cells in vitro. Moreover, we have studied whether the nobiletin effects might be modulated by the inhibition of the NF-κB pathway.

METHODS AND RESULTS

In HUVEC, ox-LDL induced TF-mRNA transcription as demonstrated by real time PCR and expression of functionally active TF as demonstrated by Western-blot, FACS analysis and pro-coagulant activity assay. Nobiletin prevented these ox-LDL-mediated effects by exerting antioxidant effects, finally leading to inhibition of the transcription factor NF-κB.

CONCLUSIONS

These data suggest that nobiletin might be a potential antithrombotic agent of dietary origin. This flavonoid, through its antioxidant proprieties, might potentially exert an antithrombotic activity by inhibiting TF expression/activity in a cell population never investigated before in this context and that is normally represented in vessel wall such as endothelial cells.

Obesity and ischemic heart disease. Is there a link between wellness’ diseases?

Obesity, the most common nutritional disorder in Western countries, is usually associated to cardiovascular diseases. However, the precise molecular pathways underlying this close association remain poorly understood. Nowadays, the adipose tissue is considered as an endocrine organ able to produce substances called adipo(cyto)kines that have different effects on lipid metabolism, closely involved in metabolic syndrome, and cardiovascular risk. The increased cardiovascular risk can be related also to peculiar dysfunction in the endocrine activity of adipose tissue observed in obesity responsible of vascular impairment (including endothelial dysfunction), prothrombotic tendency, and low-grade chronic inflammation. The present review aims at providing an up-dated overview on the adipocytederived molecules potentially involved in cardiovascular pathophysiology.

The adipokine apelin-13 induces expression of prothrombotic tissue factor

Adipocytes are cells able to produce and secrete several active substances (adipokines) with direct effects on vascular cells. Apelin, one of the most recently identified adipokines has been studied in cardiovascular system physiology in regard to vessel vasodilation and myocardial contraction, but it has not yet completely characterised for its pathophysiological role in cardiovascular disease and especially in acute coronary syndromes (ACS). Several studies have indicated that tissue factor (TF) plays a pivotal role in the pathophysiology of ACS by triggering the formation of intracoronary thrombi following endothelial injury. This study investigates the effects of apelin 12 and apelin 13 on TF in human umbilical endothelial cells (HUVECs) and monocytes. Cells were stimulated with increasing concentrations of apelin 12 or apelin 13 and then processed to evaluate TF-mRNA levels by real-time PCR as well as TF expression/activity by FACS analysis and pro-coagulant activity. Finally, a potential molecular pathway involved in modulating this phenomenon was investigated. We demonstrate that apelin 13 but not apelin 12 induces transcription of mRNA for TF. In addition, we show that this adipokine promotes surface expression of TF that is functionally active. Apelin 13 effects on TF appear modulated by the activation of the G-protein-transcription factor nuclear factor (NF)-κB axis since G-protein inhibitors suppressed NF-κB mediated TF expression. Data of the present study, although in vitro, indicate that apelin-13, induces a procoagulant phenotype in HUVECs and monocytes by promoting TF expression. These observations support the hypothesis that this adipokine might play a relevant role as an active partaker in athero-thrombotic disease.

Cardiovascular Disease and High-Mobility Group Box 1—Is a New Inflammatory Killer in Town?

High-mobility group box 1 (HMGB-1) is a nuclear protein physiologically involved in the maintaining of DNA structure in the nucleus. When tissue damage occurs, necrotic cells as well as inflammatory cells, once activated, release this protein in circulating blood, where it seems to exert a direct proinflammatory action. Thus, HMGB-1 might be involved in the pathophysiology of several diseases, including cardiovascular disease. However, the experimental evidence has not yet clarified its cardiovascular role which is still debated. Specifically, it is still not completely resolved whether HMGB-1 plays a protective or detrimental role on cardiovascular function. In this review, we consider the role of HMGB-1 in pathological conditions and comment on the role of this protein in the cardiovascular disease.

Multi-slice computed tomography assessment of stent position in a patient with acute coronary syndrome and anomalous origin of the coronary arteries

We describe the case of a woman with acute coronary syndrome who was treated by percutaneous coronary intervention (PCI) and stenting of the proximal right coronary artery, which shared its short origin with the left anterior descending artery. A multi-slice computed tomography study of the patient's coronary tree, performed after percutaneous treatment, played a fundamental role in obtaining a clearer view of the coronary anatomy, as well as of stent positioning in this particular anatomy, eliminating any doubt about the PCI result.

Adipose tissue in the pathophysiology of cardiovascular disease: Who is guilty?

Epidemiological evidence has shown how abdominal obesity is closely associated with the development of cardiovascular disease. It has been demonstrated that patients with extensive adipose tissue usually have other concomitant cardiovascular risk factors, such insulin resistance, hypertension and dyslipidemia. Moreover, obese patients have a significantly higher risk of developing thrombophilic events compared with the non-obese. Thus, obesity is actually considered an independent cardiovascular risk factor. The pathophysiological mechanisms responsible for the association between obesity and cardiovascular disease remain largely unknown. However, it has been postulated that obese patients have an “inflammatory milieu” responsible for their metabolic disorders and vascular disease. In this context, adipocyte-derived molecules with inflammatory activity might play a pivotal role in the development of these mechanisms. In the present report, we provide an updated overview on the molecules produced by adipose tissue that are potentially involved in cardiovascular pathophysiology.

Tissue Factor/Factor FVII Complex Inhibitors in Cardiovascular Disease. Are Things Going Well?

Blood coagulation is a complex biological mechanism aimed to avoid bleeding in which a highly regulated and coordinated interplay of specific proteins and cellular components respond quickly to a vascular injury. However, when this mechanisms occurs in the coronary circulation, it has not a “protective” effect, but rather, it plays a pivotal role in determining acute coronary syndromes. Coagulation recognizes Tissue Factor (TF), the main physiological initiator of the extrinsic coagulation pathway, as its starter.

Since TF:VIIa complex is the critical point of the blood coagulation cascade, it is a pharmacological attractive issue for the development of agents with anti thrombotic properties that can exert their activity by inhibiting complex formation and/or its catalytic activity. In fact, it is intuitive that an antithrombotic agent able to inhibit this initial step of the coagulation pathway has several theoretical, extremely important, advantages if compared with drugs active downstream the coagulation pathway, such as FXa or thrombin. The present report gives a brief overview of TF pathophysiology, highlighting the most recent advances in the field of inhibitors of the complex TF/VIIa potentially useful in cardiovascular disease.