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OBJECTIVE: \ud This study aims to investigate the temporal trends in utilization of invasive coronary angiography (CA) at different time points and changing profiles of patients undergoing CA following non-ST-elevation acute coronary syndrome (NSTEACS). We also describe the association between timing of CA and in-hospital clinical outcomes.\ud \ud PATIENTS AND METHODS: \ud We queried the National Inpatient Sample to identify all admissions with a primary diagnosis of NSTEACS from 2004 to 2014. Patients were stratified into early (day 0, 1), intermediate (day 2) and late strategy (day≥3) according to timing of CA. Multivariable logistic regression was used to investigate the association between timing of CA and in-hospital mortality, major bleeding, stroke and Major Adverse Cardiac and Cerebrovascular Events. \ud \ud RESULTS: \ud A total of 4 380 827 records were identified with a diagnosis of NSTEACS, out of which 57.5% received CA. The proportion of patients undergoing early CA increased from 65.6 to 72.6%, whereas late CA commensurately declined from 19.6 to 13.5%. Patients receiving early CA were younger (age: 64 vs. 70 years), more likely to be male (63.7 vs. 55.3%) and of Caucasian ethnic background (68.7 vs. 64.7%) compared with late CA group. Similarly, Women, weekend admissions and African Americans remain less likely to receive early CA. In-hospital mortality was lowest in the intermediate group (odds ratio=0.30, 95% confidence interval: 0.28-0.33).\ud \ud CONCLUSION: Use of early CA has increased in the management of NSTEACS; however, there remain significant disparities in utilization of an early invasive approach in women, African Americans, admission day and older patients in the USA.

Objective Conversion to sternotomy is a primary bailout method for robotically assisted coronary artery bypass grafting procedures. The aims of this study were to identify the primary reasons for conversion from robotically assisted coronary artery bypass grafting to sternotomy and to evaluate the in-hospital outcomes in such patients. Methods Prospectively collected data from February 2004 to April 2017 were reviewed for 72 patients (56 men; mean age = 63.8 years) who required conversion to sternotomy during a robotically assisted coronary artery bypass grafting procedure with planned endoscopic left internal thoracic artery harvest and anastomosis to the left anterior descending on the beating heart. Results The overall rate of conversion was 12.4% (72/581). Conversions occurred either during attempted endoscopic left internal thoracic artery harvest (31.9%), during endoscopic left anterior descending isolation (40.3%), during manual isolation and anastomosis of the left anterior descending (19.4%), or after anastomosis due to unsatisfactory flow (8.3%). Overall, the most common reason for conversion was an intramyocardial left anterior descending (43.1%). The median stay in the intensive care unit was 1 day (range = 0–20) and the median hospital length of stay was 5 days (range = 3–43). In-hospital complications included new atrial fibrillation (16.7%), need for blood transfusion (20.8%), mediastinitis (4.2%), postoperative myocardial infarction (2.8%), exploration for bleeding (2.8%), and 1 in-hospital death. Conclusions The reasons for conversion were primarily related to anatomical factors that created difficulties for endoscopic left internal thoracic artery harvesting and left anterior descending identification. Patients who required conversion to sternotomy from robotically assisted coronary artery bypass grafting demonstrated acceptable outcomes and low complication rates.

Left-sided cardiac masses (LSCM) are a rare finding with an estimated incidence of between 0.002% to 0.2% in the general population [(1)][1]. Most are identified following symptoms related to cardiac or cerebrovascular systems or at postmortem examination [(2)][2]. Asymptomatic left heart masses are

Balloon aortic valvuloplasty (BAV) has historically been recommended prior to transcatheter aortic valve implantation (TAVI). Pre-implantation BAV (pBAV) creates fractures at the level of calcified leaflets, thereby facilitating delivery of the transcatheter valve system across the diseased aortic valve and, enhances prosthesis implantation and expansion within the calcified aortic valve annulus. New device designs, lower profile delivery systems and increasing operator experience have enabled direct-TAVI (without pBAV), and its appeal amongst TAVI operators enhanced the dissemination of a direct TAVI approach across many centres. In this review, we discuss contemporary evidence that inform the debate on the need for routine pBAV for TAVI candidates and present a framework that may assist operators in selecting patients for pBAV.

ObjectivesOur objectives were to review the literature to identify frailty instruments in use for transcatheter aortic valve implantation (TAVI) recipients and synthesise prognostic data from these studies, in order to inform clinical management of frail patients undergoing TAVI.MethodsWe systematically reviewed the literature published in 2006 or later. We included studies of patients with aortic stenosis, diagnosed as frail, who underwent a TAVI procedure that reported mortality or clinical outcomes. We categorised the frailty instruments and reported on the prevalence of frailty in each study. We summarised the frequency of clinical outcomes and pooled outcomes from multiple studies. We explored heterogeneity and performed subgroup analysis, where possible. We also used Grading of Recommendations, Assessment, Development and Evaluation (GRADE) to assess the overall certainty of the estimates.ResultsOf 49 included studies, 21 used single-dimension measures to assess frailty, 3 used administrative data-based measures, and 25 used multidimensional measures. Prevalence of frailty ranged from 5.67% to 90.07%. Albumin was the most commonly used single-dimension frailty measure and the Fried or modified Fried phenotype were the most commonly used multidimensional measures. Meta-analyses of studies that used either the Fried or modified Fried phenotype showed a 30-day mortality of 7.86% (95% CI 5.20% to 11.70%) and a 1-year mortality of 26.91% (95% CI 21.50% to 33.11%). The GRADE system suggests very low certainty of the respective estimates.ConclusionsFrailty instruments varied across studies, leading to a wide range of frailty prevalence estimates for TAVI recipients and substantial heterogeneity. The results provide clinicians, patients and healthcare administrators, with potentially useful information on the prognosis of frail patients undergoing TAVI. This review highlights the need for standardisation of frailty measurement to promote consistency.PROSPERO registration numberCRD42018090597.

The duration of red blood cell (RBC) storage may have a negative impact on endothelial nitric oxide bioavailability. We tested the hypothesis that transfused fresh blood will have a more favorable effect on microvascular endothelial function as compared to older standard issue blood.Participants requiring chronic RBC transfusions were enrolled in a crossover design study to receive fresh (7 days of storage) or standard (up to 42 days of storage) blood on 2 separate visits. Endothelial function was assessed by reactive hyperemia peripheral arterial tonometry that was measured before and after transfusions. For each participant, the difference between endothelial function pretransfusion and posttransfusion was assessed in relation to blood storage time.Twenty-one patients (71 ± 16 years, 52% females) were enrolled. Mean age of fresh blood was 5.5 days (±1.0), and that of standard blood was 24.5 days (±7.9 days). The pretransfusion hemoglobin was 83.1 ± 2.5 g/L; and posttransfusion, 98.9 ± 2.6 g/L. An average of 2 U of packed RBCs was transfused. Microvascular endothelial function decreased more frequently after transfusion of standard blood compared to fresh blood. Standard issue blood transfusion was associated with decrease in reactive hyperemia peripheral arterial tonometry index (-0.25 ± 0.63) compared to fresh blood (+0.03 ± 0.49); P = .026.Transfusions of standard issue blood are associated with less favorable effect on microvascular endothelial function as compared to fresh blood.

The Engager aortic bioprosthesis consists of bovine pericardial leaflets mounted on a self-expandable frame with unique anatomic orientation capabilities to engage the aortic valve cusps. We report the initial North American transcatheter aortic valve implantation (TAVI) experience with the Engager device. Transapical TAVI was performed in 4 patients (mean age 80 ± 6 years, Society of Thoracic Surgeons score 5 ± 1%). The valve was anatomically oriented and successfully implanted in all patients. There were no conversions to open operation or major procedure-related adverse events. Pacemaker implantation was necessary in 1 patient. None of the patients showed paravalvular leak. The Engager device for TAVI provides anatomic orientation and anchoring that prevents coronary obstruction and paravalvular leak.

Mitral valve-in-valve implantation can be performed in a reliable fashion with excellent short- and mid-term results [(1)][1]. However, the outcome of transcatheter mitral valve-in-ring (TMVIR) replacement using transcatheter aortic valve replacement devices has been far less predictable [(2,3)][2

Transcatheter aortic valve replacement (TAVR) in the presence of a mechanical mitral valve (MMV) prosthesis is challenging due to the stiff mitral cage in the boundaries of the aorto-mitral curtain. We describe the technique for TAVR using the ACURATE-neo™ aortic bioprosthesis in a patient with a MMV prosthesis.

Severe circumferential mitral annular calcification (MAC) remains a significant challenge complicating surgical treatment of mitral valve disease. Transcatheter treatment options are attractive however, remain fraught with risks of annular fixation, paravalvular leak, atrioventricular groove disruption, and left ventricular outflow tract obstruction. We describe a novel minimally invasive hybrid technique of transcatheter mitral valve replacement in a patient with severe circumferential MAC.

Radial artery occlusion is the most common complication following trans-radial approach (TRA) for cardiac catheterization. Our aim was to compare short durations of compression hemostatic device (CHD) application post TRA in patients not receiving anticoagulation. Patients (n=450) undergoing

The StatSeal (Biolife, Sarasota, FL, USA) is a hemostasis adjunct disc utilized in conjunction with a radial hemostatic band to reduce bleeding. We aimed to assess the safety and efficacy of using the StatSeal disc in patients undergoing coronary angiography through the radial approach without

First-generation drug-eluting stents (DES) were developed and indeed proved their superiority compared to bare-metal stent in minimizing neo-intimal hyperplasia and in-stent restenosis (ISR), overall, reducing target vessel revascularization (TVR). Newer-generation DES are characterized by thinner struts, more biocompatible and either durable, biodegradable or polymer-free surfaces, better device profile and refined drug elution. Area covered: The EluNIR

Over the last 15 years, we have seen a rapid and exponential uptake of transcatheter aortic valve implantation (TAVI) for the treatment of patients with severe symptomatic aortic stenosis (1). This uptake has also been coupled with the evolution and advancement in transcatheter valve technologies. As such, a number of new TAVI devices have also been marketed, mainly with the aim of diminishing problems faced with first generation devices; notably, smaller delivery systems, less incidence of paravalvular leak (PVL) or need for permanent pacemaker implantation (PPI) and other device- or procedural related complications (2,3).

INTRODUCTION The Lotus valve system (Boston Scientific, Marlborough, Massachusetts, USA) consists of a braided wire Nitinol™ frame with three bovine pericardial leaflets. The valve is deployed by controlled mechanical expansion which allows recapturing/repositioning and full retrievability. Areas covered: While this system offers a unique seal, which conforms to irregular surfaces, thereby minimizing paravalvular leak, its main downfall is a high rate of new pacemaker implantation. This had been partially addressed with the design of the Depth Guard™ mechanism to optimize deployment by early anchoring and limiting the depth of implant. Further developments in the Lotus valve's structure and design lay the foundations for the new Lotus Edge™ valve which is designed to maintain the benefits of the first-generation of the device, while improving deliverability and optimizing deployment with the aim to reduce pacemaker implantation rates. Expert commentary: Data from clinical trials show that TAVI with the Lotus valve system is associated with low rates of all-cause mortality and paravalvular leak although with high rates of permanent pacemaker requirement. Therefore, continuing modifications in device design such as the Lotus Edge™ valve with the addition of the Depth Guard™ are highly awaited with a view to decrease pacemaker rates.

Background: Transcatheter mitral valve replacement (TMVR) may mature to become a therapeutic option for high-risk patients with severe mitral regurgitation (MR), particularly in patients at high or prohibitive surgical risk. MR patients with preexisting aortic valve prosthesis have been excluded from most TMVR trials because of the potential risks of left ventricular outflow tract obstruction or interaction between the TMVR anchoring mechanism and the aortic prosthesis. We describe the procedural and short-term outcomes of transapical TMVR with the Tiara valve in patients experiencing severe symptomatic MR with previous aortic valve replacement (AVR). Methods and Results: Twelve consecutive high surgical risk patients (11 men; mean age, 75±6 years) with aortic valve prosthesis and severe MR underwent TMVR with Tiara valve. Aortic valves were mechanical in 5 and biological in 7 patients, while 1 patient had previously undergone implantation of a transcatheter valve within a failed bioprosthetic surgical valve. Six patients (50%) had undergone redo surgical aortic valve replacement. Clinical characteristics of the group include prior mitral valve repair in 2, prior coronary bypass grafting surgery in 5, chronic atrial fibrillation in 7, renal failure in 9, and pacemaker/cardiac resynchronization device in 9 patients. Mean Society of Thoracic Surgery score and EuroSCORE II were 10.5±4.4 and 12.4±3.7, respectively. Mean baseline left ventricular ejection fraction was 35.5±5.3% (range, 30%–45%). The Tiara valve was implanted uneventfully in all patients. Device migration or left ventricular outflow tract obstruction was not observed. No patient required conversion to open heart surgery or periprocedural hemodynamic support. Procedural success was 100% with no death, MI, stroke, major bleeding, or access site complications at 30 days. MR was eliminated in all 12 patients immediately after implantation. Conclusions: Transapical mitral valve replacement with the Tiara valve in high-risk patients with severe MR and aortic valve prostheses is technically feasible and can be performed safely.

The aim of this study was to describe the rates and causes of unplanned readmissions at different time periods following percutaneous coronary intervention (PCI).The rates and causes of readmission at different time periods after PCI remain incompletely elucidated.Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for the rates, causes, predictors, and costs of unplanned readmission between 0 and 7 days, 8 and 30 days, 31 and 90 days, and 91 and 180 days after index discharge.This analysis included 2,412,000 patients; 2.5% were readmitted between 0 and 7 days, 7.6% between 8 and 30 days, 8.9% between 31 and 90 days, and 8.0% between 91 and 180 days (cumulative rates 2.5%, 9.9%, 18.0%, and 24.8%, respectively). The majority of readmissions during each time period were due to noncardiac causes (53.1% to 59.6%). Nonspecific chest pain was the most common identifiable noncardiac cause for readmission during each time period (14.2% to 22.7% of noncardiac readmissions). Coronary artery disease including angina was the most common cardiac cause for readmission during each time period (37.4% to 39.3% of cardiac readmissions). The second most common cardiac cause for readmission was acute myocardial infarction between 0 and 7 days (27.6% of cardiac readmissions) and heart failure during all subsequent time periods (22.2% to 23.7% of cardiac readmissions).Approximately 25% of patients following PCI have unplanned readmissions within 6 months. Causes of readmission depend on the timing at which they are assessed, with noncardiovascular causes becoming more important at longer time points.

Background Aortic stenosis (AS) is a common valvular abnormality and transcatheter aortic valve implantation (TAVI) is being increasingly used to treat patients considered too high risk for conventional surgery. We aimed to assess the prevalence of comorbid conditions in patients undergoing TAVI using the Charlson Comorbidity Index (CCI) and to assess their impact on clinical and procedural outcomes. Methods We analysed 158 patients who underwent a TAVI at our institution between June 2009 and September 2015 to define their co-morbid burden as measured with CCI, and study its impact on procedural characteristics and mortality at 30 days. Results One hundred fifty-eight (158) patients with a mean age of 82 ± 8 years and a mean CCI score of 2.67 underwent a TAVI. Only 12/158 patients had a CCI of 0. The commonest cardiovascular comorbidities were previous myocardial infarction (24%), congestive heart failure (15%) and diabetes mellitus (23%) whilst the commonest non-cardiovascular comorbidities were renal disease (46%) and chronic obstructive pulmonary disease (COPD) (29%). After multivariable adjustment, CCI was not independently associated with adverse clinical outcomes. The addition of CCI to scoring systems such as Logistic EuroScore (LES) and Society of Thoracic Surgeons (STS) risk models improved the area under the curve from 0.75 (95%CI: 0.44–1.00) and 0.83 (95%CI: 0.64–1.00) to 0.78 (95%CI: 0.53–1.00) and 0.89 (95%CI: 0.78–1.00) respectively. Conclusions The burden of comorbid conditions in patients undergoing TAVI is significant. The CCI score was not independently associated with a higher risk of death but can be useful in addition to LES and STS risk models in informing decision making on the selection of patients for TAVI.

Objectives: This study aimed to evaluate discharge against medical advice (DAMA) in percutaneous coronary intervention (PCI) and how DAMA affects readmissions. Background: DAMA is infrequent but associated with poor patient outcomes. DAMA in the context of PCI has not been described in the published reports. Methods: The authors analyzed patients in the Nationwide Readmission Database between 2010 and 2014 with a PCI procedure who were either discharged home or against medical advice. The primary endpoint was all-cause 30-day readmissions and their causes. Descriptive statistics were used to compare DAMA with patients discharged home, and multiple logistic regressions were used to determine patient characteristics associated with DAMA and readmission. Results: Among the 2,021,104 patients in the analysis, the proportion of patients who DAMA was 0.5% (n = 10,049). The 30-day readmission rate for patients who were DAMA and those discharged home was 16.8% and 8.5%, respectively (p < 0.001). Important predictors of DAMA included diagnosis of acute myocardial infarction (odds ratio [OR]: 1.37; 95% confidence interval [CI]: 1.25 to 1.51; p < 0.001), smoking (OR: 1.71; 95% CI: 1.57 to 1.86; p < 0.001), drug abuse (OR: 1.82; 95% CI: 1.60 to 2.06; p < 0.001), and alcohol misuse (OR: 1.53; 95% CI: 1.32 to 1.78; p < 0.001). DAMA was the strongest predictor for readmission (OR: 1.89; 95% CI: 1.71 to 2.08; p < 0.001). DAMA patients were more likely to have neuropsychiatric reasons for noncardiac causes of readmission (8.3% vs. 2.4%) and acute myocardial infarction for cardiac causes of readmission (39.4% vs. 19.5%) compared with patients discharged home. Conclusions: DAMA occurs in approximately 0.5% of patients following PCI and is strongly associated with readmission within 30 days. Interventions should be developed to reduce DAMA in high-risk groups and initiate interventions to avoid complications and readmission when it occurs.

Aims\ud Coronary angiography and intervention to saphenous venous grafts (SVGs) remains challenging. This study aimed to investigate the feasibility and safety of the radial approach compared to femoral access in a large cohort of patients undergoing SVG angiography and intervention.\ud \ud Methods and Results\ud Data from 1481 patients from Canada, United States and Spain who underwent procedures between 2010 and 2016 were collected. Patients must have undergone SVG coronary angiography and/or intervention. Demographics, procedural data and in-hospital complications were recorded. Procedures were undertaken by either the radial (n=863, 211 intervention) or femoral (n=618, 260 intervention) approach. The mean number of SVGs per-patient was similar between groups (radial 2.3±0.7 versus femoral 2.6±1.1, P=0.61) but the radial group required a fewer number of catheters (2.6±1.7 versus 4.1±1.1, P

Background: Aspirin therapy improves saphenous vein graft (SVG) patency in patients undergoing coronary artery bypass graft (CABG), however, its use in the pre-operative period remains controversial. Therefore, we conducted a systematic review and meta-analysis of randomized-controlled trials (RCTs) to update the evidence about risk and benefits of pre-operative aspirin therapy in patients undergoing CABG. Methods: Electronic databases (Medline, Embase, PubMed, Cochrane Library, and Scopus) were searched to identify RCTs evaluating the effect of aspirin versus placebo/control before CABG. Two investigators independently and in duplicate screened citations and extracted data and rated the risk of bias. The strength of evidence was appraised using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Meta-analysis was performed using a random-effects model. The main outcomes of interest were 30-day mortality, peri-operative myocardial infarction (MI), chest tube drainage and SVG occlusion. Results: A total of 13 RCTs involving 4,377 participants (2,266/2,111 pre-operative aspirin/control) met the inclusion criteria. Pre-operative aspirin reduced the risk of SVG occlusion [risk ratio (RR): 0.69, 95% confidence interval (CI): 0.49–0.97, P=0.03, I 2 =16%], but no differences in mortality (RR: 1.41, 95% Cl: 0.73–2.74, I 2 =0%) and MI (RR: 0.84, 95% CI: 0.69–1.03, I 2 =0%) were found. However, pre-operative aspirin increased chest tube drainage (MD: 100.40 mL, 95% CI: 24.32–176.47 mL, P=0.01, I 2 =84%) and surgical re-exploration (RR: 1.52, 95% CI: 1.02–2.27, P=0.04, I 2 =8%), with no significant difference in RBC transfusion (RR: 1.06, 95% CI: 0.90–1.25, I 2 =35%). Conclusions: Based on trials where the rated body of evidence was of low to very-low quality, pre-operative aspirin improves SVG patency but increases chest tube drainage and need for surgical re-exploration.

Women who undergo percutaneous coronary intervention (PCI) are at higher risk of adverse outcomes compared with men, but it is unknown whether gender affects early unplanned rehospitalization. We analyzed 832,753 patients who underwent PCI from 2013 to 2014 in the Nationwide Readmissions Database. We compared gender differences in incidences, predictors, causes, and cost of unplanned 30-day readmissions and examined the effect of co-morbidity. A total of 832,753 men and women who survived the index PCI and were not admitted for a planned readmission were included in the analysis. Overall, 9.4% of patients had an unplanned readmission within 30 days. Thirty-day readmission rates were higher in women compared with men (11.5% vs 8.4%, p

This study sought to assess the clinical outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) with early discharge (ED) versus standard discharge (SD) pathways.Minimalist approaches for TAVR have been developed targeting different aspects of the procedure such as local anesthesia or sedation, intraprocedural imaging, vascular access, post-operative monitoring and care, and discharge planning. Their incorporation into routine clinical practice aims to reduce length of hospital stay and health care cost utilization without adversely affecting outcomes when compared with standard approaches.The authors conducted a search of MEDLINE and EMBASE to identify studies that investigated ED (≤3 days) versus SD in TAVR patients. Random-effects meta-analyses were used to estimate the effect of ED compared with SD with regard to 30-day mortality after discharge, 30-day readmission rate, and need for permanent pacemaker implantation (PPI) following discharge.Eight studies including 1,775 participants (ED, n = 642) fulfilled the inclusion criteria. The mean age was 82.4 years and STS score was 6.7. Meta-analyses evaluating discharge to 30-day mortality (odds ratio [OR]: 0.65; 95% confidence interval [CI]: 0.23 to 1.82; IED following uncomplicated TAVR is safe in terms of discharge to 30-day mortality or need for PPI following discharge. Moreover, ED patients experienced a lower rate of readmissions. These data support the safety of programs aiming an ED pathway in selected TAVR patients. Institutional protocols with the input from different members of the multidisciplinary heart team should be devised to optimize discharge processes to improve health care resource utilization.

Objectives There are substantial potential benefits to noninvasive cardiac monitoring methods, such as electrical cardiometry (EC), over more invasive methods, including significantly reduced risk of complications, lower up-front and operational costs, ease of use, and continuous monitoring. To take advantage of these technologies, clinical equivalence to currently established methods must be determined. The authors sought to determine if the noninvasive measurement of cardiac index (CI) by EC was clinically equivalent to thermodilution (TD) in adult patients with aortic stenosis (AS). Design This is a cross-sectional study comparing measurement devices in a single patient group. Setting Single-center, university teaching hospital. Participants The study included 52 adult patients with aortic stenosis undergoing right heart catheterization. Interventions Cardiac output (CO) was measured concurrently using EC with an ICON device and TD in 52 participants with AS. CI values were to determine the accuracy and precision of EC in reference to TD. Percentage error (PE) was used to assess their clinical equivalence. The participants were divided further into groups (normal and overweight/obese) based on body mass index and the analysis was repeated. Measurements and Main Results CO measurement made by EC in adult patients with obesity or overweight was reduced significantly relative to TD. This was not observed in normal-weight adult AS patients. EC provided clinically equivalent measurements to TD for measuring CI in normal-weight adult AS patients (PE = 25.0%), but not for those adult AS patients with overweight or obesity (PE = 42.3%). Conclusion Overall, the ICON device produced lower CO and index measurements relative to TD in adult patients with AS. Overweight and obesity also significantly affected the relative precision and accuracy of the ICON electrical cardiometric device to measure CI in these patients.

Background— Retroperitoneal hemorrhage (RH) is a rare bleeding complication of percutaneous coronary intervention, which can result as a consequence of femoral access or can occur spontaneously. This study aims to evaluate temporal changes in RH, its predictors, and clinical outcomes in a national cohort of patients undergoing percutaneous coronary intervention in the United Kingdom. Methods and Results— We analyzed RH events in patients who underwent percutaneous coronary intervention between 2007 and 2014. Multiple logistic regression models were used to identify factors associated with RH and to quantify the association between RH and 30-day mortality and major adverse cardiovascular events. A total of 511 106 participants were included, and 291 in hospital RH events were recorded (0.06%). Overall, rates of RH declined from 0.09% to 0.03% between 2007 and 2014. The strongest independent predictors of RH events were femoral access (odds ratio [OR], 19.66; 95% confidence interval [CI], 11.22–34.43), glycoprotein IIb/IIIa inhibitor (OR, 2.63; 95% CI, 1.99–3.47), and warfarin use (OR, 2.53; 95% CI, 1.07–5.99). RH was associated with a significant increase in 30-day mortality (OR, 3.59; 95% CI, 2.19–5.90) and in-hospital major adverse cardiovascular events (OR, 5.76; 95% CI, 3.71–8.95). A legacy effect was not observed; patients with RH who survived 30 days did not have higher 1-year mortality compared with those without this complication (hazard ratio, 0.97; 95% CI, 0.49–1.91). Conclusions— Our results suggest that RH is a rare event that is declining in the United Kingdom, related to transition to transradial access site utilization, but remains a clinically important event associated with increased 30-day mortality but no long-term legacy effect.

[This corrects the article DOI: 10.21037/jtd.2018.05.187.].

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© Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved., Left ventricular endomyocardial biopsy (LV-EMB) may offer a superior diagnostic yield compared with right ventricular endomyocardial biopsy (RV-EMB) in conditions predominantly affecting the LV but is underused compared with RV-EMB. Despite the steep uptake of radial approach in coronary interventions, LV-EMB is usually performed via the femoral artery in contemporary practice. Therefore, the aim of this study was to assess the safety and feasibility of LV-EMB via a transradial approach in a multicentre registry., Contexte La biopsie endomyocardique du ventricule gauche (BEM-VG) peut offrir un rendement diagnostique supérieure à celui de la BEM du ventricule droit (BEM-VD) dans des troubles qui touchent principalement le ventricule gauche (VG), mais est sous-utilisée par rapport à la BEM-VD. Malgré l’augmentation rapide de l’utilisation de la voie radiale dans les interventions coronariennes, la BEM-VG s’effectue en général par l’artère fémorale dans la pratique contemporaine. Par conséquent, l’objectif de cette étude était d’évaluer, à partir d’un registre multicentrique, la sûreté et la faisabilité de la BEM-VG par la voie transradiale. Méthodologie Cent deux patients qui avaient subi une BEM-VG par l’approche transradiale ont été inclus. Les caractéristiques cliniques et les données relatives à l’intervention, à l’innocuité et à la faisabilité ont été analysées. Résultats La BEM-VG a été effectuée avec succès par la voie transradiale chez 101 (99 %) patients. Spasme radiale légère ou modérée s’est produit chez 12 (12 %) patients, mais la conversion en voie fémorale n’a été nécessaire que chez 1 (0,98 %) patient en raison d’un spasme sévère. Au total, 80 (78 %) patients ont subi une BEM-VG au moyen d’un cathéter guide sans gaine d’introducteur (sheathless). Pour ces interventions, le diamètre externe du guide sans gaine d’introducteur inséré était de 7,5 French chez 77 (96,3 %) patients et de 8,5 French chez 3 (3,8 %) patients. Un introducteur radiale a été utilisé chez les 22 autres patients, d’un diamètre externe de 5 French chez 21 de ces derniers. Une dose médiane de 5000 (3000–5000) unités internationales (UI) d’héparine a été administrée à 93,1 % des patients. Pour les autres patients, une stratégie provisoire a été appliquée en fonction de l’obtention d’une hémostase manifeste. Aucune complication liée à la voie d’accès n’a été rapportée. Il n’y a eu aucune complication majeure (tamponnade péricardique, arythmie potentiellement mortelle, accident vasculaire cérébral ou décès). Conclusion Dans une population de patients ayant subi une BEM-VG par la voie transradiale, le taux de succès de l’intervention a été élevé et présentait un excellent profil d’innocuité. Des études ultérieures portant sur la comparaison des voies transradiale et transfémorale pourraient être utiles pour contribuer à populariser le recours à la voie transradiale dans les BEM-VG.

Coronary artery disease (CAD) is common among patients undergoing transcatheter aortic valve implantation (TAVI) with a prevalence of up to 75%, and no clear recommendations around its treatment (1) and conflicting evidence around whether to perform coronary revascularization or not. Moreover, the role of revascularization on long-term morbidity and mortality is still not clear in octogenarians (2).

ObjectivesTo investigate the association of the CharlsonComorbidity Index (CCI) with clinical outcomes after transcatheter aortic valve implantation (TAVI).BackgroundPatients undergoing TAVI have high comorbid burden; however, there is limited evidence of its impact on clinical outcomes.MethodsData from 1887 patients from the UK, Canada, Spain, Switzerland and Italy were collected between 2007 and 2016. The association of CCI with 30-day mortality, Valve Academic Research Consortium-2 (VARC-2) composite early safety, long-term survival and length of stay (LoS) was calculated using logistic regression and Cox proportional hazard models, as a whole cohort and at a country level, through a two-stage individual participant data (IPD) random effect meta-analysis.ResultsMost (60%) of patients had a CCI ≥3. A weak correlation was found between the total CCI and four different preoperative risks scores (ρ=0.16 to 0.29), and approximately 50% of patients classed as low risk from four risk prediction models still presented with a CCI ≥3. Per-unit increases in total CCI were not associated with increased odds of 30-day mortality (OR 1.09, 95% CI 0.96 to 1.24) or VARC-2 early safety (OR 1.04, 95% CI 0.96 to 1.14) but were associated with increased hazard of long-term mortality (HR 1.10, 95% CI 1.05 to 1.16). The two-stage IPD meta-analysis indicated that CCI was not associated with LoS (HR 0.97, 95% CI 0.93 to 1.02).ConclusionIn this multicentre international study, patients undergoing TAVI had significant comorbid burden. We found a weak correlation between the CCI and well-established preoperative risks scores. The CCI had a moderate association with long-term mortality up to 5 years post-TAVI.

The risk and benefit ratio of glycoprotein IIb/IIIa inhibitors with dual oral antiplatelet therapy after failed thrombolysis and rescue percutaneous coronary intervention (PCI) is unclear. Using a randomized placebo-controlled, double-blind design, we compared intravenous (IV) and intracoronary (IC) abciximab delivery in 74 patients referred for rescue transradial PCI. The primary angiographic end points were the final thrombolysis in myocardial infarction flow and myocardial blush grades. Secondary end points included acute and 6-month outcomes using angiographic parameters, platelet aggregation parameters, cardiac biomarkers, cardiac magnetic resonance measurements (CMR) and clinical end points. After rescue PCI, normal thrombolysis in myocardial infarction 3 flows were obtained in 70% in the IC group, 48% in the IV group, and 71% in the placebo group, respectively (p = 0.056). Final myocardial blush grades 2 and 3 were obtained in 43% and 39% in the IC group, 48% and 26% in the IV group, and 46% and 42% in the placebo group (p = 0.67), respectively. Acutely, peak release of cardiac biomarkers, necrosis size, myocardial perfusion and no-reflow as assessed by CMR, and clinical end points were similar between the groups and did not suggest a benefit for IC or IV abciximab compared with placebo. There was no increase in bleeding or access site-related complications with abciximab compared with placebo. Clinical, angiographic, and CMR outcomes at 6 months remained comparable between the groups. In patients with ST-elevation myocardial infarction presenting with failed thrombolysis undergoing transradial rescue PCI, IC or IV abciximab had no significant clinical impact.

A 77-year-old man presented with severe symptomatic aortic stenosis. He had multiple comorbidities, including significant chronic obstructive pulmonary disease and severe peripheral vascular disease. Doppler echocardiography demonstrated a heavily calcified and severely stenotic aortic valve, with a

BACKGROUND The use of radial approach for coronary angiography, followed by same-day inter-facility transfer for percutaneous coronary intervention (PCI) has not yet been evaluated. OBJECTIVES We sought to assess the safety and feasibility of using the transradial as compared to the transfemoral approach in patients undergoing diagnostic angiogram with same-day transfer to a PCI facility. METHODS Patients that underwent diagnostic coronary angiography between January 2011 and June 2017 in a referring facility, and were transferred for same-day PCI were included. Patients' demographics, as well as procedural data and in-hospital outcome, were collected. RESULTS Three hundred fifty-two participants were included. Of these, 36 (10.2%) patients received transradial access. Patients in the transradial group were older (68 ± 10 vs 62 ± 12 years, P = 0.007), and received a significantly higher total dose of heparin including both, diagnostic and PCI procedures (5935 ± 1865 vs 10029 ± 2771 units, P

This study aimed to examine the 30-day unplanned readmissions rate, predictors of readmission, causes of readmissions, and clinical impact of readmissions after percutaneous coronary intervention (PCI).Unplanned rehospitalizations following PCI carry significant burden to both patients and the local health care economy and are increasingly considered as an indicator of quality of care.Patients undergoing PCI between 2013 and 2014 in the U.S. Nationwide Readmission Database were included. Incidence, predictors, causes, and cost of 30-day unplanned readmissions were determined.A total of 833,344 patients with PCI were included, of whom 77,982 (9.3%) had an unplanned readmission within 30 days. Length of stay for the index PCI was greater (4.7 vs. 3.9 days) and mean total hospital cost ($23,211 vs. $37,524) was higher for patients who were readmitted compared with those not readmitted. The factors strongly independently associated with readmissions were index hospitalization discharge against medical advice (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.65 to 2.22), transfer to short-term hospital for inpatient care (OR: 1.62; 95% CI: 1.38 to 1.90), discharge to care home (OR: 1.57; 95% CI: 1.51 to 1.64), and chronic kidney disease (OR: 1.50; 95% CI: 1.44 to 1.55). Charlson Comorbidity Index score (OR: 1.28; 95% CI: 1.27 to 1.29) and number of comorbidities (OR: 1.18; 95% CI: 1.17 to 1.18) were independently associated with unplanned readmission. The majority of readmissions were due to noncardiac causes (56.1%).Thirty-day readmissions after PCI are relatively common and relate to baseline comorbidities and place of discharge. More than one-half of the readmissions were due to noncardiac causes.

Surgical aortic valve replacement (SAVR) has historically been the treatment of choice for patients with severe symptomatic aortic stenosis (AS). More recently, transcatheter aortic valve implantation (TAVI) has become a well-established alternative option for patients considered at high and intermediate preoperative surgical risk. TAVI provides effective relief of valve obstruction with excellent immediate and short-term outcomes. However, long-term (ie >10 years) durability of TAVI, relative to the known durability of surgical bioprosthetic valves,1 also needs to be considered. Indeed, there is, up to now, very few data addressing durability of TAVI beyond 5 years,2 which is particularly important in younger patients and those with few comorbidities who have many remaining expected years of life. Hence, long-term structural valve degeneration/deterioration (SVD) has become an important issue for patients and physicians making an informed decision between the choice of TAVI and SAVR bioprostheses. Two different mechanisms have been described for bioprosthetic valve failure. Structural valve deterioration/degeneration refers to acquired intrinsic changes of the prosthesis and includes leaflet calcification, leaflet tear, stent fracture or creep, and suture line disruption.3 4 Non-structural deterioration/degeneration includes prosthesis-patient mismatch (PPM), valve thrombosis, pannus ingrowth, paravalvular leakage (PVL) and endocarditis (figure 1). SVD due to progressive deterioration of valve leaflet tissue is the most common cause of surgical bioprostheses failure. A recent systematic review1 of 93 studies including 53 884 (age 53–92 years) patients with AS that focused on prognosis after SAVR with bioprosthetic valves showed that the median survival among those aged ≤65, 65–75, 75–85 and ≥85 years was 16, 12, 7 and 6 years, respectively. Importantly, the freedom from reoperation for valve dysfunction at 10, 15 and 20 years was 94%, 81.7% and 52%, respectively.1 Figure 1 Structural valve deterioration. Schematic drawing showing examples of structural and non-structural valve deterioration with a surgical or transcatheter bioprosthetic valve. The normal …

Axillary access for an intra-aortic balloon pump allows patients with advanced heart failure (HF) to sit upright and ambulate while waiting for destination therapy or bridging to heart transplantation. We describe the combination of radial access for positioning a 4F pigtail catheter to allow axillary angiography and provide a target for a micropuncture needle entry point in a fully anticoagulated patient with advanced HF.

To assess the predictive value of Pd/Pa after nitroglycerin administration (Pd/Pa[N]) as compared with standard fractional flow reserve (FFR).Consecutive patients with intermediate coronary lesions assessed by FFR between January 2014 and October 2015 were included. We measured Pd/Pa at baseline, Pd/Pa(N), and Pd/Pa after incremental doses of intracoronary adenosine.A total of 134 patients (27% females; mean age, 65 years) were included. The diagnostic performance of Pd/Pa(N) and identification of cut-off value for Pd/Pa(N) compared with FFR threshold of 0.8 using receiver-operating characteristic (ROC) area under the curve analysis was between 0.98 (95% confidence interval, 0.95-1.00; P.05) for 48 μg and 0.86 (95% confidence interval, 0.79-0.94; P.05) for 240 μg adenosine. Pd/Pa(N) ≤0.8 had 100% positive predictive value. Pd/Pa(N) ≥0.94 provided 100% negative predictive value with a high sensitivity (92%). Optimal diagnostic accuracy of Pd/Pa(N) was achieved for values ≤0.84. The Pearson's correlation between Pd/Pa(N) and FFR varied between 0.89 for 24 μg adenosine and 0.77 for 240 μg (P.01).Pd/Pa(N) values can be used for diagnosis of hemodynamically significant lesions. Pd/Pa(N) correlates well with standard FFR. Pd/Pa(N) cut-off of ≤0.8 can be considered significant without need for adenosine injection. The value of using adenosine whenever Pd/Pa(N) is ≥0.94 is limited.

Background: The safety and efficacy of a novel cobalt alloy-based coronary stent with a durable elastomeric polymer eluting the antiproliferative agent ridaforolimus for treatment of patients with coronary artery disease is undetermined. Methods: A prospective, international 1:1 randomized trial was conducted to evaluate in a noninferiority design the relative safety and efficacy of ridaforolimus-eluting stents (RESs) and slow-release zotarolimus-eluting stents among 1919 patients undergoing percutaneous coronary intervention at 76 centers. Inclusion criteria allowed enrollment of patients with recent myocardial infarction, total occlusions, bifurcations lesions, and other complex conditions. Results: Baseline clinical and angiographic characteristics were similar between the groups. Overall, mean age was 63.4 years, 32.5% had diabetes mellitus, and 39.7% presented with acute coronary syndromes. At 12 months, the primary end point of target lesion failure (composite of cardiac death, target vessel-related myocardial infarction, and target lesion revascularization) was 5.4% for both devices (upper bound of 1-sided 95% confidence interval 1.8%, P noninferiority =0.001). Definite/probable stent thrombosis rates were low in both groups (0.4% RES versus 0.6% zotarolimus-eluting stent, P =0.75); 13-month angiographic in-stent late lumen loss was 0.22±0.41 mm and 0.23±0.39 mm ( P noninferiority =0.004) for the RES and zotarolimus-eluting stent groups, respectively, and intravascular ultrasound percent neointimal hyperplasia was 8.10±5.81 and 8.85±7.77, respectively ( P noninferiority =0.01). Conclusions: In the present trial, which allowed broad inclusion criteria, the novel RESs met the prespecified criteria for noninferiority compared with zotarolimus-eluting stents for the primary end point of target lesion failure at 12 months and had similar measures of late lumen loss. These findings support the safety and efficacy of RESs in patients who are representative of clinical practice. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01995487.

Purpose We implemented and validated a compressed sensing (CS) based algorithm for reconstructing dynamic contrast-enhanced (DCE) CT images of the heart from sparsely sampled X-ray projections. Methods DCE CT imaging of the heart was performed on five normal and ischemic pigs after contrast injection. DCE images were reconstructed with filtered backprojection (FBP) and CS from all projections (984-view) and 1/3 of all projections (328-view), and with CS from 1/4 of all projections (246-view). Myocardial perfusion (MP) measurements with each protocol were compared to those with the reference 984-view FBP protocol. Results Both the 984-view CS and 328-view CS protocols were in good agreements with the reference protocol. The Pearson correlation coefficients of 984-view CS and 328-view CS determined from linear regression analyses were 0.98 and 0.99 respectively. The corresponding mean biases of MP measurement determined from Bland-Altman analyses were 2.7 and 1.2ml/min/100g. When only 328 projections were used for image reconstruction, CS was more accurate than FBP for MP measurement with respect to 984-view FBP. However, CS failed to generate MP maps comparable to those with 984-view FBP when only 246 projections were used for image reconstruction. Conclusion DCE heart images reconstructed from one-third of a full projection set with CS were minimally affected by aliasing artifacts, leading to accurate MP measurements with the effective dose reduced to just 33% of conventional full-view FBP method. The proposed CS sparse-view image reconstruction method could facilitate the implementation of sparse-view dynamic acquisition for ultra-low dose CT MP imaging.

Background Recent recommendations suggest that in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation and coexistent significant coronary artery disease, the latter should be treated before the index procedure; however, the evidence basis for such an approach remains limited. We performed a systematic review and meta‐analysis to study the clinical outcomes of patients with coronary artery disease who did or did not undergo revascularization prior to transcatheter aortic valve implantation. Methods and Results We conducted a search of Medline and Embase to identify studies evaluating patients who underwent transcatheter aortic valve implantation with or without percutaneous coronary intervention. Random‐effects meta‐analyses with the inverse variance method were used to estimate the rate and risk of adverse outcomes. Nine studies involving 3858 participants were included in the meta‐analysis. Patients who underwent revascularization with percutaneous coronary intervention had a higher rate of major vascular complications (odd ratio [OR]: 1.86; 95% confidence interval [CI], 1.33–2.60; P =0.0003) and higher 30‐day mortality (OR: 1.42; 95% CI, 1.08–1.87; P =0.01). There were no differences in effect estimates for 30‐day cardiovascular mortality (OR: 1.03; 95% CI, 0.35–2.99), myocardial infarction (OR: 0.86; 95% CI, 0.14–5.28), acute kidney injury (OR: 0.89; 95% CI, 0.42–1.88), stroke (OR: 1.07; 95% CI, 0.38–2.97), or 1‐year mortality (OR: 1.05; 95% CI, 0.71–1.56). The timing of percutaneous coronary intervention (same setting versus a priori) did not negatively influence outcomes. Conclusions Our analysis suggests that revascularization before transcatheter aortic valve implantation confers no clinical advantage with respect to several patient‐important clinical outcomes and may be associated with an increased risk of major vascular complications and 30‐day mortality. In the absence of definitive evidence, careful evaluation of patients on an individual basis is of paramount importance to identify patients who might benefit from elective revascularization.

Background Transcatheter aortic valve implantation (TAVI), widely used to treat high-risk patients with severe symptomatic aortic stenosis, has recently been extended to younger patients at lower operative risk in whom long-term durability of TAVI devices is an important concern. Therefore, we conducted a systematic review and meta-analysis of observational studies addressing the frequency of structural valve deterioration (SVD) after TAVI. Methods We searched Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to September 2016. We included observational studies following patients with TAVI for at least 2 years. Independently and in duplicate, we evaluated study eligibility, extracted data, and assessed risk of bias for SVD post-TAVI. Our review used the GRADE system to assess quality of evidence. We pooled incidence rates using a random effects model. Results Thirteen studies including 8914 patients, with a median follow-up between 1.6 and 5 years, reported an incidence of SVD post-TAVI between 0 to 1.34 per 100 patient years. The pooled incidence of SVD was 28.08 per 10 000 patients/year (95% CI 2.46 to 73.44 per 100 patient years). Of those who developed SVD, 12% underwent valve re-intervention. Confidence in the evidence was moderate due to inconsistency among studies. Conclusion Structural valve deterioration is probably an infrequent event within the first 5 years after TAVI. Ascertaining the impact of SVD and the need for valve-related re-interventions to inform recommendations for patients with a longer life-expectancy will require studies including a large number of patients with longer follow-up (>10 years).