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Transcatheter aortic valve replacement (TAVR) has emerged as a life-saving and effective alternative to surgical valve replacement in high-risk, elderly patients with severe calcific aortic stenosis. Despite its early promise, certain limitations and adverse events, such as suboptimal placement and valve migration, have been reported. In the present study, it was aimed to evaluate the effect of various TAVR deployment locations on the procedural outcome by assessing the risk for valve migration. The deployment of a balloon-expandable Edwards SAPIEN valve was simulated via finite element analysis in a patient-specific calcified aortic root, which was reconstructed from CT scans of a retrospective case of valve migration. The deployment location was parametrized in three configurations and the anchorage was quantitatively assessed based on the contact between the stent and the native valve during the deployment and recoil phases. The proximal deployment led to lower contact area between the native leaflets and the stent which poses higher risk for valve migration. The distal and midway positions resulted in comparable outcomes, with the former providing a slightly better anchorage. The approach presented might be used as a predictive tool for procedural planning in order to prevent prosthesis migration and achieve better clinical outcomes.

Objectives The aim of this study was to determine the impact of pre-existing right bundle branch block (RBBB) on clinical outcomes after transcatheter aortic valve replacement (TAVR). Background The impact of pre-existing RBBB on clinical outcomes after TAVR is unknown. Methods Between October 2013 and August 2015, 749 patients undergoing TAVR using the Edwards SAPIEN XT prosthesis were prospectively enrolled in the OCEAN-TAVI (Optimized Transcatheter Valvular Intervention) registry from 8 Japanese centers. Electrocardiograms were obtained at baseline. After the procedure, follow-up outpatient visits or telephone interviews were conducted at 30 days, 6 months, and yearly. Results A total of 102 patients (13.6%) had pre-existing RBBB. The incidence of new pacemaker implantation was significantly higher in the RBBB group (17.6% vs. 2.9%; p Conclusions Patients with RBBB demonstrated an increased risk for cardiovascular mortality after TAVR, and patients with RBBB and without pacemakers were at higher risk for cardiac death early after discharge. Patients with prior RBBB should be carefully monitored after undergoing TAVR.

Underfilling or overfilling of balloon-expandable transcatheter heart valves (THVs) during transcatheter aortic valve implantation (TAVI) is commonly used to improve conformity to small or calcified annuli in order to avoid serious complications. However, little is known about this technique. This study assessed the effects of underfilling and overfilling of THVs.Data from 213 consecutive TAVI patients treated with balloon-expandable THVs in 4 Japanese centers between October 2013 and December 2014 were prospectively analyzed; 23-mm and 26-mm THVs were implanted in 96 cases (56 underfilling, 22 nominal filling, and 18 overfilling) and 38 cases (23 underfilling and 15 nominal filling), respectively. Pre/postprocedural multidetector computed tomography (MDCT) and echocardiographic data were compared. MDCT revealed that the minimum area of the underfilled 23-mm THVs was significantly decreased compared to that of nominal filled and overfilled THVs (308.3 SD 26.1 vs. 333.9 SD 14.7 vs. 347.8 SD 21.3mm(2), respectively, p0.0001); analogous results were demonstrated for underfilled 26-mm THVs compared to nominal filled THVs (386.2 SD 34.6 vs. 423.6 SD 17.3mm(2), respectively, p=0.0004). The postprocedural transvalvular gradient of underfilled 23-mm THVs was significantly higher than that of nominal filled and overfilled THVs, while there were no differences for 26-mm THVs.Underfilling or overfilling of THVs is safe and feasible, conforming to the original annulus and covering a continuous range of annular sizes with limited THV size options. However, care should be taken when underfilling 23-mm THVs due to the potential for increased transvalvular gradient.

Currently, there are no recommendations regarding the selection of valve type for a transcatheter heart valve (THV)-in-THV procedure. A supra-annular valve design may be superior in that it results in a larger effective orifice area and may have a lower chance of valve thrombosis after THV-in-THV. In this report, we describe the use of a supra-annular valve strategy for an early degenerated THV.

BACKGROUND The SAPIEN 3 (S3) addresses several limitations of the SAPIEN XT (SXT) for the performance of transfemoral (TF-) balloon expandable transcatheter aortic valve implantation (TAVI). OBJECTIVES We aimed to determine whether their altered features translate into improved outcomes in a real-world TF-TAVI patient population. METHODS Data for 3,314 patients were extracted from the European registries SOURCE-XT and SOURCE-3. Patients were propensity-score (PS) matched (n = 1,169/group). RESULTS In the PS matched comparison, device success was higher in the S3 (99.2%) compared to the SXT group (98.2%; p = .04). S3 patients experienced a lower rate of procedural death (0.7 vs. 2.6%; p = .0004), moderate/severe paravalvular leakage (PVL; 1.4 vs. 5.5%; p

Pressure recovery downstream of the aortic valve constitutes an important factor affecting the calculation of pressure gradient (PG) across the valve and therefore the accuracy of the calculated aortic valve area. Some clinical studies hypothesized that stent and valve cusps design contribute to flow acceleration and Doppler-measured valve gradients across the balloon-expandable transcatheter aortic valve. This study aims at elucidating the physical mechanisms behind pressure recovery variations between Edwards SAPIEN 3 and Medtronic Evolut TAVs through the measurements of sensitive and precise axial pressure profiles. A 23 mm Edwards SAPIEN3 and a 26 mm Medtronic Evolut were deployed in a pulse duplicator. A Millar catheter was used to record 50 cycles of pressure data along the centerline of the valve chamber upstream and downstream of the valve. The peak PG obtained with SAPIEN at vena contracta (VC) is 18.83 ± 0.75 mmHg and after recovery, 9.56 ± 0.78 mmHg. For Evolut at VC, peak PG is 18.25 ± 0.63 mmHg and after recovery, 10.3 ± 0.57 mmHg. The differences in peak PG at VC and at the recovery were statistically significant (p

AIMS In the absence of randomised data, we aimed to compare the transapical ACURATE and transfemoral ACURATE neo with the SAPIEN 3 prosthesis using propensity matching. METHODS AND RESULTS From 2012 to 2016, 1,306 patients at three German centres received either the ACURATE/ACURATE neo prosthesis (n=591) or the SAPIEN 3 prosthesis (n=715). Through nearest neighbour matching with exact allocation for access route and centre, pairs of 329 patients (250 transfemoral, 79 transapical) per group were determined. Patients were 81 years old on average and had a logistic EuroSCORE I of 19%. Predilatation and post-dilatation were more frequent in the ACURATE group (97.6% versus 52.1%, p

To date, comparisons between the balloon-expandable Edwards Sapien S3 (S3) versus the self-expanding Evolut R or PRO (Evolut) valves have been limited with respect to procedural outcomes. We aim to compare the safety, efficacy, and procedural efficiency of the S3 versus the Medtronic Evolut bioprostheses in patients who underwent transcatheter aortic valve implantation for severe aortic stenosis. Retrospective analysis was performed of all consecutive transcatheter aortic valve implantation procedures performed through the transfemoral approach with either S3 or Evolut at our hospital between September 2015 and January 2019. A total of 581 patients were included. There were no significant differences between S3 (n = 452) and Evolut (n = 129) concerning in-hospital or 30-day safety outcomes. S3 was associated with significantly shorter fluoroscopy times, lower fluoroscopy Air Kerma, and higher contrast use. S3 had lower postprocedure aortic valve area (1.71 ± 0.45 vs 1.84 ± 0.50 cm2, p = 0.004), larger peak gradient at 30 days (10.7 ± 3.8 vs 7.0 ± 3.2 mm Hg, p 26 mm). Severe prosthesis-patient mismatch was higher in S3 (14.8% vs 7.9%, p

Left ventricular assist device (LVAD) outflow graft injury is a very rare complication after LVAD implantation and is usually treated surgically. This is a case report of successful stenting of the damaged outflow graft 2.5 years after LVAD implantation, followed by successful heart transplantation.

Background: The safety of next-day discharge (NDD) after transcatheter aortic valve replacement (TAVR) with a self-expandable valve is unknown. We investigated the safety of NDD after TAVR in patients who received a self-expandable valve or balloon-expandable valve. Methods and Results: We retrospectively evaluated consecutive patients who underwent elective minimalist TAVR between January 2017 and July 2018. We investigated the success rates and predictors of NDD after TAVR. Ninety-day and 1-year outcomes in patients managed with NDD after self-expandable ACURATE neo or balloon-expandable SAPIEN 3 replacement were compared. In 315 TAVRs, 249 patients received an ACURATE neo (n=146) or SAPIEN 3 (n=103) valve. There were no differences in baseline characteristics. In the ACURATE neo and SAPIEN 3 groups, NDD was achieved in 60% (n=87) and 55% (n=57) of patients, respectively ( P >0.50). Predictors of NDD included chronic obstructive pulmonary disease (odds ratio, 0.49; 95% CI, 0.25–0.94) and low pre-TAVR hemoglobin (odds ratio, 0.98; 95% CI, 0.96–0.99) but not type of valve (odds ratio, 1.20; 95% CI, 0.71–1.98 for ACURATE neo). After excluding non-NDD cases, there were no significant differences in 90-day mortality (0% versus 0%; P >0.90) or new pacemaker implantation (1% versus 0%; P >0.40) between ACURATE neo and SAPIEN3, respectively. No significant difference in 1-year mortality between ACURATE neo and SAPIEN 3 groups after NDD (8% versus 10%; log-rank, P >0.80) was observed. Conclusions: The safety of NDD using ACURATE neo was similar that using SAPIEN 3, with comparable 90-day and 1-year outcomes.

BackgroundPredilation of the native valve has long been deemed necessary in transfemoral transcatheter aortic valve implantation (TF-TAVI), despite little trial evidence to support its clinical use. As most evidence is derived from retrospective analyses of observational studies, we conducted a two-armed, prospective multicentre registry.MethodsPatients undergoing TF-TAVI with the Edwards SAPIEN 3 valve, with or without balloon aortic valvuloplasty (BAV), were included and their procedural characteristics, short-term safety and short-term efficacy outcomes compared. We hypothesised that BAV may be safely omitted in many patients and omission could be associated with procedural benefits.ResultsOverall, 196 consecutive patients underwent TF-TAVI, 56 with BAV and 140 without. The mean age was 81.2±6.2 years, and the mean logistic EuroSCORE I was 17.1±13.6. Device success according to Valve Academic Research Consortium-2 (VARC-2) was achieved in 96.4%. The median procedural duration was shorter without BAV (56 min vs 90 min; p=0.001), as was fluoroscopy time (10 min vs 13 min; p=0.001). The need for balloon postdilation was less frequent in patients without BAV (15.7% vs 30.4%, p=0.029). There was no difference in the proportion of patients meeting the VARC-2 defined composite safety endpoint at 30 days (9.3% without vs 8.9% with BAV; adjusted OR (adjOR) 2.55; 95% CI 0.56 to 18.84) and at 6 months (15.2% without vs 16.4% with BAV; adjOR 1.66; 95% CI 0.49 to 6.55).ConclusionsIn the majority of patients, BAV can be safely omitted from the TAVI procedure without adverse effects. The omission of BAV is associated with shorter procedural duration and could be advantageous for the majority of patients.Trial registration numberNCT02760771.

BACKGROUND: Among patients with aortic stenosis who are at intermediate or high risk for death with surgery, major outcomes are similar with transcatheter aortic-valve replacement (TAVR) and surgical aortic-valve replacement. There is insufficient evidence regarding the comparison of the two procedures in patients who are at low risk. METHODS: We randomly assigned patients with severe aortic stenosis and low surgical risk to undergo either TAVR with transfemoral placement of a balloon-expandable valve or surgery. The primary end point was a composite of death, stroke, or rehospitalization at 1 year. Both noninferiority testing (with a prespecified margin of 6 percentage points) and superiority testing were performed in the as-treated population. RESULTS: At 71 centers, 1000 patients underwent randomization. The mean age of the patients was 73 years, and the mean Society of Thoracic Surgeons risk score was 1.9% (with scores ranging from 0 to 100% and higher scores indicating a greater risk of death within 30 days after the procedure). The Kaplan-Meier estimate of the rate of the primary composite end point at 1 year was significantly lower in the TAVR group than in the surgery group (8.5% vs. 15.1%; absolute difference, -6.6 percentage points; 95% confidence interval [CI], -10.8 to -2.5; P

Background: To report the long-term outcomes of balloon-expandable bare stent (BEBS) as chimney stent (CS) in thoracic endovascular aortic repair (TEVAR) for supra-aortic branches reconstruction. Methods: A total of 33 patients with thoracic aortic diseases underwent TEVAR using BEBSs as CSs for supra-aortic branches reconstruction in our center from 2010 to 2015. The demographics and procedural details were prospectively collected and retrospectively reviewed. All patients were followed up at 1, 3, 6 months and every 1 year thereafter. Postoperative complications and long-term outcomes were recorded. Results: The technical success rate was 100%. A total of 36 BEBSs were utilized as CSs to reconstruct the supra-aortic branches during TEVAR. The rate of immediate endoleak was 42.4% (14/33), including 12 (36.4%) type Ia endoleaks and 2 (6.1%) type II endoleaks. Two of type Ia endoleaks were managed by balloon dilation and disappeared, while the rest were left with close follow-up. Two type II endoleaks were embolized by coils and excluded by a plug, respectively. One patient (3.0%) died 2 days after the procedure due to the acute rupture of aortic dissection. The mean follow-up time was 61.8 (ranged from 12 to 102) months. The unmanaged 10 type Ia endoleaks were closely observed during the follow-up, of which 7 disappeared at 1 year and 1 disappeared at 2 years. The rest 2 type Ia endoleaks existed without further dilation of the aorta. One patient (3.0%) was re-intervened for the increased false lumen due to the distal residual tears. The long-term mortality was 9.1% (3/33). All CSs kept patent till the end of follow-up. No other complications were found. Conclusions: The balloon-expandable stent (BES) is a feasible choice as CS for supra-aortic branches reconstruction with long-term patency during TEVAR. However, BEBS may be related to a higher rate of early endoleak.

Purpose: To evaluate the advantages of chimney endovascular aneurysm repair (chEVAR) using an Endurant stent-graft with uncovered balloon-expandable stents (BES) for patients with juxtarenal aortic aneurysms. Materials and Methods: Twenty-two patients (mean age 78.5±9.0 years; 13 men) who underwent chEVAR using Endurant and uncovered BES between January 2014 and December 2017 were analyzed retrospectively. The maximum aneurysm diameter was 59.1±11.9 mm, and the proximal neck length was 5.2±2.9 mm. Of the 22 cases, 9 (40%) involved proximal neck angulation and 9 (40%) had a conical neck. Single and double chimneys were performed using BES in 19 and 3 cases, respectively. In 2 cases, an additional self-expanding covered stent was used inside the uncovered BES. Results: The technical success was 91% (20/22) as 2 (9%) cases showed minor type Ia endoleak. No postoperative systemic complications or acute renal dysfunction (Acute Kidney Injury Network classification stage 2 or higher) were observed. The mean radiologic observation period was 16.1±9.6 months, and no aneurysm expansion (>5 mm) was observed during this time. The mean maximum aneurysm diameter decreased to 52.9±10.2 mm (p

Current balloon expandable and self-expanding valves have limitations for the treatment of the enlarged right ventricular outflow tract. We report the first use of a tailored Zenith graft in composition with an Edwards Sapien S3 valve as an alternative to high-risk surgery for the treatment of a spontaneously ruptured homograft in an adult congenital heart disease patient.

Background Transcatheter aortic valve implantation (TAVI) is an innovative and effective treatment in high-surgical-risk (HR) and inoperable patients with symptomatic severe aortic stenosis. Objectives This cost-effectiveness analysis of transfemoral TAVI (TF-TAVI) compared with surgical aortic valve replacement (SAVR) conforms with the methodological guidelines for cost-effectiveness evaluation by the Ministry of Health, Labor, and Welfare in Japan. Methods The cost-effectiveness of TF-TAVI using SAPIEN XT was evaluated using a lifetime Markov simulation from the national payer perspective. Comparators were SAVR for HR patients and standard of care (SOC) for inoperable patients. A systematic literature review for clinical evidence of TF-TAVI and comparators was conducted. The evidence for TF-TAVI was derived from the SOURCE XT registry and Japanese post marketing surveillance. Because there was no literature directly or indirectly comparing TF-TAVI using SAPIEN XT with comparators, the comparator data were selected from relevant published studies, considering the similarity of study eligibility criteria and patient backgrounds (eg, age and surgical risk scores). Sensitivity analyses were used to validate the robustness of results. Results The incremental cost-effectiveness ratio of TF-TAVI versus SAVR for HR patients was ¥1.3 million/quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio of TF-TAVI versus SOC for inoperable patients was ¥3.5 million/QALY. Conclusions TF-TAVI was cost-effective when compared with SAVR for HR patients and when compared with SOC for inoperable patients, using a threshold of ¥5 million/QALY.

In the last 15 years, transcatheter aortic valve implantation (TAVI) has had an impressive advancement, transforming a challenging intervention into a very standardized and streamlined procedure. The latest generation of TAVI devices have incorporated features to reduce the delivery catheter profile, facilitate deployment, and in some cases enable repositioning and retrieval capability. According to the type of deployment, current TAVI devices can be divided into the categories of balloon-expandable, self-expanding, and mechanically expandable. Despite their widespread utilization, there are still no clear indications as to which is the best device for specific anatomical situations. In this chapter we will provide a brief summary of the current TAVI technologies, we will summarize key results of trials comparing different TAVI devices, and we will present several clinical scenarios in which a specific device could be more suitable than the others.

Transcatheter aortic valve replacement (TAVR) is now mainstream treatment for severe symptomatic aortic stenosis (AS). Unique risks of this procedure have been described, including a small incidenc...

Objectives This study sought to evaluate SAPIEN 3 (S3) (Edwards Lifesciences, Irvine, California) positioning using different strategies. Background Aortic valve-in-valve (ViV) is associated with high risk of elevated gradients. Methods S3 aortic ViV procedures in stented bioprostheses were studied. Transcatheter heart valve (THV) positioning was analyzed in a centralized core lab blinded to clinical outcomes. A combined endpoint of severely elevated mean gradient (≥30 mm Hg) or pacemaker need was established. Two positioning strategies were compared: central marker method and top of S3 method. Optimal final depth was defined as S3 depth ≤20%. Results A total of 113 patients met inclusion criteria and were analyzed (76.5 ± 9.7 years of age, 65.8% male, STS score 8 ± 7.6%). THVs had incomplete shortening in comparison to fully expanded valves (92 ± 3.4%), and expansion was more complete in optimal positioning cases compared with others (93.2 ± 2.7% vs. 91.5 ± 3.5%; p = 0.027). The central marker method demonstrated greater correlation with final implantation depth than the top of S3 method (R2 of 0.48 and 0.14; p Conclusions Optimal S3 positioning in aortic ViV is associated with better outcomes. Central marker positioning is more reliable than top of S3 positioning. Central marker bottom position should be 3 mm to 6 mm above the ring.

Among new-generation devices for transcatheter aortic valve implantation (TAVI), the Allegra device, developed by New Valve Technology, represents an interesting adjunct to the interventionalist’s armamentarium. In particular, this self-expandable device consists of a nitinol metallic frame with bovine pericardium leaflets, boasting also dedicated gold markers for optimal positioning and a 12-mm sealing area to minimize paravalvular leak. It is available in 23 mm, 27 mm, and 31 mm sizes, suitable for annuluses ranging from 19 mm to 28 mm in diameter. Its low invasiveness (18 French cartridge/15 French shaft which ensure compatibility with a 13.5 French balloon expandable introducer sheath) and controlled-release features make this a promising device for TAVI.

Introduction: Coronary bifurcations are encountered in about 15% to 20% of percutaneous coronary interventions (PCIs). They are considered technically challenging and associated with worse clinical outcomes than nonbifurcation lesions. The BiOSS LIM C is a dedicated bifurcation balloon expandable stent made of cobalt-chromium alloy (strut thickness 70 μm) releasing sirolimus (1.4 μg/mm2) from the surface of a biodegradable coating comprised of a copolymer of lactic and glycolic acids. Conclusion: The aim of the randomized, multicenter, open-label, controlled POLBOS III trial is to compare BiOSS LIM C with limus second-generation drug-eluting stents (DES) in the treatment of non-left main stem coronary bifurcations (ClinicalTrials.gov NCT03548272).

Purpose: To evaluate the safety and integrity of a new stent-graft as a potential bridging device in fenestrated stent-grafts using an in vitro fenestrated model. Materials and Methods: Polyester test sheets with ten 6-mm- or 8-mm-diameter fenestrations were used to simulate a fenestrated main body endoprosthesis. In total, 50 Viabahn balloon-expandable (VBX) stent-grafts of varying lengths (29 and 39 mm) and diameters (6, 7, and 8 mm) were implanted in the fitting fenestrations. After release, the 6- and 7-mm-diameter stent-grafts were flared with a 10×20-mm angioplasty balloon; a 12×20-mm balloon was used in the 8-mm-diameter devices. Safety of the devices was defined as absence of fractures detected on radiography or computed tomography (CT), as well as material failure detected by microscopy and water permeability testing. The forces (in Newtons, N) needed for perpendicular dislocation (pullout force) and axial dislocation (shear stress force) were also evaluated. Results: Forty VBX stent-grafts were subjected to digital radiographic imaging and multiplanar CT. None showed any stent fracture. Subsequent microscopy indicated no damage to the fabric or separation of the graft after flaring. Ten VBX stent-grafts underwent water permeability testing after flaring; no water passed through the graft wall during a 10-minute period under an intraluminal pressure at 120 mm Hg. Testing of 25 VBX stent-grafts revealed initial pullout forces between 11.3 and 31 N. Shear stress tests showed that the average force needed to dislocate the stent-grafts by 50% of their diameter ranged between 5.75 and 6.91 N (mean 6.1±0.5 N) for the 6-mm stents and between 3.31 and 5.4 N (mean 4.4±0.8) for the 8-mm stents. Conclusion: This preliminary study demonstrated the applicability of the VBX as a bridging stent-graft in a simulated fenestration model. A comparison with other stent-grafts and clinical assessment are required.

Objective To evaluate and compare studies reporting the outcomes of the use of covered balloon-expandable (CBE) stents for the treatment of aortoiliac occlusive disease. Methods A systematic literature search was conducted to identify studies that investigated the use of CBE stents for the treatment of aortoiliac occlusive disease and were published between 2000 and 2019. Baseline demographic data, procedural variables, and long-term outcomes were extracted from publications for analysis. Results A total of 15 published articles about 14 studies were included in the review. Of these, eight studies were prospective clinical trials and six studies were retrospective real-world studies. The articles included data regarding five different CBE stents, namely, the iCast/Advanta V12, Viabahn VBX, BeGraft, LifeStream, and JOSTENT. Lesion severity was higher in real-world studies, with more TransAtlantic Inter-Society Consensus Classification class D lesions and a higher percentage of occlusions. All studies showed high rates of technical success and patency over the course of 12 months. Long-term data were only available for the iCast/Advanta V12 device, which had a primary patency rate of 74.7% at 5 years. Conclusions CBE stents are a viable treatment option for patients with complex aortoiliac lesions because of their high rates of technical success and favorable patency across all devices at 12 months. However, long-term data are only available for a single device, the iCast/Advanta V12. The results of using this device were favorable over the course of 5 years.

The aim of this study was to evaluate the impact of increased aortic angulation (AA) on acute procedural success following transcatheter aortic valve replacement (TAVR).The degree of angulation between the aorta and the heart can make accurate positioning of the bioprosthesis during TAVR more demanding, particularly in instances of an extremely angulated or horizontal aortic root. Nonetheless, there are limited data on the impact of AA on the acute success of TAVR.We assessed 582 patients who underwent TAVR at our institute and had contrast computed tomography available for AA evaluation. TAVR endpoints, device success, and adverse events were considered according to the Valve Academic Research Consortium-2 definitions.The mean angulation of the aorta was 47.3 ± 8.7°. Patients were therefore divided into 2 groups: AA 48° and AA ≥48°. AA in the 480 patients who underwent balloon-expandable (BE) TAVR did not influence acute procedural success or short-term clinical outcome. In contrast, increased AA among the 102 patients who underwent self-expandable (SE) TAVR was found to significantly attenuate procedural success (area under the curve: 0.73; 95% confidence interval: 0.61 to 0.85; p = 0.008). The numerical cutoff for AA with the highest sum of sensitivity and specificity for device success was ≥48° (sensitivity 85%, specificity 61%). Moreover, patients whose AA was ≥48° were also associated with an increased need for a second valve and post-dilation, had increased fluoroscopy time and increased valve embolization, and had increased post-procedural paravalvular regurgitation greater than or equal to mild following SE TAVR. Major complications at 30 days, including mortality were similar between AA groups. Six-month mortality was also similar between both AA groups.Increased aortic root angulation adversely influences acute procedural success following SE but not BE TAVR. Because of these data, BE valves may be preferred when evaluating patients with high AA before TAVR.

Endovascular stenting has evolved over the last 50 years since its inception into the framework of management of vascular atherosclerotic disease. Stent design has evolved as lesion complexity has increased. Nevertheless, certain first principles regarding stent design have been recapitulated time and again with every iteration of endovascular stents. This article reviews principles of endovascular stent design and compares and contrasts key aspects of balloon expandable and self-expanding stents.

Optimization of hemodynamics during transcatheter aortic valve replacement (TAVR) using the commercially available balloon expandable and self-expanding valves is often accomplished through post-dilation of the valves' metallic frame. The direct flow medical (DFM) valve is a uniquely designed second-generation TAVR prosthetic without a rigid metallic frame. It is not widely known whether balloon dilation of this valve is beneficial when valve hemodynamics after initial deployment suboptimal due to valve underexpansion. We present the first two US patients who underwent TAVR using the DFM valve who had underexpansion in the setting of bulky leaflet calcification that resulted in elevated valve gradients and were treated successfully using intraprocedural balloon dilation. © 2016 Wiley Periodicals, Inc.

Thrombotic aortic valve restenosis following transcatheter aortic valve replacement (TAVR) has not been extensively reported and the rates of TAVR valve thrombosis are not known. We present three cases of valve-in-valve (VIV) restenosis following TAVR with the balloon expandable transcatheter heart valves, presumably due to valve thrombosis that improved with anticoagulation. © 2016 Wiley Periodicals, Inc.

Background Vascular complications (VC) are a serious and frequent complication of transfemoral transcatheter aortic valve implantation (TAVI) and result in increased morbidity and mortality. It has been suggested that newly developed vascular sheaths may increase the ability to perform transfemoral TAVI in patients with normal and access-limiting peripheral artery disease (PAD) and reduce vascular complications. Aims We sought to assess the safety and efficacy of the 19 French (F) SoloPath balloon-expandable transfemoral vascular access system in patients who underwent transfemoral TAVI at our center between 2011 and 2014. Methods and results Single-center retrospective study of 90 patients who underwent transfemoral TAVI with the use of the SoloPath sheath. Patients were categorized into two groups according to a sheath to femoral artery ratio (SFAR) of less than or equal to 1.05, or greater than 1.05. Overall, the incidence of major bleeding complications was low, 4.4%. No significant differences were found in technical or procedural success rates (100% in both groups and 100% vs. 91.3; P = 0.09; respectively), total vascular complications (20.8 vs. 21.7; P = 0.92) or total bleeding complications (20.8 vs. 30.4; P = 0.36 between those with SFAR greater or less than 1.05. Conclusions The use of the SoloPath balloon-expandable sheath is feasible and safe even in patients with SFAR > 1.05, showing no increased vascular or bleeding complications compared to patients with larger vascular access. © 2016 Wiley Periodicals, Inc.

Atherosclerotic iliac artery disease is increasingly being treated with endovascular techniques. A number of new stent technologies can be utilized with high long-term patency, including self-expanding stents, balloon-expandable stents, and covered stents, but comparative data on these stent types and in more complex lesions are lacking. This article provides a review of currently available iliac stent technologies, as well as complex procedural aspects of iliac artery interventions, including approaches to the treatment of iliac bifurcation disease, long segment occlusions, choice of stent type, and treatment of iliac artery in-stent restenosis.

Transcatheter implantation of balloon expandable valves in high-risk patients with degenerated tricuspid bioprostheses has been reported since 2010 [1, 2]. Although there have been cases where the SAPIEN valve was implanted in the tricuspid position without rapid pacing [3, 4], invasive rapid ventricular pacing is usually applied during valve deployment. We present a case report documenting for the first time the use of noninvasive, external rapid pacing delivered through defibrillation sticker-pads during transfemoral implantation of the Edwards SAPIEN XT valve for tricuspid valve bioprosthesis stenosis.

A 73-year-old woman with arteriosclerosis obliterans (ASO) was underwent a crossover stenting for an aortoiliac bifurcation from the right common iliac artery (CIA) with a self-expandable bare-metal stent (SE-BMS); however, a new stenosis later occurred just behind the bifurcation of the left CIA. An ex vivo experiment demonstrated that culotte-stenting by additional implantation of a balloon-expandable bare-metal stent (BE-BMS) through stent struts of the SE-BMS would be empirically infeasible. Although we had initially planned a T-stenting for the additional implantation of a BE-BMS in the left CIA, we finally deployed the stent in the CIA with the proximal end protruding into the previously-implanted SE-BMS through the stent struts to avoid incomplete coverage of the stenosis by reference to the ex vivo experiments. The patient has had no recurrence for 36 months.

Four dogs were diagnosed with nasopharyngeal stenosis using endoscopy and magnetic resonance imaging. Treatment using balloon-expandable metallic stent, placed under fluoroscopic and endoscopic guidance, resulted in immediate resolution of clinical signs. All dogs were clinically normal 40 to 62 months following stent placement.

Access options for transcatheter aortic valve replacement (TAVR) currently include transfemoral, transaortic, transapical, transsubclavian, and other approaches. Transsubclavian access for balloon expandable valves is gaining popularity when transfemoral access is not suitable, given its peripheral access compared with central access. With the transsubclavian approach, second femoral or radial artery access is necessary for pigtail catheter placement. We describe a "double-stick" transsubclavian technique that eliminates secondary arterial access. With this technique, the transsubclavian approach can still be used in patients with advanced femoral disease, and it allows for rapid ambulation in most patients.

Bioprosthetic valve dysfunction leading to haemodynamically significant consequences is well recognised. Traditional treatment of choice has been conventional re-do surgical valve replacement. However, over the last decade, percutaneous solutions such as Valve-in-valve (VIV) implantations has emerged as a well-established option for such patients Dvir et al. (2014), V. Bapat et al. (2012) and Piazza et al. (2011). We report India’s first tricuspid valve-in-valve implantation with a balloon expandable valve through a trans-jugular approach to treat dysfunctional tricuspid valve dysfunction.