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Key Clinical Message Increasing longevity of heart transplantation recipients and aging donor population accompanied by the older age at transplantation led to an increase in the prevalence of degenerative valvular disease in particular aortic stenosis. TAVI is considered a safe and feasible alternative compared to conventional SAVR in this high‐risk population., Increasing longevity of heart transplantation recipients and aging donor population accompanied by the older age at transplantation led to an increase in the prevalence of degenerative valvular disease in particular aortic stenosis. TAVI is considered a safe and feasible alternative compared to conventional SAVR in this high‐risk population.

Objectives We sought to analyze the percutaneous coronary intervention (PCI) outcomes of very elderly patients (V. Eld. group, age >80 years) and compare their outcomes to a less elderly cohort (Eld. group, age 75-80 years) traditionally reported in the literature. Background Limited data exist on peri-procedural and long-term outcomes following PCI in the V. Eld. (age >80 years), with under-representation of this cohort in randomized controlled trials. These patients present with advanced complex coronary disease and multiple comorbidities. Methods All 580 consecutive patients aged ≥75 years (age 80 ± 4.9 years, 57.4% males) undergoing PCI between April 2006 and November 2011 were included. A total of 624 consecutive lesions were identified and analyzed. All V. Eld. patients (n = 253) were subsequently selected, and their outcomes compared to Eld. patients (n = 327). Mean follow-up was 30.8 ± 2.7 months with 98% clinical follow-up achieved. Results All comparative data are expressed as (V. Eld. vs Eld.) unless otherwise specified. All-cause mortality was significantly higher in the V. Eld. group (11.9% vs 6.1%), although this did not translate into a significant difference in cardiac mortality (6.3% vs 3.7%) or major adverse cardiac and cerebrovascular events (16.2% vs 12.5%). The composite incidence of myocardial infarction (MI), stroke, definite/probable stent thrombosis, and TIMI major bleed was 4.7%, 1.4% 1.9%, and 6.4%, respectively with no significant difference between both cohorts. Conclusions This study demonstrates an acceptable occurrence of MI, death, repeat intervention, and stent thrombosis in a high-risk group of V. Eld. patients with de novo lesions. Age alone in the absence of other non-cardiac factors should not prohibit a patient from access to PCI.

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Objectives To evaluate the feasibility and safety of direct transcatheter aortic valve implantation (TAVI) by the transfemoral approach without balloon pre-dilatation using the Edwards SapienXT valve. Background TAVI is established in selected high-risk patients with severe aortic stenosis. Balloon aortic valvuloplasty (BAV) is recommended prior to valve implantation, but may contribute to procedural risk. It is unknown whether this is necessary for successful passage and deployment of the device. Methods 81 patients (mean age 84 [95%CI:82–85.8], 62% male, median EuroScore 22.8% [95%CI:20.5–27]) undergoing transfemoral TAVI (35 by direct implantation [direct group]; 46 with balloon pre-dilatation [balloon group]) between 2010 and 2013 were analyzed for efficacy and safety endpoints. Results Procedural success was 100%. Pre and post-procedural peak gradients in the direct group were 66mmHg (95%CI:59–72.8) and 14mmHg (95%CI:12–17.8)(P

To evaluate the feasibility and safety of direct transcatheter aortic valve implantation (TAVI) by the transfemoral approach without balloon pre-dilatation using the Edwards SapienXT valve.TAVI is established in selected high-risk patients with severe aortic stenosis. Balloon aortic valvuloplasty (BAV) is recommended prior to valve implantation, but may contribute to procedural risk. It is unknown whether this is necessary for successful passage and deployment of the device.81 patients (mean age 84 [95%CI:82-85.8], 62% male, median EuroScore 22.8% [95%CI:20.5-27]) undergoing transfemoral TAVI (35 by direct implantation [direct group]; 46 with balloon pre-dilatation [balloon group]) between 2010 and 2013 were analyzed for efficacy and safety endpoints.Procedural success was 100%. Pre and post-procedural peak gradients in the direct group were 66mmHg (95%CI:59-72.8) and 14mmHg (95%CI:12-17.8)(P 0.0001) compared to 76.5mmHg (95%CI:73.7-94.0) and 17mmHg (95%CI:16-19)(P 0.0001) in the balloon group. Post-dilatation was performed in 4/35(11.4%) of the direct group and 3/46(6.5%) of the balloon group (P = 0.83). Post procedure moderate AR was present in 1/35(2.9%) in the direct group and none in the balloon group. In-hospital mortality (2.9% direct vs. 0% balloon group), stroke (2.9% vs. 4.4%), tamponade (2.9% vs. 2.2%), major vascular complications (2.9% vs. 8.7%) and new permanent pacing (2.2% vs. 0) were similar. Pacing time, inflations, radiation dose and contrast use were all significantly lower in the direct group.Direct implantation of the Edwards SapienXT valve during TAVI by the transfemoral route appears safe, efficacious and feasible in those without extreme calcification. © 2016 Wiley Periodicals, Inc.

Introduction Transcatheter Aortic Valve Implantation (TAVI) is being used increasingly in patients with severe symptomatic Aortic Stenosis (AS). There are few data on length of stay (LOS) in this elderly and co-morbid population. This study evaluates the safety of selective early discharge post TAVI. Methods Data were collected prospectively on all 121 patients who underwent TAVI between 2009 and October 2012. Subjects with severe symptomatic AS were selected for TAVI by the heart team if they had logistic Euroscore >20 and/or were deemed inoperable after direct surgical review. All patients received an Edwards Sapien or Sapien XT valve via transfemoral (n = 89), trans-apical (n = 23) or direct aortic (n = 9) routes. Complications (VARC-2 criteria), LOS and 30 day re-admissions were recorded. Pre-defined minimum LOS was discharge on day 3 post TAVI. Patients were divided into early ( Results Median LOS was 4 days. 40% of patients had been discharged by day 3 post TAVI and 61% by day 4. Transfemoral patients had a significantly shorter median LOS than other routes (3 days vs 6.5 days, p = 0.001). The overall early (30 day) re-admission rate was 10/121 (8.3%). There was no significant difference in re-admissions between the early and delayed discharge groups (9.5% vs 6.4%). There were no deaths between discharge and 30 days and no patients required readmission for PPM. Discussion This study suggests that selective early discharge post TAVI is not associated with higher rates of readmission, sudden death or PPM. Mean LOS of 6 days compares favourably to data from other centres reporting mean LOS of 6.8–15 days. Other studies have recorded readmission rates of between 8–15% so our policy of selective early discharge does not appear to be at a cost of higher readmission. Re-admission rate was lowest in our transfemoral group at 5.6%. Conclusion Selective early discharge following TAVI appears to be safe and is not associated with increased early readmission or delayed complications.

Introduction The response to cardiac resynchronisation therapy (CRT) can be heterogeneous. Most studies aim to improve patient selection in order to achieve better outcomes.However, the adjustment of device timing intervals in conjunction with optimisation of medical therapy may maximise the effectiveness of CRT. This approach provides a new paradigm in the management of advance heart failure where not only medical therapies but also CRT timing intervals are tailored to individual needs. We describe our four years experience with CRT optimisation performed in a consultant-run heart failure (HF) clinic. Methods All patients attending the combined CRT optimisation and HF clinic during the period of 2008–2012 had a clinical assessment followed by echocardiography guided optimisation of their device. A-V optimisation was performed using the Iterative method on a pre-set sequence of paced and sensed AV delays. V-V optimisation was based on the maximal left ventricular outflow tract VTI as a surrogate for stoke volume.The following end-points were used: EuroQol (EQ visual analogue score (VAS)) health questionnaire, 6-minute walk test (6MWT), regional wall motion abnormality scoring (RWMA), left ventricular ejection fraction (LVEF), Yu Index (SD of time to peak systole in a 12 segment LV model as a measure of intra-ventricular dyssynchrony) and the difference between aortic and pulmonary ejection times (IVMD) a marker of inter-ventricular dyssynchrony. Patients were re-assessed after 8–12 weeks at which point optimisations of medical therapy were performed. Results 87 patients underwent CRT optimisation (68 (78%) were males). 92% of patients had NYHA Class II or III. CRT optimisation was performed at a mean 36 weeks post implantation and the follow-up visit took place at a mean of 9 weeks later. Post CRT optimisation there were reduction in intra-ventricular dyssynchrony (Yu Index decreased from 36 to 30ms (p = 0.02)) and inter-ventricular dyssynchrony (IVMD from 20 to 12 ms (P Conclusions This study suggests echocardiography guided CRT optimisation results in an improvement in measures of dyssynchrony and LV systolic function with a trend towards clinical improvement. This lends support to the individualisation of CRT timing intervals rather than relying on standard box settings as part of a heart failure service.

Syncope is a common symptom of patients attending emergency departments, yet presents significant diagnostic and therapeutic challenges. We present a rare cause of recurrent vasovagal syncope with predominant cardioinhibitory response due to lymphoma surrounding and compressing the carotid artery treated successfully with radiotherapy.