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Delayed coronary obstruction is a rare but often fatal complication of transcatheter aortic valve replacement that can present within 24 hr after the transcatheter aortic valve replacement procedure. We present a case of a 77-year-old woman whose distal left main coronary artery bifurcation became obstructed by an embolized piece of native valve leaflet material 16 hours after the uncomplicated transfemoral implantation of an Edwards Sapien Ultra 23 mm aortic valve, which was successfully treated with the simultaneous kissing stent technique.

An 88-year-old man with small lymphocytic lymphoma presented to the hospital with shortness of breath and was diagnosed with heart failure. Serial blood cultures and echocardiography revealed Staphylococcus epidermidis endocarditis, complicated by severe aortic regurgitation. Despite intravenous antibiotic therapy and aggressive intravenous diuresis therapy in the hospital, he decompensated into cardiogenic shock, requiring invasive haemodynamic monitoring and inotrope therapy. With multidisciplinary discussion involving the patient and his children, there was a joint decision that at his advanced age, he would not pursue surgical aortic valve replacement and instead proceed with a transcatheter aortic valve replacement (TAVR) with palliative intent. He underwent TAVR with subsequent symptomatic and functional improvement as well as resolution of cardiogenic shock.

Objectives To evaluate the outcomes of intravascular ultrasound (IVUS) directed endovascular exclusion of popliteal artery aneurysm (PAA) using stent grafts. Methods Clinical data of seven patients who underwent endovascular exclusion of PAA using IVUS guidance between 2009 and 2011 were retrospectively analyzed. Outcome measures included graft patency, endoleak, and clinical symptoms. Results A total of seven patients were treated with Viabahn stent grafts using IVUS guidance. No patients were lost to follow-up (mean 12 ± 2 months). Patients had an average of two vessel runoff at the end of the procedure. All patients were symptom free with patent stents and no evidence of endoleak at follow-up. Conclusions Use of IVUS during endovascular treatment of PAA allows the physician to fully appreciate the anatomy of PAA, including location and extent of thrombus burden and the diameter and location of desired landing zones for appropriate sealing of the aneurysm proximally and distally. IVUS-guided treatment is associated with excellent outcomes and does not increase procedural radiation and contrast load. © 2015 Wiley Periodicals, Inc.

Risk assessment models for transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement in high-risk patients and TAVR versus palliation in inoperable patients are based on surgical data and have limited discrimination and calibration in the setting of TAVR. Several novel risk models specifically designed for TAVR have improved discrimination over existing models but require further validation. Several clinical and echocardiographic variables, such as chronic lung disease, mitral regurgitation, and stroke volume index, influence outcomes. This article reviews current and novel risk models and important predictors of TAVR outcomes and proposes a framework to integrate them into clinical decision-making for patients with severe, symptomatic aortic stenosis.

Aortic valve (AV) replacement with a pulmonary autograft (ROSS Procedure) has been used for treatment of aortic stenosis (AS), but degeneration of the aortic position pulmonary autograft and pulmonary position homograft often requires repeat surgical intervention. 63 year old male presented with

Introduction Left ventricular assist device (LVAD) outflow graft obstruction is a well-known and significant complication. The typical management involves treatment of presumed thrombosis of the graft with intensified anticoagulation or surgery. More recently, endovascular stenting has been reported as a possible treatment option. We describe the management of a LVAD outflow cannula obstruction with never reported intravascular ultrasound (IVUS)-guided covered endovascular stenting. Case report A 68 year-old female with non-ischemic cardiomyopathy status-post LVAD implantation in March 2016 presented with persistent symptomatic low flow alarms and clinical signs of heart failure. Symptoms seemed to worsen when she laid on her right side. She was compliant with her anticoagulation and lactate dehydrogenase level was found to be near her baseline. A CT scan with IV contrast revealed intraluminal obstruction of the LVAD outflow graft secondary to a kinked portion of the outflow cannula near the bend relief with a possible thrombotic component. The severe angulation of the cannula likely developed due to the patient's gradual weight gain of 28kg in the 24 months since LVAD implantation. Given the patient's risk profile, a percutaneous endovascular stenting approach was taken. IVUS was used to visualize the obstruction and kinking of the graft. A balloon-expandable covered stent was deployed at the stenotic site while the LVAD was briefly stopped to avoid stent/balloon migration. A covered stent was used to minimize the risk of thrombus migration/extrusion. IVUS was used again after post-dilation of the stent to confirm placement with no thrombus extrusion. Several hours later the patient had recurrent low-flow alarms. A repeat CT scan revealed that the kink had migrated and been transmitted within the outflow cannula towards the LVAD. The patient returned to the angiography suite where 2 balloon expandable stents were deployed more proximally within the outflow cannula and in an overlapping fashion with the original covered stent. Non-covered stents were used for the second procedure as there was no suspected thrombotic component. IVUS showed no significant residual kinking post-stenting. This was confirmed with a repeat CT scan. The patient recovered without any hemodynamic or neurologic sequelae. Conclusion Percutaneous endovascular stenting is an emerging option for treatment of outflow tract obstruction in LVAD patients that are not candidates for surgery. IVUS can be a valuable tool during intervention to confirm proper stent position, thrombus isolation, and outflow cannula geometry.

Aims The aim of this study was to determine whether platelet reactivity on clopidogrel therapy, as measured by a point-of-care platelet function assay, is associated with thrombotic events after percutaneous coronary intervention (PCI) with drug-eluting stents (DESs). Methods and results Platelet reactivity on clopidogrel (post-treatment reactivity) was measured with the VerifyNow P2Y12 assay (Accumetrics Inc., San Diego, CA, USA) in 380 patients undergoing PCI with sirolimus-eluting stents. Receiver-operating characteristic curve analysis was used to derive the optimal cut-off value for post-treatment reactivity in predicting 6 month out-of-hospital cardiovascular (CV) death, non-fatal MI, or stent thrombosis. The mean post-treatment reactivity was 184 ± 85 PRU (P2Y12 reaction units). The optimal cut-off for the combined endpoint was a post-treatment reactivity ≥235 PRU [area under the curve 0.711 (95% confidence interval 0.529–0.893), P = 0.03], which was similar to the threshold of the upper tertile (231 PRU). Patients with post-treatment reactivity greater than the cut-off value had significantly higher rates of CV death (2.8 vs. 0%, P = 0.04), stent thrombosis (4.6 vs. 0%, P = 0.004), and the combined endpoint (6.5 vs. 1.0%, P = 0.008). Conclusion High post-treatment platelet reactivity measured with a point-of-care platelet function assay is associated with post-discharge events after PCI with DES, including stent thrombosis. Investigation of alternative clopidogrel dosing regimens to reduce ischaemic events in high-risk patients identified by this assay is warranted.

The management of drug and standard catheter ablation refractory scar mediated ventricular tachycardia remains a therapeutic challenge. This can be made more difficult if the presentation is complicated by unstable hemodynamics status. The patient is an 82 year old male with history of coronary

To evaluate the outcomes of intravascular ultrasound (IVUS) directed endovascular exclusion of popliteal artery aneurysm (PAA) using stent grafts.Clinical data of seven patients who underwent endovascular exclusion of PAA using IVUS guidance between 2009 and 2011 were retrospectively analyzed. Outcome measures included graft patency, endoleak, and clinical symptoms.A total of seven patients were treated with Viabahn stent grafts using IVUS guidance. No patients were lost to follow-up (mean 12 ± 2 months). Patients had an average of two vessel runoff at the end of the procedure. All patients were symptom free with patent stents and no evidence of endoleak at follow-up.Use of IVUS during endovascular treatment of PAA allows the physician to fully appreciate the anatomy of PAA, including location and extent of thrombus burden and the diameter and location of desired landing zones for appropriate sealing of the aneurysm proximally and distally. IVUS-guided treatment is associated with excellent outcomes and does not increase procedural radiation and contrast load.

Activity-induced brain-derived neurotrophic factor (BDNF) expression is negatively modulated by circulating adrenal steroids. The rat BDNF gene gives rise to four major transcript forms that each contain a unique 5′ exon (I–IV) and a common 3′ exon (V) that codes for BDNF protein. Exon-specific in situ hybridization was used to determine if adrenalectomy has differential effects on basal and activity-induced BDNF transcript expression in hippocampus. Adrenalectomy alone had only modest effects on BDNF mRNA levels with slight increases in exon III-containing mRNA with 7–10-day survival and in exon II-containing mRNA with 30-day survival. In the dentate gyrus granule cells, adrenalectomy markedly potentiated increases in exon I and II cRNA labeling, but not increases in exon III and IV cRNA labeling, elicited by one hippocampal afterdischarge. Similarly, for the granule cells and CA1 pyramidal cells, hilus lesion (HL)-induced recurrent limbic seizures elicited greater increases in exon I and II cRNA hybridization in adrenalectomized (ADX) as compared to adrenal-intact rats. In this paradigm, adrenalectomy modestly potentiated the increase in exon III-containing mRNA in CA1 but had no effect on exon IV-containing mRNA content. These results demonstrate that the negative effects of adrenal hormones on activity-induced BDNF expression are by far the greatest for transcripts containing exons I and II. Together with evidence for region-specific transcript expression, these results suggest that the effects of stress on adaptive changes in BDNF signalling will be greatest for neurons that predominantly express transcripts I and II.

In the adult rat forebrain, brain-derived neurotrophic factor (BDNF) expression is very rapidly induced by neuronal activity, suggesting that this might occur without intervening protein synthesis. The ratBDNFgene has four differentially regulated promoter regions; each gives rise to an mRNA containing a unique 5′ exon (I–IV) and a common 3′ exon (V) that codes for mature BDNF protein. The present study used exon-specificin situhybridization and bothin vivoandin vitropreparations to determine whether activity induces BDNF as an “immediate-early gene” (IEG) from specific promoter regions and to compare the regulation of BDNF and nerve growth factor (NGF). In cultured hippocampal slices, kainic acid markedly increased pan-BDNF (exon V) and NGF mRNA content; cycloheximide attenuated the effect of kainic acid on both.In vivostimulation of a paroxysmal afterdischarge increased both pan-BDNF and NGF mRNA levels in the dentate gyrus granule cells; pretreatment with anisomycin modestly attenuated the paroxysmal afterdischarge-induced increase of both transcripts. To determine whether partial drug effects on BDNF expression reflect the differential regulation of transcript species, levels of mRNAs containing exons I–IV were evaluated. A single afterdischarge increased exon I–IV-containing mRNA levels; anisomycin significantly attenuated the increase in exon I- and II-containing mRNAs but had no effect on the increase in exon III- and IV-containing mRNAs. These data show that for mature forebrain neurons, activity induces the expression of BDNF exon III- and IV-containing transcripts as IEG responses.