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Introduction although transcatheter aortic valve replacement (TAVR) represents a milestone in the treatment of degenerative aortic stenosis, stroke remains an important complication compared to surgical aortic valve replacement (SAVR). Multiple magnetic resonance imaging (MRI) studies demonstrated a substantial rate of new cerebral ischemic lesions after TAVR. In order to avoid debris passage into the circulation and to prevent procedure-related embolic stroke, cerebral embolic protection (CEP) devices were developed. However, their safety and efficacy remain controversial. Very recently, new studies provided additional evidence on this topic. Aim to assess the entire body of evidence from randomized controlled studies about neurological outcomes after TAVR. Materials and Methods a systematic meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched MEDLINE, Scopus, and Google Scholar for randomized controlled studies. The following keywords were used for the search: “transcatheter aortic valve implantation” or “stroke prevention” or “embolic protection” and “cerebral protection”. Study groups were defined as a the “CEP group” and the “control group”. Non-randomized studies reporting outcomes with cerebral embolic protection (CEP) during TAVR were excluded to reduce the selection and confounding bias of observational pilot studies. The primary outcome was post-procedural stroke. Secondary outcomes included total lesion volume on MRI and new ischemic lesions on MRI. Results nine trials including 4077 patients were eligible for analysis and included to the meta-analysis. Of those, 2203 patients were randomized to cerebral embolic protection and 1874 patients to control group. Despite the rate of post-procedural stroke was higher in the CEP arm (2.27%) compared to the control arm (2.87%, p Conclusions use of cerebral embolic protection devices during TAVR is a safe procedure. However, the current outline of results from all randomized controlled trials available does not support its routine use, as no significant reduction of stroke risk was evident. The use of these devices might be considered in selected high-risk patients, such as in the setting of heavy calcified cusps or atherosclerotic aortic lesions.

While transcatheter aortic valve replacement (TAVR) gradually emerges as first line therapy for aortic disease in most surgical risk groups, structural prosthetic degeneration remains an issue that may must be considered when planning procedures in younger patients. We present the case of a 74 years old female who underwent a valve-in-valve TAVR following degeneration of a previously implanted TAVR which had initially been complicated by distal embolization of two prosthetic valves. The patient initially underwent TAVR in 2010 for severe aortic regurgitation and a porcelain aorta. The procedure was complicated by distal embolization of two prosthetic valves; firstly a 26 mm Sapien valve migrated to the pre-renal abdominal aorta. This was followed by the embolization of a 29 mm CoreValve to the descending thoracic aorta. Finally, on the third attempt, a 29 mm CoreValve was successfully implanted without complication. The patient remained clinically stable until February 2022 when she developed progressively worsening effort angina and dyspnea. Echocardiographic evaluation demonstrated prosthetic aortic valve degeneration with cusp fibrosis and calcification, with severe aortic regurgitation. Interestingly, neither of the embolized prosthetic valves showed signs of deterioration on CT imaging. The valve that had migrated to the abdominal aorta did not show any significant increase in gradient or regurgitation on Doppler evaluation. After careful evaluation and Heart Team discussion, a transfemoral valve-in-valve (ViV) procedure was performed uneventfully with a 23 mm Sapien Ultra implant, that resulted in complete abolition of regurgitation with mild prosthesis-patient mismatch (mean gradient 15 mmHg, EOA 0.8 cm2/m2). Post-procedural CT imaging confirmed a satisfactory result with no signs of dislocation of the previous valve prostheses (Figure 3). The patient was safely discharged on day 4 post-op on oral anticoagulation (due to a history of atrial fibrillation), and was asymptomatic at 30-day follow-up. This case report describes a challenging but successful ViV TAVR implantation.

Aims Post-procedural bleedings have a significant impact on mortality in patients undergoing transcatheter aortic valve replacement (TAVR). Unfortunately, the source of these bleedings is often undetermined, causing difficulties in diagnosis and related treatment. Furthermore, the frequency and determinants of ‘non-overt’ bleeding are largely lacking in TAVR studies. Accordingly, in this analysis, we aimed to assess the frequency and determinants of haemoglobin drop without overt bleeding in patients undergoing TAVR. Methods Patients undergoing TAVR at Magna Graecia University in Catanzaro from September 2008 to November 2020 were included in this study. Post-procedural haemoglobin (Hb) drop was calculated subtracting the lowest value observed after the procedure to the one obtained at admission (Hb drop). The association between baseline clinical and procedural variables with Hb drop was investigated with a linear regression model. Results Out of 407 patients undergoing TAVR at our institution, 119 (29.2%) were excluded because experiencing overt bleeding, red blood cells transfusion, were treated with only balloon angioplasty, or for procedural unsuccess. Among the 288 patients included in the final analysis, 239 (83.0%) were older than 74 y.o., 148 (51.4%) were female, 94 (32.6%) were diabetics, and 69 (24.0%) had CKD. All the patients were deemed at intermediate/high operatory risk and treated using the transfemoral approach. After TAVR, Hb significantly decreased (12.6 ± 1.6 g/dL to 9.7 ± 1.3 g/dL, P Conclusions Post-procedural reduction of Hb without overt bleeding or RBC transfusion is frequent, involving almost half of the patients undergoing TAVR. The introduction in clinical practice of new-generation valve devices is significantly associated with a reduction of this adverse event. However, further and thorough investigation should be accomplished to reclassify this large part of patients into a well-defined category.

Aims Acute coronary syndrome (ACS) are a leading cause for mortality and morbility worldwide. Despite ACS usually affects the older population, it also occurs in younger individuals. Young ACS patients (YACS) have a significantly worse prognosis compared to their age-mates in the general population. Despite YACS are characterized by a different risk profiles compared to their older mates, many aspects still remain elusive. Aim of this study was to describe the clinical profile of young adults with Acute Coronary Syndrome. Methods and results Young patients (≤50 years) with the first diagnose of Acute Coronary Syndrome admitted to the Magna Graecia University Hospital were enrolled in the ongoing GENEPAMY registry. Over 7 years, a total of 675 eligible patients with Acute Coronary Syndrome aged 44 ± 8 years were included. Men accounted for 84.9% of all patients. Overall, 11.9% of patients had diabetes, 69.1% hypertension, 17.6% obesity, 93.6% dyslipidemia, while 75.5% were smokers. In the overall cohort, 44.1% were first diagnosed with STEMI, 45.9% with NSTEMI, while the remaining had been admitted for Unstable Angina. Cardiogenic shock was present at admission in 2.7% of cases. Multivessel disease was present in 39% of cases and was significantly less frequent in women (P Conclusions Our data highlight that YACS present a peculiar clinical profile. In particular, the high cardiovascular risk profile demands attention. Finally, despite most patients were men, young women with ACS present several relevant differences compared to men, needing a more careful clinical management.

An 82 years old woman was admitted to our Division for worsening dyspnoea. Her past medical history showed: arterial hypertension, chronic atrial fibrillation on oral anticoagulation, a non-critical single-vessel coronary artery disease, previous mitral transcatheter edge-to-edge repair through 2 Mitraclip NTR. After an initial improvement in clinical symptoms following Mitraclip implantation, the patient was admitted several times for acute decompensated heart failure. Haematological exams at admission were normal, exception of NTproBNP (1909 pg/mL). The ECG documented atrial fibrillation with normal ventricular rate. Transthoracic echocardiography demonstrated mid-range heart failure (EF 45–50%) with D-shape morphology of the left ventricle. Colour-doppler analysis shows presence of Mitraclip devices in place with mild residual insufficiency, dilation of the right side, torrential tricuspid regurgitation (tTR) with estimated pulmonary arterial pressure of 45 mmHg. Preprocedural transesophageal echocardiography confirmed these findings showing dilation of the tricuspid annulus with two large regurgitating jets. After positioning Amplatzer Superstiff guide in superior vena cava through guide catheter TSGC0202, a Triclip XT was placed in commissural region between anterior and septal leaflets. A two-grade reduction in tricuspid regurgitation (TR) grade from torrential (5+) to moderate (3+) was achieved without significant transvalvular gradient. The patient was successful discharged after 2 days, asymptomatic and in good clinical conditions. A great reduction in NTproBNP values at discharge was observed (1612 pg/mL). We report a case of successful tricuspid transcatheter repair in patient with chronic decompensated heart failure and previous Mitraclip treatment. The clinical impact of TR reduction is probably due to a positive right ventricular (RV) remodelling, with a reduction in RV size. RV dysfunction and its implications (liver, renal, and haemostatic consequences) are definitely a matter of concern for fragile patients with TR. In fact, many patients with severe TR have a reduced RV function. The reduction in volume and pressure overload of the right heart side, the progressive anatomic and functional reverse of the RV disfunction, may lead to a significant clinical benefit and to a lower hospitalizations rates also through to an important improvement of the left ventricular function as a consequence of the reduction in pressure overload.

Aims conduction disturbances requiring pacemaker implantation (PPM) are among the most common complications in patients undergoing transcatheter aortic valve replacement (TAVR). Introduction in clinical practice of a new generation of TAVR devices is contributing to a significant reduction in procedural complications. However, limited data is available regarding PPM implantation after TAVR with the latest available devices. Accordingly, in this analysis we aimed to investigate the incidence and risk factors for new permanent pacemaker implantation after TAVR according to the type and diameter of valve implanted. Methods Patients who underwent TAVR at our Institution from September 2008 to November 2020 were included in this analysis. Out of 407, 38 (9.3%) were excluded because they already presented a PPM/ICD, received only balloon angioplasty or for procedural unsuccess. The independent association between baseline clinical and procedural variables and the occurrence of PPM implantation was investigated with cross-sectional logistic regression analysis. Results Out of 368 TAVR procedures included in the final analysis, 89 (24.2%) required in-hospital PPM implantation. No differences were observed for age and common cardiovascular risk factors between groups. Among procedural variables, patients requiring PPM had lower left ventricular ejection fraction (LVEF) and experienced a longer intensive care unit stay. Valve types used were Corevalve n = 98 (26.6%) (first-generation devices), Evolute R, n = 191 (51.9%), Evolute Pro, n = 3 (1.1%), Portico n = 2 (0.5 %), or Sapien 3, n = 73 (19.8%) (second-generation devices). Clinical and procedural correlates of PPM implantation were depicted in Figure. Of note, compared to the first generation of self-expandable devices, the second generation is associated with a lower risk of PPM implantation, albeit non-significant for the subgroup of second generation self-expandable devices. Finally, valve diameter was also an independent predictor of PPM implantation Conclusions PPM was required in 24.2% of patients who underwent TAVR with first- and second-generation balloon or self-expandable valves. For instance, in our population, second-generation TAVR devices were associated with a lower risk of PPM implantation compared to the previous generation. However, further investigations are warranted to assess the impact of new implantation techniques and valve technology on such an important outcome.

Aims A small effective orifice area (EOA) by body surface area (BSA), defined as prosthesis–patient mismatch (PPM), is associated with elevated transprosthetic pressure gradients, less ventricular remodelling, and a worse prognosis. Calculating PPM by dividing the normal reference value of EOA for the model and size of the prosthetic valve (predicted PPM), instead of using the continuity equation has been recently confirmed as more accurate after trans catheter aortic valve intervention (TAVI), providing a stronger association with post-procedural haemodynamic outcomes. However, current evidence using this new definition is still limited, thus impairing generalizability. Accordingly, this analysis aims to extend such evidence providing incidence, and determinants of predicted PPM (PPMp) in an all-comers population undergoing TAVR with a high prevalence of self-expandable devices. Methods 395 patients who underwent TAVI at our Institution from September 2008 to November 2020 were included in this analysis. PPMp was then classified as moderate if ≤ 0.85 cm2/m2 and severe if ≤ 0.65 cm2/m2 as well as moderate if ≤ 0.70 cm2/m2 and severe if ≤ 0.55 cm2/m2 for patients with a body mass index > 30, as recommended by the Valve Academic Research Consortium-3 definition. The independent association between baseline clinical and procedural variables and the presence of moderate or severe PPMp was investigated with cross-sectional logistic regression analysis. Results 11 patients (2.78%) had severe and 33 (8.35%) moderate PPMp. Patients with moderate or severe PPMp (m/s PPMp) were younger, female, with a higher prevalence of hypercholesterolaemia, prior aortic valve implantation and balloon expandable device and lower prevalence of chronic obstructive disease (COPD). Post-procedural mean gradient was higher in patients with m/s PPMp. The independent clinical and procedural correlates associated with higher likelihood of m/s PPMp were valve in valve procedure (ViV) and the use of a balloon-expandable device. Conclusions Moderate or severe PPMp was observed only in a small part of patients underwent TAVI, leading, however, a higher post-procedural mean gradient compared to those without PPMp. Balloon expandable devices and ViV were the strongest determinant of moderate or severe PPM.

Aims Many efforts have been made in the last decade to minimize the risk of bleeding in patients undergoing transcatheter aortic valve replacement (TAVR), such as a less intensive antithrombotic therapy and technical improvement in devices implantation. Conversely, evidence on high atherothrombotic status (HATR) is still lacking in patients undergoing TAVR. Accordingly, in this analysis, we aimed to evaluate frequency and impact of atherothrombotic status in patients undergoing transcatheter aortic valve replacement. Methods Patients who underwent TAVR at our Institution from September 2008 to November 2020 were included in this analysis. Out of 407 patients, 6 (1.5%) were excluded as they underwent only balloon angioplasty or for procedural unsuccess. HATR status includes patients with prior percutaneous coronary intervention/coronary artery bypass graft, prior stroke/transient ischaemic attack (TIA), or with a diagnosis of diabetes. Continuous variables following normal distribution were compared with the student’s t-test and categorical data were analysed with the chi-square test. A Cox regression model was used to evaluate the association between HART status and all-cause mortality at one 1-year follow-up. Results Compared to patients with low atherothrombotic status (LATR) (n = 238; 59.4%), HART patients (n = 163; 40.6%) were older, more likely female and with a higher prevalence of common cardiovascular risk factors including chronic kidney disease, smoke, and hyperlipidaemia. Between LATR and HATR groups, no differences have been observed, in terms of procedural time, type of devices used (Balloon vs. self-expandable device), or hospitalization length. Compared to LART, HART patients were more likely to be discharged on statin (63.7% vs. 83%, P Conclusion In our population, no differences in procedural and in-hospital adverse events have been observed according to the atherothrombotic profile. HATR patients were more likely to be discharged with more intensive antithrombotic and hypolipidaemic strategies, despite the coexistent high prevalence of bleeding determinants. However, ATR status does not impact 1-year mortality even after adjustment for baseline characteristics.