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Transcatheter aortic valve replacement (TAVR) is indicated for the treatment of patients with severe aortic stenosis (AS) at low, intermediate, and high risk. Immediate complications post-TAVR that lead to hemodynamic compromise include: retroperitoneal bleeding, aortic dissection or rupture, pericardial tamponade, coronary ostial obstruction, acute severe central or paravalvular regurgitation, heart block, and suicide left ventricle. The presence of significant paravalvular leak (PVL) after TAVR is now an uncommon complication with newer generation devices. We present a case of an 82-year-old frail female patient who presented to our clinic with dyspnea upon minimal exertion and orthopnea. She was found to have severe AS that was treated with TAVR. The procedure was complicated by hemodynamic compromise due to severe PVL and left ventricular outflow tract (LVOT) obstruction which was underestimated by transthoracic echocardiography. The PVL was eventually treated with a vascular plug device and the LVOT obstruction was treated with alcohol septal ablation. This case highlights the vital role of early and aggressive work up in unstable patients post-TAVR and the importance of transesophageal echocardiography in patients with unexplained hypotension post-TAVR to unmask the severe PVL and dynamic LVOT obstruction. < Learning objective: Early and aggressive work-up is necessary in unstable patients post-transcatheter aortic valve replacement. Anesthesia is needed in high-risk cases to quickly deal with hemodynamic changes. Transesophageal echocardiography is particularly required when a patient develops unexplained hypotension as it can unmask severe paravalvular leak and dynamic left ventricular outflow obstruction.> [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to evaluate the use of transcatheter heart valves (THV) for the treatment of noncalcific pure native aortic valve regurgitation (NAVR) and failing bioprosthetic surgical heart valves (SHVs) with pure severe aortic regurgitation (AR). Background Limited data are available about the “off-label” use of transcatheter aortic valve replacement (TAVR) to treat pure severe AR. Methods The study population consisted of patients with pure severe AR treated by TAVR at 18 different centers. Study endpoints were device success, early safety, and clinical efficacy at 30 days, as defined by Valve Academic Research Consortium 2 criteria. Results A total of 146 patients were included, 78 patients in the NAVR group and 68 patients in the failing SHV group. In the NAVR group, device success, early safety, and clinical efficacy were 72%, 66%, and 61%, respectively. Device success and clinical efficacy were significantly better with newer generation THVs compared with old-generation THVs (85% vs. 54% and 75% vs. 46%, respectively, p < 0.05); this was mainly due to less second THV implantations and a lower rate of moderate to severe paravalvular regurgitation (10% vs. 24% and 3% vs. 27%, respectively). Independent predictors of 30-day mortality were body mass index <20 kg/m 2 , STS surgical risk score >8%, major vascular or access complication, and moderate to severe AR. In the failing SHV group, device success, early safety, and clinical efficacy were 71%, 90%, and 77%, respectively. Conclusions TAVR for pure NAVR remains a challenging condition, with old-generation THVs being associated with THV embolization and migration and significant paravalvular regurgitation. Newer generation THVs show more promising outcomes. For those patients with severe AR due to failing SHVs, TAVR is a valuable therapeutic option. [ABSTRACT FROM AUTHOR]

Contemporary clinical trials, registries, and meta-analyses, supported by recent results from the EXCEL (Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease) and NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trials, have established percutaneous coronary intervention of left main coronary stenosis as a safe alternative to coronary artery bypass grafting in patients with low and intermediate SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) scores. As left main percutaneous coronary intervention gains acceptance, it is imperative to increase awareness for patient selection, risk scoring, intracoronary imaging, vessel preparation, and choice of stenting techniques that will optimize procedural and patient outcomes. [ABSTRACT FROM AUTHOR]

Background Although the trans-radial approach (TR) has been applied to various subsets of patients in percutaneous coronary intervention, the feasibility, efficacy, acute procedural and long-term outcomes of TR versus trans-femoral approach (TF) for alcohol septal ablation (ASA) have not yet been determined. Objectives The aim of this study was to compare the short and long-term outcomes of ASA with the TR approach compared to the TF approach. Methods We retrospectively analyzed 240 patients who underwent an ASA procedure at our institution from November 1999 to November 2015. The TR approach was performed in 172 cases and the TF approach in the remaining 68 cases. Results The use of TR approach progressively increased from 62% in 1999–2005 to 91% in 2011–2015 (p = 0.0001). The TF and TR group had similar age, baseline NYHA class (NYHA 3 or 4) and mean left ventricular outflow tract peak gradient before ASA. Total contrast used (TR: 73.2 ± 47.2 ml; TF: 88.7 ± 49.3 ml, p = 0.11), total radiation Air kerma area product (TR: 43.7 ± 48.0 Gy cm − 2 ; TF: 55.9 ± 48.2 Gy cm − 2 ; p = 0.39) and peak left ventricular outflow tract gradient immediately after ASA (TR: 19.1 ± 19.6 mmHg; TF: 20.4 ± 18.0 mmHg, p = 0.63) were similar in both groups. Procedural success was 91.9% and 91.2% in the TR and TF groups, respectively (p = 0.53). At 30 days, there was 2 intra-hospital death (1 in TF and 1 in TR), 1 major stroke in the TF group and 1 coronary artery dissection in the TR group. Vascular complications were less frequent in the TR group (0.58% vs. 7.3%; p = 0.002). The mean length of follow-up was 4.56 ± 4.34 years (IQR 0.69–8.2; median 2.92 years; maximum: 15.5 years). By Kaplan–Meier estimate, the observed survival in the overall cohort was comparable to the expected survival for a sex and age-matched comparable general French population at 10 years (86.9 vs. 83.6%, p = 0.88). Survival was similar between the TR and TF group (92.1% vs. 89.7% at 6 years, respectively; p = 0.71). Conclusions Alcohol septal ablation from the radial approach can be performed with similar acute and long-term success, but with lower vascular complications compared to the femoral approach. [ABSTRACT FROM AUTHOR]

Coronary bifurcations are frequent and account for approximately 20% of all percutaneous coronary interventions. Nonetheless, they remain one of the most challenging lesion subsets in interventional cardiology in terms of a lower procedural success rate and increased rates of long-term adverse cardiac events. Provisional side branch stenting should be the default approach in the majority of cases and we propose easily applicable and reproducible stepwise techniques associated with low risk of failure and complications. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to investigate the prevalence, predictors, and outcomes of patients with post-operative ventricular arrhythmia (POVA) in a large cohort of patients. Background: New-onset POVA after cardiac surgery (CS) is uncommon and has controversial prognostic value. Methods: A total of 14,720 consecutive patients undergoing CS at Emory University between January 2004 and July 2010 were included in the study. Data on all-cause mortality were obtained from Social Security Administration death records. Multivariable regression models were constructed to determine the risk factors for POVA and to estimate the independent impact of POVA on long-term survival after adjusting for 40 different covariates. Results: POVA occurred in 248 patients (1.7%). Patients with POVA were older (63.5 vs. 61.6 years), had lower left ventricular ejection fraction (EF) (43.7 vs. 51.3), and had greater comorbidities (Society of Thoracic Surgeons mortality risk score of 7.2% vs. 3.1%, p < 0.001). Multivariable analysis showed that older age (odds ratio [OR]: 1.018 per 1-year increase, p < 0.001), emergent surgery (OR: 1.77, p = 0.019), and the presence of PVD (OR: 1.41, p = 0.049) were associated with a higher incidence of POVA, whereas higher left ventricular EF (OR: 0.97 per 1% increase, p < 0.001), mild chronic obstructive pulmonary disease (OR: 0.37, p < 0.001), and off-pump surgery (OR: O.41, p < 0.001) were associated with a lower incidence of POVA. POVA was associated with substantially increased adjusted long-term mortality (hazard rate: 2.53, p < 0.001) over 3.5 years of follow-up. Conclusions: POVA is associated with increased long-term mortality after CS. Older age, PVD, lower EF, and emergent surgery are associated with a higher risk of POVA, whereas off-pump surgery seems to be protective. [ABSTRACT FROM AUTHOR]

Intravascular ultrasound (IVUS) provides valuable information on the coronary vascular lumen and wall and has been an important tool in the cardiac catheterization laboratory for over 2 decades. The major utility of IVUS relates to optimizing stent deployment, particularly in complex lesions. In percutaneous coronary intervention with bare-metal stents, IVUS guidance reduces restenosis. In percutaneous coronary intervention with drug-eluting stents, IVUS guidance may reduce rates of stent thrombosis with little affect on restenosis. The benefit of IVUS guidance is most important in complex lesion subsets, such as left main and bifurcation lesions, where studies suggest that IVUS guidance may reduce mortality. Whereas IVUS luminal area measurements have been used to assess intermediate lesion severity, recent studies have demonstrated that IVUS accurately identifies nonischemic lesions for which percutaneous coronary intervention can be safely deferred, but cannot accurately predict hemodynamically significant lesions and should not solely be used to justify revascularization. In the current review, we focus on clinical applications of IVUS in interventional cardiology. [Copyright &y& Elsevier]

Summary: Polymicrobial Gram-negative pericarditis is a rare entity. We describe the first case of suppurative pericarditis with Citrobacter diversus and Proteus mirabilis. [Copyright &y& Elsevier]

Abstract Background Percutaneous coronary intervention (PCI) has been established as an alternative treatment option to coronary artery by-pass graft (CABG) surgery in patients with left main coronary artery disease (LMCAD). Whether the findings of randomized controlled trials are applicable to a real-world patient population is unclear. Methods We compared the outcomes of PCI with new-generation DES in the all-comer, international, multicenter DELTA-2 registry retrospectively evaluating mid-term clinical outcomes with the historical CABG cohort enrolled in the DELTA-1 registry according to the EXCEL key inclusion or exclusion criteria. The primary endpoint was the composite of death, myocardial infarction, or stroke at the median time of follow-up time of 501 days. The consistency of the effect of DELTA-2 PCI versus DELTA-1 CABG according to the EXCEL enrollment criteria was tested using propensity score-adjusted Cox regression models. Results Out of 3986 patients enrolled in the DELTA-2 PCI registry, 2418 were EXCEL candidates and 1568 were not EXCEL candidates. The occurrence of the primary endpoint was higher among non-EXCEL candidates compared with EXCEL candidates (15.4% vs. 6.9%; hazard ratio 2.52; 95% confidence interval 2.00–3.16; p < 0.001). Among 901 patients enrolled in the historical DELTA-1 CABG cohort, 471 were EXCEL candidates and 430 were not EXCEL candidates. When comparing the DELTA-2 PCI with the DELTA-1 CABG cohort, the occurrence of the primary endpoint was lower in the PCI group compared with the historical CABG cohort among EXCEL candidates (6.9% vs. 10.7%; adjusted hazard ratio: 0.65; 95% confidence interval: 0.45–0.92), while no significant difference was observed among non-EXCEL candidates (15.4% vs. 12.5%; adjusted hazard ratio: 0.94; 95% confidence interval: 0.67–1.33) with evidence of statistical interaction (adjusted interaction p-value = 0.002). Conclusions In a real-world population, PCI can be selected more favorably as an alternative to CABG in patients fulfilling the enrollment criteria of the EXCEL trial. Highlights • PCI with DES for LMCAD has become an acceptable alternative to CABG in selected patients • The DELTA-2 registry is an all-comers, international, multicenter registry of unprotected LM PCI with new-generation DES • In the real-world data, EXCEL candidates had lower risk of major adverse cardiac events than non-EXCEL candidates • PCI can be selected more favorably as an alternative to CABG only among EXCEL candidates • The applicability and generalizability of findings from RCTs should be taken into account to inform clinical decision-making [ABSTRACT FROM AUTHOR]

Abstract: Background: Coronary artery disease (CAD) is one of the major causes of morbidity and mortality in the world. The disease is determined by many risk factors such as age, gender, diabetes, dyslipidemia, smoking, as well as elevated serum levels of lipoprotein (a) (Lp(a)), homocysteine, C-reactive protein (CRP) and uric acid. In this study, we evaluated the association of biologic and metabolic parameters with CAD in a group of Lebanese patients. Methods: Three hundred patients were recruited for the study. Biologic and blood metabolic parameters were measured. Patients were then divided into 3 groups according to their catheterization result: 0% stenosis (controls), <50% stenosis and ≥50% stenosis. Results: Hyperlipidemias, CRP, homocysteine and uric acid levels in CAD patients were not different from those of the controls. However, age, elevated fasting blood glucose (FBG) and elevated serum Lp(a) levels were found to be strong independent predictors of CAD in our study population. Association with CAD was also shown for gender, hypertension, diabetes and family history of CAD. Conclusion: We report the importance of serum Lp(a) levels and FBG in the prediction and prevention of CAD in our population. [Copyright &y& Elsevier]