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Aims To assess the incidence, management and long-term outcomes of transcatheter heart valve thrombosis (THVT). Methods and results Between August 2007 and February 2016, 1396 patients were included in the Bern TAVI Registry and prospectively followed-up through echocardiographic and clinical evaluation. THVT was suspected in case of: (i) a mean transvalvular pressure gradient greater than 20 mmHg at transthoracic echocardiography, or (ii) an increase of more than 50% of the mean transvalvular pressure gradient compared with previous measurements or (iii) new symptoms or signs of heart failure with the presence of thrombus documented by transoesophageal echocardiography or multi-slice computed tomography. THVT occurred in 10 patients (0.71%) at variable time points after TAVI. Increased transvalvular pressure gradients were recorded in all patients and 7 out of 10 patients were symptomatic. Oral anticoagulant therapy (with vitamin K antagonists or non-Vitamin K antagonists) was initiated in all but two patients and resulted in normalization of transvalvular pressure gradients and amelioration of clinical status within 1 month. At long-term follow-up (between 10 and 25 months after valve thrombosis), echocardiographic findings were stable and no adverse events were reported. Conclusion THVT is rarely detected at routine clinical and echocardiographic evaluation after TAVI. Oral anticoagulation appears effective to normalize transvalvular gradients in the majority of cases with stable clinical and haemodynamic evolution during long-term follow-up.

There have been no reports evaluating the impact of long-acting loop diuretics (LLD) on the outcome of heart failure (HF) and arrhythmia treatment in HF with reduced ejection fraction (HFrEF) patients implanted with a cardiac resynchronization therapy (CRT) device.This was a prospective, single-blind, randomized crossover study. We allocated 21 consecutive CRT implanted patients into 2 groups. The furosemide group received furosemide as a first treatment and azosemide as a second treatment. The azosemide group received this treatment in the reverse order. The first treatment was given to each group for 6 months and the second treatment continued for an additional 6 months. We combined the data of each medication regimen in each group and analyzed it at baseline, 6 months, and 1 year. The primary endpoints were the variation of fluid index and thoracic impedance measured by CRT at 6 months.The baseline characteristics were similar for both groups. The difference in the primary endpoints was not statistically significant between the 2 medication arms (fluid index: -29.6 ± 64.4 versus 16.2 ± 48.2; P = 0.22, thoracic impedance: -0.49 ± 17.8 versus 2.45 ± 12.5; P = 0.56). Likewise, the clinical outcome of HF and the CRT derived parameters in both arms were comparable.HFrEF patients taking LLD after CRT implantation might be comparable to those taking short-acting loop diuretics in the treatment of HF and HF-associated arrhythmias.

An 85-year-old man with chronic obstructive pulmonary disease was referred to our institution to treat congestive heart failure caused by severe aortic valve stenosis (AS). Pre-procedural computed tomography assessments showed type 1 functional bicuspid AS with fused right and left coronary cusps ([

Background Mitral annular calcification (MAC) and mitral valve diseases (MVD) have been identified as strong predictors of mortality in patients undergoing transcatheter aortic valve replacement (TAVR). However, the association between MAC and MVD, and the prognostic implications in these patients remain unclear. Purpose This study sought to investigate the association between severity of MAC and the prevalence of MVD as well as to assess the prognostic impact of MAC depending on the presence or absence of MVD in patients undergoing TAVR. Methods We identified 967 patients who have comprehensive echocardiographic and computed tomographic assessment of MVD and MAC from our institutional registry that is a part of the Swiss TAVI registry (NCT01368250) between August 2007 and June 2017. Results Among these patients, mild or moderate MAC was present in 45.2% and severe MAC was present in 17.8%. The prevalence of MVD was significantly higher in severe MAC patients, while the prevalence in patients with mild and moderate MAC was similar to patients without MAC. Compared to patients without severe MAC and MVD, an increased risk of all-cause death at 1 year was observed in patients with severe MAC and MVD (hazard ratio [HR]: 2.81, 95% confidence interval [CI]: 1.72–4.59, p Conclusions Severe MAC was associated with higher prevalence of MVD. Severe MAC concomitant with MVD was associated with increased risks of mortality at 1 year and conduction abnormalities after TAVR, whereas severe MAC without MVD was not.

Background: The extracellular volume (ECV) calculated by T1 mapping, and tissue-tracking strain using cardiac magnetic resonance (CMR) are useful for assessing the left ventricular (LV) function. However, those parameters are controversial for assessing left atrial (LA) function. This study aimed to investigate the usefulness of CMR to evaluate the LA function using those parameters. Furthermore, those LA function parameters were compared in each LV function. Methods: A total of 65 consecutive patients who underwent contrast CMR were prospectively enrolled (age 55.7 ± 14. 6 years, males 67.7%). Among the 65 patients, there were 15 without hypertension, diabetes, or atrial fibrillation (Healthy group). The remaining 50 patients were divided into two groups according to a left ventricular ejection fraction (LVEF) of 50%. We assessed the correlations between the LV- and LA-CMR parameters among the three groups (LVEF

Background Concomitant structural degeneration of surgical mitral bioprostheses and paravalvular leak (PVL) is rare but potentially fatal. Data pertaining to simultaneous transcatheter mitral valve implantation (TMVI) and percutaneous PVL closure are limited, and the optimal treatment strategy remains undetermined. We report a case of simultaneous TMVI and double percutaneous PVL closure in a patient with a degenerated bioprosthetic mitral valve and associated medial and lateral PVLs. Case summary A 75-year-old woman who underwent combined aortic (Edwards Perimount Magna 19 mm) and mitral (Edwards Perimount Magna 25 mm) surgical valve replacement 6 years ago was referred for treatment of new-onset orthopnoea and severely reduced exercise capacity. Transoesophageal echocardiography revealed severe mitral stenosis and concomitant moderate to severe mitral regurgitation, originating from two PVLs located medial and lateral from the surgical bioprosthesis. Due to high surgical risk, we performed successful transseptal mitral valve-in-valve (ViV) implantation combined with the closure of two PVLs during the same procedure. Discussion Although surgery should be considered as a first-line treatment in this setting, most patients have extremely high or prohibitive surgical risk inherent to repeat open heart surgery. Mitral ViV implantation appears a reasonable treatment option for patients with failed mitral bioprostheses. Furthermore, a recent study of percutaneous PVL closure showed no significant difference in long-term all-cause mortality compared with redo open-heart surgery. Simultaneous TMVI and percutaneous PVL closure appears feasible in selected high-risk patients.

Aims We sought to evaluate the outcomes of transcatheter mitral valve replacement (TMVR) for patients with degenerated bioprostheses [valve-in-valve (ViV)], failed annuloplasty rings [valve-in-ring (ViR)], and severe mitral annular calcification [valve-in-mitral annular calcification (ViMAC)]. Methods and results From the TMVR multicentre registry, procedural and clinical outcomes of ViV, ViR, and ViMAC were compared according to Mitral Valve Academic Research Consortium (MVARC) criteria. A total of 521 patients with mean Society of Thoracic Surgeons score of 9.0 ± 7.0% underwent TMVR (322 patients with ViV, 141 with ViR, and 58 with ViMAC). Trans-septal access and the Sapien valves were used in 39.5% and 90.0%, respectively. Overall technical success was excellent at 87.1%. However, left ventricular outflow tract obstruction occurred more frequently after ViMAC compared with ViR and ViV (39.7% vs. 5.0% vs. 2.2%; P

Background: The left-ventricular myocardial performance index Tei is an echocardiographic parameter that incorporates the information of systolic and diastolic time intervals. While the prognostic value of selected systolic and diastolic parameters is well established after transcatheter aortic valve replacement, the role of Tei has not been evaluated in this setting. Methods and Results: Between August 2007 and December 2015, consecutive patients with symptomatic, severe aortic stenosis and transthoracic echocardiography pre- and post-transcatheter aortic valve replacement were considered eligible for this analysis. The primary end point was all-cause mortality at 1 year after transcatheter aortic valve replacement. Of 824 patients with echocardiographic images to calculate Tei, pre-Tei was normal (adj ] 3.62; 95% CI, 1.89–6.91) and 1 year (HR adj 2.56; 95% CI, 1.78–3.69). Similarly, post-Tei was associated with an increased risk of mortality between 30 days and 1-year follow-up (HR adj 6.70; 95% CI, 4.22–10.63). At multivariable analysis Tei emerged as an independent predictor of early (pre-Tei index per 0.1–HR adj 1.40; 95% CI, 1.23–1.60) and late mortality (post-Tei index per 0.1–HR adj 1.40; 95% CI, 1.31–1.50), respectively. Conclusions: The left-ventricular myocardial performance index Tei is associated with impaired clinical outcomes during short- and longer-term follow-up after transcatheter aortic valve replacement. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01368250.

Background: Aortic valvular resistance (VR) may be a surrogate for shear stress in patients with aortic stenosis. Stenosis-induced shear stress is known to affect platelet function and bleeding tendency. The aim of this study is to assess the association between VR and bleeding events in patients undergoing transcatheter aortic valve replacement (TAVR). Methods: VR was calculated in 708 patients undergoing TAVR between August 2007 and December 2015. All subjects were stratified into a high VR (HVR; ≥238 dynes·cm−5) and a low VR (LVR; Results: After adjustment for confounding factors, patients with HVR had a higher risk of bleeding events at 1 year (HRadj 2.09, 95% CI 1.56–2.80) than those with LVR. The difference emerged within the first month after intervention (HRadj 2.20, 95% CI 1.62–2.99) and was driven by procedural (HRadj 1.82, 95% CI 1.33–2.72) and non-procedural (HRadj 1.86, 95% CI 1.15–3.00) bleeding events. The effect was consistent across access sites and valve types. Of note, the unfavorable effect with regard to bleeding attenuated beyond 30 days post-TAVR (HR 1.01, 95% CI 0.32–3.14). In a multivariable analysis, HVR, renal failure at baseline, transapical approach, and moderate or greater post-TAVR aortic regurgitation were identified as independent predictors of bleeding within 1 year after TAVR. Conclusions: HVR at baseline was associated with bleeding events after TAVR; however, bleeding tendency in this setting improved within 30 days after releasing stenosis at the aortic position. Abbreviations: AR, aortic regurgitation; AS, aortic stenosis; AVA, aortic valve area; CI, confidence interval; MACCE, major adverse cardiac and cerebrovascular events; NYHA, New York Heart Association; RHC, right heart catheterization; TAVR, transcatheter aortic valve replacement; VARC, the Valve Academic Research Consortium; VR, valvular resistance

OBJECTIVES The purpose of this study was to investigate the association between right ventricular dysfunction (RVD) and cardiovascular death after transcatheter aortic valve replacement (TAVR). BACKGROUND There is conflicting evidence on the effect of RVD on clinical outcomes after TAVR. METHODS A total of 1,116 TAVR patients (age 82 ± 6 years; 51% female) who were consecutively enrolled into a prospective registry underwent detailed pre-operative assessment of right ventricular (RV) function and were dichotomized into 2 groups for the purposes of the present retrospective analysis. RVD was assessed using fractional area change (

OBJECTIVES A large, prospective international registry was developed to evaluate the initial clinical applications of transcatheter tricuspid valve intervention (TTVI) with different devices. BACKGROUND TTVI for native tricuspid valve dysfunction has been emerging during the last few years as an alternative therapeutic option to serve a large high-risk population of patients with severe symptomatic tricuspid regurgitation (TR). METHODS The TriValve Registry included 312 high-risk patients with severe TR (76.4 ± 8.5 years of age; 57% female; EuroSCORE II 9 ± 8%) at 18 centers. Interventions included repair at the level of the leaflets (MitraClip, Abbott Vascular, Santa Clara, California; PASCAL Edwards Lifesciences, Irvine, California), annulus (Cardioband, Edwards Lifesciences; TriCinch, 4TECH, Galway, Ireland; Trialign, Mitraling, Tewksbury, Massachusetts), or coaptation (FORMA, Edwards Lifesciences) and replacement (caval implants, NaviGate, NaviGate Cardiac Structures, Lake Forest, California). Clinical outcomes were prospectively determined during mid-term follow-up. RESULTS A total of 108 patients (34.6%) had prior left heart valve intervention (84 surgical and 24 transcatheter, respectively). TR etiology was functional in 93%, and mean annular diameter was 46.9 ± 9 mm. In 75% of patients the regurgitant jet was central (vena contracta 1.1 ± 0.5; effective regurgitant orifice area 0.78 ± 0.6 cm). Pre-procedural systolic pulmonary artery pressure was 41 ± 14.8 mm Hg. Implanted devices included: MitraClip in 210 cases, Trialign in 18 cases, TriCinch first generation in 14 cases, caval valve implantation in 30 cases, FORMA in 24 cases, Cardioband in 13 cases, NaviGate in 6 cases, and PASCAL in 1. In 64% of the cases, TTVI was performed as a stand-alone procedure. Procedural success (defined as the device successfully implanted and residual TR ≤2+) was 72.8%. Greater coaptation depth (odds ratio: 24.1; p = 0.002) was an independent predictor of reduced device success. Thirty-day mortality was 3.6% and was significantly lower among patients with procedural success (1.9% vs. 6.9%; p = 0.04); Actuarial survival at 1.5 years was 82.8 ± 4% and was significantly higher among patients who had procedural success achieved. CONCLUSIONS TTVI is feasible with different technologies, has a reasonable overall procedural success rate, and is associated with low mortality and significant clinical improvement. Mid-term survival is favorable in this high-risk population. Greater coaptation depth is associated with reduced procedural success, which is an independent predictor of mortality.

Serum indoxyl sulfate (IS; a uremic toxin) levels, which are significantly higher in patients with chronic kidney disease, including those undergoing hemodialysis, than in the robust, are associated with both cardiovascular disease (CVD) and CVD-related mortality. Furthermore, coronary artery calcium (CAC) is an independent predictor of cardiovascular events in patients undergoing hemodialysis. This study aimed to interpret the association between serum IS levels and coronary plaque burden (CPB) or CAC.A total of 30 consecutive patients on hemodialysis, who underwent 320-row coronary multidetector computed tomography (MDCT) angiography for suspected coronary artery disease, were enrolled in this prospective study. Coronary artery percent atheroma volume (a CPB marker) and percent calcium volume (a CAC marker) assessed using MDCT were evaluated. Furthermore, various oxidative and inflammatory markers typified by serum IS levels at a dialysis-free day were measured. Using these data, we investigated correlation between the inflammatory marker IS and CPB or CAC.Multivariable analysis indicated that serum IS levels were positively correlated with CAC [partial regression coefficient, 2.89; 95% confidence interval (CI), 0.35-5.43; P = 0.03] but not with CPB, even after adjustment for cofounders. Composite cardiovascular events, namely, as all-cause death, non-fatal myocardial infarction, disabling stroke, and hospital admission for other cardiovascular events, were reported to be 50% in all patients (95% CI, 32.1-67.9).In patients undergoing hemodialysis, serum IS levels were significantly associated with CAC but not with CPB.

OBJECTIVES This study sought to determine the impact of left ventricular (LV) diastolic dysfunction (LVDD) on clinical outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND LV hypertrophy in response to afterload increase promotes the development of LVDD and represents an early stage in the progression to valvular heart failure. METHODS In a consecutive cohort of 777 aortic stenosis patients undergoing TAVR, LVDD was categorized according to the latest guidelines. The primary endpoint was 1-year all-cause mortality. RESULTS There were 545 (70.1%) patients with LVDD. Ninety-eight (18.0%), 198 (36.3%), and 104 (19.1%) patients were classified as LVDD grades I, II, and III, respectively. In 145 (26.6%) patients, LVDD grade could not be determined because of only 1 or 2 discrepant variables. One-year all-cause mortality was higher in patients with LVDD grades I (16.3%; HR: 2.32; 95% CI: 1.15 to 4.66), II (17.9%; HR: 2.58; 95% CI: 1.43 to 4.67), and III (27.6%; HR: 4.21; 95% CI: 2.25 to 7.86) than in those with normal diastolic function (6.9%). The difference in clinical outcome emerged within 30 days, was driven by cardiovascular death, and maintained in a sensitivity analysis of patients with normal systolic LV function. Furthermore, LVDD grades I (HR: 2.36; 95% CI: 1.17 to 4.74), II (HR: 2.58; 95% CI: 1.42 to 4.66), and III (HR: 4.41; 95% CI: 2.37 to 8.20) were independent predictors of 1-year mortality. CONCLUSIONS Advancing stages of LVDD are associated with an incremental risk of all-cause mortality after TAVR, driven by cardiovascular death and taking effect as early as 30 days after the intervention.

BACKGROUND The impact of baseline renal dysfunction on early and late clinical outcomes after transcatheter aortic valve implantation (TAVI) remains to be defined. METHODS 927 patients included in the prospective Bern TAVI registry were classified on the basis of the baseline estimated glomerular filtration rate (eGFR), as having none or mild (eGFR ≥60mL/min/1.73m2, n=284, 30.6%), moderate (eGFR between 30 and 59mL/min/1.73m2, n=535, 57.7%) and severe (eGFR

OBJECTIVES. To evaluate the association between pre-procedure left ventricular hypertrophy (LVH) patterns and clinical outcomes after transcatheter aortic valve replacement (TAVR). BACKGROUND. The association between pre-procedure LVH pattern and severity and clinical outcomes after TAVR is uncertain. METHODS. Patients (n=31,199) across 422 sites who underwent TAVR from November 2011 through June 2016 as part of the STS/ACC Transcatheter Valve Therapies Registry linked with the Centers for Medicare and Medicaid database were evaluated by varying LVH patterns, according to sex-specific cutoffs for left ventricular mass index (LVMI) and relative wall thickness (RWT). The association between LVH pattern (concentric remodeling, concentric LVH, and eccentric LVH) and outcomes (rates of mortality, myocardial infarction (MI), stroke, new dialysis requirement) at one-year follow-up were evaluated using multivariable hazard models. RESULTS. There were no significant associations between concentric remodeling [death: adjusted hazards ratio (HR) 1.03 (95% confidence interval 0.93–1.14), MI: HR 1.06 (0.76–1.47), stroke: HR 1.11 (0.89–1.39), new dialysis: HR 0.86 (0.64–1.15)], concentric LVH [death: HR 1.04 (0.95–1.15), MI: HR 1.12 (0.82–1.52), stroke: HR 1.14 (0.92–1.41), new dialysis: HR 1.17 (0.90–1.51)], or eccentric LVH [death: HR 0.98 (0.87–1.11), MI: HR 1.07 (0.71–1.63), stroke HR 1.01 (0.78–1.32), new dialysis: HR 1.25 (0.92–1.70)] and outcomes at one-year when compared with patients without LVH. CONCLUSIONS. In a contemporary cohort of patients who underwent TAVR, pre-procedure LVH according to LVMI and RWT was not associated with adverse outcomes at one-year follow-up. TAVR is likely to benefit patients with severe AS regardless of the presence of LVH.

Previous studies reporting that statin increases coronary artery calcium (CAC) were conducted exclusively on patients with statin as a prevention, regardless of the presence or absence of dyslipidemia. The impact of sex on CAC has not been fully evaluated. We aimed to determine the association of dyslipidemia and sex with CAC using 320-row multi-detector computed tomography (MDCT).Of the 356 consecutive patients who underwent coronary MDCT, 251 patients were enrolled, after excluding those with prior stenting and/or coronary bypass grafting or images showing motion artifacts. The primary outcome measures were the percent calcium volume (PCV) and percent atheroma volume (PAV) per coronary vessel.Multivariable analyses indicated that PCV was significantly higher in dyslipidemia patients without statins than in the subjects without dyslipidemia [partial regression coefficient (PRC): 2.59, 95% confidence interval (CI): 0.83 to 4.34, P = 0.004]. In contrast, PCV was similar in dyslipidemia patients taking statins and those without dyslipidemia (PRC: -1.09, 95% CI: -2.82 to 0.65, P = 0.22). There was no significant difference in PCV between men and women, although women exhibited a significantly lower PAV (PRC: -2.87, 95% CI: -4.54 to -1.20, P = 0.001).In low-risk patients, these results could be translated into hypotheses, which should be tested in future prospective studies. Furthermore, there was no significant difference in CAC between men and women, but women had lower PAV than men.

Background Limited data exist regarding transcatheter mitral valve replacement (TMVR) for patients with failed mitral valve replacement and repair. Objectives This study sought to evaluate the outcomes of TMVR in patients with failed mitral bioprosthetic valves (valve-in-valve [ViV]) and annuloplasty rings (valve-in-ring [ViR]). Methods From the TMVR multicenter registry, procedural and clinical outcomes of mitral ViV and ViR were compared according to Mitral Valve Academic Research Consortium criteria. Results A total of 248 patients with mean Society of Thoracic Surgeons score of 8.9 ± 6.8% underwent TMVR. Transseptal access and the balloon-expandable valve were used in 33.1% and 89.9%, respectively. Compared with 176 patients undergoing ViV, 72 patients undergoing ViR had lower left ventricular ejection fraction (45.6 ± 17.4% vs. 55.3 ± 11.1%; p < 0.001). Overall technical and device success rates were acceptable, at 92.3% and 85.5%, respectively. However, compared with the ViV group, the ViR group had lower technical success (83.3% vs. 96.0%; p = 0.001) due to more frequent second valve implantation (11.1% vs. 2.8%; p = 0.008), and lower device success (76.4% vs. 89.2%; p = 0.009) due to more frequent reintervention (16.7% vs. 7.4%; p = 0.03). Mean mitral valve gradients were similar between groups (6.4 ± 2.3 mm Hg vs. 5.8 ± 2.7 mm Hg; p = 0.17), whereas the ViR group had more frequent post-procedural mitral regurgitation moderate or higher (19.4% vs. 6.8%; p = 0.003). Furthermore, the ViR group had more frequent life-threatening bleeding (8.3% vs. 2.3%; p = 0.03), acute kidney injury (11.1% vs. 4.0%; p = 0.03), and subsequent lower procedural success (58.3% vs. 79.5%; p = 0.001). The 1-year all-cause mortality rate was significantly higher in the ViR group compared with the ViV group (28.7% vs. 12.6%; log-rank test, p = 0.01). On multivariable analysis, failed annuloplasty ring was independently associated with all-cause mortality (hazard ratio: 2.70; 95% confidence interval: 1.34 to 5.43; p = 0.005). Conclusions The TMVR procedure provided acceptable outcomes in high-risk patients with degenerated bioprostheses or failed annuloplasty rings, but mitral ViR was associated with higher rates of procedural complications and mid-term mortality compared with mitral ViV.

There have been no reports evaluating the impact of long-acting loop diuretics (LLD) on the outcome of heart failure (HF) and arrhythmia treatment in HF with reduced ejection fraction (HFrEF) patients implanted with a cardiac resynchronization therapy (CRT) device.This was a prospective, single-blind, randomized crossover study. We allocated 21 consecutive CRT implanted patients into 2 groups. The furosemide group received furosemide as a first treatment and azosemide as a second treatment. The azosemide group received this treatment in the reverse order. The first treatment was given to each group for 6 months and the second treatment continued for an additional 6 months. We combined the data of each medication regimen in each group and analyzed it at baseline, 6 months, and 1 year. The primary endpoints were the variation of fluid index and thoracic impedance measured by CRT at 6 months.The baseline characteristics were similar for both groups. The difference in the primary endpoints was not statistically significant between the 2 medication arms (fluid index: -29.6 ± 64.4 versus 16.2 ± 48.2; P = 0.22, thoracic impedance: -0.49 ± 17.8 versus 2.45 ± 12.5; P = 0.56). Likewise, the clinical outcome of HF and the CRT derived parameters in both arms were comparable.HFrEF patients taking LLD after CRT implantation might be comparable to those taking short-acting loop diuretics in the treatment of HF and HF-associated arrhythmias.

The aim of this study was to examine the frequency, timing, and association of access-site and non-access-site bleeding with mortality in the setting of transcatheter aortic valve replacement (TAVR) during long-term follow-up.Bleeding is frequent and associated with impaired prognosis in patients undergoing TAVR. It is currently unknown whether the site of bleeding differentially influences the outcomes of TAVR patients.In total, 926 consecutive patients undergoing TAVR from 2007 through 2014 were evaluated. Bleeding was assessed according to the Valve Academic Research Consortium 2 criteria. The primary outcome of interest was all-cause mortality up to 5 years of follow-up.A total of 285 patients (30.7%) experienced at least 1 (minor, major, or life-threatening) bleeding event up to 5 years. Compared with patients not experiencing bleeding, the adjusted risk for all-cause mortality was significantly increased among patients with access-site (hazard ratio: 1.34; 95% confidence interval: 1.01 to 1.76; p = 0.04) and non-access-site bleeding (hazard ratio: 2.08; 95% confidence interval: 1.60 to 2.71; p 0.001). However, non-access-site bleeding conferred a significantly higher risk for mortality compared with access-site bleeding (hazard ratio: 1.56; 95% confidence interval: 1.12 to 2.18; p = 0.009). At multivariate analysis, female sex was a significant correlate of access-site bleeding, whereas chronic kidney disease and the Society of Thoracic Surgeons score were significantly associated with non-access-site bleeding.Among patients with severe aortic stenosis undergoing TAVR, access-site and non-access-site bleeding were independently associated with an increased risk for mortality, with the greatest risk related to non-access-site bleeding during long-term follow-up.

Background The prognostic role of concomitant coronary artery disease (CAD) among patients undergoing transcatheter aortic valve implantation (TAVI) is still uncertain. Methods Data from the Bern TAVI Registry and the Bern PCI Registry were analyzed. Patients with concomitant CAD undergoing TAVI (TAVI+CAD) were age- and gender-matched to the following two cohorts: patients without CAD undergoing TAVI (TAVI-noCAD) and patients with stable CAD undergoing percutaneous coronary intervention (CAD-noAS). Major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of cardiovascular death, myocardial infarction, or cerebrovascular events, represented the primary endpoint at 1-year. Results Out of 9478 procedures performed between 2007 and 2013 (807 TAVI; 8671 PCI), three cohorts, each including 248 subjects, were derived. At 1-year, MACCE were significantly increased among TAVI+CAD compared with TAVI-noCAD (16.8% vs. 9.8%, hazard ratio, HR, 1.75, 95% confidence intervals, CI, 1.06–2.89, p=0.030) and CAD-noAS patients (16.8% vs. 9.5%, HR 1.85, 95%CI 1.11–3.09, p=0.018) whereas no difference was found between TAVI-noCAD and CAD-noAS patients. The higher rate of MACCE among TAVI+CAD patients was mainly driven by an increased risk of cardiovascular mortality compared with the TAVI-noCAD (HR 1.86, 95%CI 1.03–3.36, p=0.040) and CAD-noAS cohorts (HR 2.29, 95%CI 1.22–4.30, p=0.010). The 1-year rate of MACCE was similar between TAVI-noCAD and CAD-noAS patients (9.8% vs. 9.5%, HR 1.05, 95%CI 0.59–1.87, p=0.86). Conclusions Concomitant CAD in the setting of TAVI conveyed an increased risk of ischemic events and cardiovascular mortality at 1-year follow-up.

AIMS The aim of the study was to evaluate the prognostic utility of right heart catheterisation (RHC)-derived measures among patients undergoing transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS Data of 469 patients included in the Bern TAVI Registry between August 2007 and December 2012 and undergoing preoperative RHC were analysed. The relationship between haemodynamic parameters and survival was evaluated with Cox proportional hazards models. At two-year follow-up, 118 patients had died (25.1%). At multivariable analysis, diabetes (hazard ratio [HR] 1.95, 95% confidence interval [CI]: 1.28-2.96, p=0.001), transapical access (HR 1.66, 95% CI: 1.07-2.56, p=0.02), and moderate or severe mitral regurgitation (HR 1.55, 95% CI: 1.00-2.39, p=0.04) were independent predictors of two-year mortality, whereas no correlation between RHC-derived measures and mortality was found. Furthermore, the addition of haemodynamic variables did not significantly improve the prognostic power of a model incorporating clinical and echocardiographic data (Harrell's C-index: 0.667, 95% CI: 0.615-0.719 vs. 0.662, 95% CI: 0.612-0.713, p=0.47). CONCLUSIONS On the basis of a comprehensive clinical and echocardiographic evaluation, RHC performed prior to TAVI does not add incremental prognostic value.

Background In long-term follow-up after drug-eluting stents (DES) implantation, late target lesion revascularization (TLR) is occasionally required. However, the incidence and predictors for late TLR with DES have not been fully investigated. Methods and results Between August 2004 and March 2005, 249 consecutive patients underwent percutaneous coronary intervention with sirolimus-eluting stents (SES) at our institution. Angiographic follow-up data were obtained in 228 patients (91.6%) with 274 lesions (91.6%) at 8 months. TLR incidence was evaluated up to 5 years. The 5-year clinical follow-up data were obtained in 222 patients (97.4%) with 264 lesions (96.4%). The incidence of early TLR before 1 year was 16.7%, and that of late TLR (1-5 years) was 8.3% (2.1% per year). Multivariate analysis indicated that significant predictors for late TLR were insulin-treated diabetes mellitus (DM) (odds ratio (OR) 10.88, P=0.001), stent fracture (OR 27.24, P=0.012), and age (OR 0.94, P=0.026). No association was observed between late TLR and lesion characteristics, including parameters measured by quantitative coronary angiography other than stent fracture, at baseline, post procedure, and follow-up. Conclusions Late TLR after SES implantation occurred in approximately 2.1% of lesions per year after the first year without attenuation up to 5 years. Significant predictors for late TLR were insulin-treated DM, stent fracture and younger age. Careful long-term follow-up after SES implantation might be recommended.

The aim of this study was to address 7-year clinical outcomes and impact of prolonged dual antiplatelet therapy (DAPT) after coronary stenting in hemodialysis patients. Our study included 123 consecutive hemodialysis patients who had undergone percutaneous coronary intervention with a drug-eluting stent (DES) or bare-metal stent (BMS) (DES: 64, BMS: 59) in our institution. We compared long-term clinical outcomes following DES with BMS implantation as well as clinical outcomes in patients on DAPT for ≥1 year (DAPT on group, 89) with those on DAPT for

Aim Contemporary data comparing early versus newer generation transcatheter heart valve (THV) devices in routine clinical practice are lacking. We sought to compare the safety and efficacy of early versus newer generation THVs in unselected patients undergoing transcatheter aortic valve implantation (TAVI). Methods and results We performed a propensity score matched analysis of patients undergoing transfemoral TAVI at a single centre with early versus newer generation devices between 2007 and 2016. Patients were matched for balloon-expandable versus self-expandable valves and Society of Thoracic Surgeons score. The primary end point was the Valve Academic Research Consortium (VARC)-2 early safety composite end point at 30 days. Among the 391 matched pairs, no differences between early (21.2%) and newer generation (20.8%) THVs regarding the early safety composite end point (HR 0.98, 95% CI 0.72 to 1.33, P=0.88) were observed. The rates of valve embolisation (0.8% vs 4.2%, P=0.005), bleeding events (24.8% vs 32.0%, P=0.028) and moderate-to-severe paravalvular regurgitation (PVR) (3.1% vs 12.1%, P

Objective To determine the features of alexia or agraphia with a left angular or supramarginal gyrus lesion. Methods We assessed the reading and writing abilities of three patients using kanji (Japanese morphograms) and kana (Japanese syllabograms). Results Patient 1 showed kana alexia and kanji agraphia following a hemorrhage in the left angular gyrus and the adjacent lateral occipital gyri. Patient 2 presented with minimal pure agraphia for both kanji and kana after an infarction in the left angular gyrus involving part of the supramarginal gyrus. Patient 3 also showed moderate pure agraphia for both kanji and kana after an infarction in the left supramarginal and postcentral gyri. All three patients made transposition errors (changing of sequential order of kana characters) in reading. Patient 1 showed letter-by-letter reading and a word-length effect and made substitution errors (changing hiragana [one form of kana] characters in a word to katakana [another form of kana] characters and vice versa) in writing. Conclusion Alexia occurs as “angular” alexia only when the lesion involves the adjacent lateral occipital gyri. Transposition errors suggest disrupted sequential phonological processing from the angular and lateral occipital gyri to the supramarginal gyrus. Substitution errors suggest impaired allographic conversion between hiragana and katakana attributable to a dysfunction in the angular/lateral occipital gyri.

Coronary computer tomographic angiography (CCTA) for screening intra-arterial vessel disease is gaining rapid clinical acceptance in recent years, but its use for such assessments in metal-stented vessel segments is very limited due to blooming artifacts introduced by the metal. However, vessel segments treated by the polymeric everolimus-eluting bioresorbable vascular scaffolds (Absorb) are readily monitored for intravascular disease over time with CCTA. The data on the accuracy of multi-detector computed tomography (MDCT) in patients treated with Absorb is still sparse. Results on 5 Japanese case studies from ABSORB EXTEND are presented here. Five patients were treated with Absorb, and follow-up angiography was conducted at 8 to 14 months as per routine site standard of practice. 320-row MDCT scan was performed within 1 month before the angiography. By MDCT, all Absorb-treated lesions were clearly evaluated and restenosis were not observed. Minimal diameter and % diameter stenosis were similar between MDCT and quantitative angiography (2.07 +/- 0.13 vs. 2.03 +/- 0.06 mm, P = 0.86, and 22.5 +/- 5.0 vs. 21.5 +/- 4.5 %, P = 0.88, respectively). MDCT appears to be feasible and useful for evaluating lumen patency and vessel disease in segments implanted with Absorb at follow-up.

The prevalence of abdominal aortic aneurysm (AAA) is reported to be high in patients with coronary artery disease (CAD). However, it has not been fully investigated in patients with acute myocardial infarction (AMI). The aim of this study is to evaluate the prevalence of AAA and its risk factors in

Transcatheter aortic valve replacement (TAVR) is an established treatment for high surgical risk or inoperable patients with severe aortic stenosis (AS) (1-3). Interestingly, unlike percutaneous coronary intervention (PCI), approximately 50% of patients who undergo TAVR are female, despite the fact that female patients have fewer comorbidities than male patients (4-6). Furthermore, female patients have been found to have favorable outcomes as compared to male patients (5-10). However, to date, it remains unclear why male patients have a higher incidence of mortality after TAVR. Understanding this might help determine the effect of sex differences in patients with severe AS undergoing TAVR and should therefore be evaluated.

The SYNTAX score stratifies risk among drug-eluting stent-treated patients and is based on lesion characteristics alone. The Clinical SYNTAX Score (CSS) combines the SYNTAX score with age, ejection fraction, and creatinine clearance. We assessed its ability to stratify long-term outcomes in sirolimus-eluting stents (SES)-treated patients. Between August 2004 and March 2005, 249 patients were treated with SES. Clinical follow-up was evaluated at more than 5 years. The CSS was available for 206 patients. More than 5-year clinical follow-up data (mean 2114 ± 107 days) and CSS (range 1-322, mean 35.3 ± 49.9, median 17.5) were available for 201 patients. We divided these scores into tertiles: CSS-LOW ≤ 9.5, 9.5 CSS-MID ≤ 28, and CSS-HIGH 28. CSS-HIGH was associated with a higher death rate (CSS-LOW 9.0 %, CSS-MID 11.9 %, CSS-HIGH 41.8 %; log-rank p 0.001) and major adverse cardiovascular events (MACE) (CSS-LOW 29.8 %, CSS-MID 35.8 %, CSS-HIGH 61.2 %; log-rank p = 0.004). Independent predictors for death were hemodialysis [hazard ratio (HR) 3.82; p 0.001], age (HR 1.67; p = 0.003), ejection fraction (HR 0.98, p = 0.012) and CSS (HR 1.73, p = 0.028), and those for MACE were hemodialysis (HR 2.53, p = 0.002) and CSS (HR 1.40, p = 0.028). Areas under the curve for the SYNTAX score and CSS for death were 0.60 and 0.78 (p 0.001), whereas those for MACE were 0.58 and 0.68 (p 0.001), respectively. The CSS predicts long-term outcomes among SES-treated patients better than the SYNTAX score.

This study evaluated the diagnostic performance of quantitative 320 detector-row coronary computed tomography angriography (CCTA) and transluminal attenuation gradient (TAG) for detecting flow-limiting coronary artery stenoses. We studied 49 patients with 55 intermediate lesions (30%-69% diameter

Ventricular tachycardia (VT) associated with the His-Purkinje system has been infrequently reported in patients with structural heart disease. A 69-year-old man presented with nausea and diaphoresis. ECG showed wide QRS tachycardia with a right bundle branch block configuration as right axis deviation, 240 bpm. The tachycardia was temporarily terminated with verapamil but reinitiated and required several electrical cardioversions. Coronary angiography revealed no significant stenosis and left ventricular ejection fraction 34%. He underwent electrophysiological study to make a diagnosis of wide QRS tachycardia. When a ventricular tachycardia was induced, the presence of His deflections preceded every ventricular deflection and oscillations in the H-H cycle length resulted in variations in V-V cycle length. This suggested the possibility of the His-Purkinje entity. During the VT, the diastolic potential (DP) was recorded at the anteroseptal left ventricle. Changes in the QRS morphology were associated with the time between DP and onset of QRS complex (V), and prolongation of DP-V interval terminated the VT. Different exits from relatively large area of slow conduction around the left ventricular base area might have produced the polymorphic VTs. In addition, the delayed potentials were seen during sinus rhythm around this area. We report this case of a patient who had non-ischemic cardiomyopathy and developed Purkinje reentrant polymorphic VT.

High temperature fusion behavior of mixtures of ash exhibiting a wide range of melting temperature and additive has been investigated under reducing (CO/CO2) at mospheres. Six additives were used: limestone, two iron ores, red mud, CaO obtained by calcin-ing CaCO3 reagent, and Fe2O3 reagent. Characteristic ash fusion temperatures were measured in an electric furnace in conformity to the JIS M8801 method. A microscope equipped with a high temperature heating stage was also used to perform in-situ observation of the reaction and fu-sion behavior between the ash and the additive. The mixtures, treated in several temperature ranges from 900 V to the fluid temperature, were quenched rapidly and identified by the X-ray diffraction.(1) It was found that fusion behavior of ash-iron are mixtures and ash-imestone mix-tures approximately coincided with that of the ash-reagent mixtures. The minimum value of hemispherical temperature was 100°C to 500DC f-fect of red mud was lower than that of Fe2O3 reagent.(2) Partially fused phases were observed at temperatures 100°C to 200°C below the softening temperature. From X-ray analysis FeO was found to be the principal fluxing element that controls partial ash melting(3) At softening temperature a shift from the local solid-solid reaction mode to the liquid-solid slurry reaction mode was observed. Above the hemispherical temperature volatiles and CO2 gas were released in the form of bubbles and the shape of molten ash was changed into a sphere in a graphite crucible. This melting behavior was observed in all ashes irrespective of the presence of additives.

High temperature behavior of mixtures of ash exhibiting a wide range of melting temperature and CaO additive under both oxidizing (Air) and reducing (CO/CO2) atmospheres has been investigated by RS M 8801 and by X-ray diffraction method.(1) Hemispherical temperature of ash with CaO decreased with the increased addition of CaO until CaO content reached about 30wt% and the minimum value of hemispherical temperature was ranged of 1250 to 1350°C under oxidizing atmospheres. Above 40wt% of CaO, the hemispherical temperature went above that of original ash.(2) The U shaped trend of the hemispherical temperature was also observed under reducing atmospheres. The minimum hemispherical temperature under reducing atmospheres was about loot lower than that under oxidizing atmospheres. The percent of CaO corres-ponding to the minimum hemispherical temperature was as low as 10wt%. All the hemispherical temperatures obtained at about 30wt% addition of CaO are found in a range of 1200 to 1350°C.(3) Depending on CaO content, the principal compounds detected were anorthite, gehle-nite, pseudowolla stonite, and rankinite. The minimum hemispherical temperatures of the mixtures of ash and CaO additive were almost equal to the lowest temperature eutectic points in the Ca0-Al2O3-SiO2 phase diagram.

In order to investigate the actual state of cancer within the jurisdiction of the Kawagoe Helth Centre of the Saitama Prefecture, we have visited all the 110 hospitals and clinics within the jurisdiction, under the cooperation of the Doctors' Ass'n., and the Health Centre. We have not only inquired of the doctors, but have also gone through the protocols of the patients who have come during the investigation period, and we have chosen those who were diagnosed as cancer or malignant ulcer, making our observations according to sex, age, and disease types. We have calculated the death rate by comparing the contraction percentage of cancer, the prevalence rate, and the death certificate ; and have compared it with the figures of various parts of the U.S.A., and the Miyagi, Okayama, and Saitama Prefectures. Furthermore, the monthly survival rate was obtained, and the drawing up of basic data was attempted in order to devise measures of the prevention of cancer.

During the period of a year and five months (May 1958-October 1659), I have from the standpoint of constitutional anthropology, made measurements of the living bodies (trunk, limbs, head, face, etc.) of 565 adult males and 325 adult females who are the inhabitants of the SuhO district of Yamaguchi Prefecture. I have made detailed observations based upon the measurement values and index values of 27 items, and have made a comparative study with those of other districts. The following is the result, although here I have restricted the comparative study to adult males.1) The average height of the SuhO district males is 159.98cm and belongs to the “small” group according to Martin's height classification, but as a Japanese adult male they belong to the “below medium” group. Their measurements resemble those of the adult males of the districts of Tosa, Takachiho, Kaga plain, and South Noto.2) The maximum length of the head measured 184.00mm, resembling that of the peoples of Shinshu-Iida, Izumo, and Koma, while the maximum width of the head measured 151.70mm., resembling that of Tosa, Oku-Noto, Bitchu, and Izumo.3) The index number of the length and width of the head is 82.65, belonging to the small-head type, far exceeding the average index value of 81.31 of the district measured by Dr. Koya. This reveals the fact that the maximum length of the head is short in comparison to its maximum width. As seen in view of Martin's head classification, 44.15% of the SuhO district males belong to the 'small head type, and 31.86% to the medium head type. The classification curve and T.D. strongly resembles that of the adult males of Izumo, Koma, Harima, Yamato, Inaba, and Shinshu-Kami-Ina. The resemblance to the Ainu of Hokkaido and to the people of Etcha is negligible.4) Comparing the SuhO district males with those of other districts according to the M.T.D., those of the Koma, Yamato, Izumo, Harima, Bitchu, East Saitama, and Shinshu-Iida, reveal a M.T.D. of below 5.50. This is an interesting discovery in view of the fact that the districts just mentioned all retain the history of immigration from the Asian Mainland. On the other hand, the people of Etcha and Noto who are considered to be of Ainu origin, together with the Ainu of HokkaidO, reveal a M.T.D. of over 12.00, and the relationship is vague.From the above data the general conclusion can be drawn that the people of SuhO district, judging from the measurement results of the various qualities of the highest value in constitutional anthropology, are highly similar to the Yamato, Izumo, Bitchaand Koma people, descendants of immigrants from the Asian Mainland and who had boasted of the highest form of civillization in Japan, and also to the peoples who held active communication with the Asian Mainland. The Suho people had relations with the Yamato dynasty since the era of the tenth Emperor Sujin and went under the leadership of the Yamato dynasty by the time it completed the unification of the country around the middle of the fourth century. They thus were able to prosper, and due to dommunication facilities they probably received the influence of both the Sanyo and San-in sides of the mountainous area, and further by constitutional anthropological study, they show strong racial affiliality to the peoples of Yamato and Izumo. It is also an interesting fact to note that they also show a strong resemblance to the peoples of Bitcht and Harima situated along the Sanyo highway.