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Background Stent under-expansion, often caused by severe circumferential coronary calcification, must be prevented as it increases the risk of neoatherosclerosis and stent thrombosis. Intravascular lithotripsy (IVL) is an effective lesion preparation strategy to enable sufficient expansion of a stent that was initially not sufficiently expanded. Case summary A 62-year-old male patient presented in our emergency department due to unstable angina. Coronary angiography revealed one-vessel coronary artery disease with high-grade stenosis of the proximal to mid right coronary artery. Direct implantation of a drug-eluting stent was performed. However, stent under-expansion was noticed. Post-dilatation with semi-compliant balloon up to 24 bar was unsuccessful. Subsequent dilatation with an ultra-high-pressure OPN non-compliant balloon at 50 bar resulted to balloon rupture but stent under-expansion remained. Therefore, IVL was performed, resulting in complete stent expansion already at 4 bar. The patient was put on dual platelet treatment, and his further clinical course was uneventful after 6 months of follow-up. Discussion The present case report highlights the role of IVL as a safe and effective treatment option in case of immediate stent under-expansion. This has significant implications on daily practice as under-expansion may lead to high rates of in-stent restenosis and stent thrombosis. Furthermore, this case report underlines the impact of lesion preparation, even in presumably less complex lesion by angiographic criteria. [ABSTRACT FROM AUTHOR]

Background/Objectives: For patients with percutaneous coronary intervention (PCI) of an unprotected left main coronary artery (uLMCA) stenosis, the optimal duration of dual antiplatelet therapy (DAPT) remains a matter of debate. The purpose of this study was to compare clinical outcomes of 6- versus 12-month DAPT duration in patients with PCI of an uLMCA and stable angina. Methods: In this retrospective analysis, we included consecutive patients of our centre who underwent PCI of uLMCA stenosis for stable angina and who received DAPT with acetylsalicylic acid and clopidogrel for either 6 or 12 months. The primary endpoint was the composite of all-cause mortality, myocardial infarction, and target lesion revascularization at one year. Secondary endpoints included individual components of the primary endpoint, definite/probable stent thrombosis, and bleeding. Clinical outcomes were assessed by unadjusted analysis and by inverse probability of treatment weighting (IPTW). Results: Out of 984 included patients, 339 (34.5%) received DAPT for 6 months and 645 (65.5%) for 12 months. The primary endpoint occurred in 51 patients (15.2%) in the 6-month group and in 104 (16.3%) in the 12-month group (p = 0.674). Incidences of stent thrombosis (0.9% versus 0.3%, p = 0.224) and BARC 3,4,5 bleeding (6% versus 5.8%, p = 0.808) were also comparable in both groups. We found no significant differences in the primary endpoint and its components or BARC 3,4,5 bleeding between 6 and 12 months. Conclusions: Our findings do not support the extension of DAPT beyond 6 months after PCI for uLMCA in patients with stable angina. [ABSTRACT FROM AUTHOR]

Background Delayed coronary obstruction (DCO) is a rare but potentially life-threatening complication after transcatheter aortic valve implantation (TAVI) mostly affecting the left main coronary artery (LMCA) and often caused by prosthesis endothelialization or thrombus formations. Herein, we report an unusual case of a delayed LMCA-obstruction caused by a calcium nodule, which was diagnosed 4 months after TAVI due to recurrent ventricular tachycardia (VT) episodes. Case summary A 73-year-old patient was readmitted to an external hospital with syncope three months after TAVI. Fast VT could be induced in electrophysiological examination, why the patient received a two-chamber implantable cardioverter defibrillator (ICD). However, after 1 month the patient was readmitted to our department with another syncope. Implantable cardioverter defibrillator records revealed multiple fast VT episodes (200–220 b.p.m.). In addition, the patient reported new-onset exertional dyspnoea (New York Class Association Stage III) and elevated high-sensitive cardiac troponin of 115 ng/L. Due to the symptoms and laboratory markers indicating potential myocardial ischaemia, a cardiac computed tomography angiography (CCTA) was performed. Cardiac computed tomography angiography revealed obstruction of the LMCA likely caused by calcium shift during TAVI. After CCTA-guided percutaneous coronary intervention, patient's course remained uneventful. Discussion The present case report highlights the role of CCTA as a powerful non-invasive diagnostic tool in complex settings after TAVI. Delayed coronary obstruction as a procedural complication can occur after TAVI and manifest with various symptoms, including new-onset or recurrent VTs, like in the present case. Cardiac computed tomography angiography provided accurate assessment of the implanted prosthesis and detection of DCO, thus guiding the subsequent PCI. [ABSTRACT FROM AUTHOR]

Background: The goal of our study is to evaluate a method to quantify aortic valve calcification (AVC) in contrast-enhanced computed tomography for patients with suspected severe aortic stenosis pre-interventionally. Methods: A total of sixty-five patients with aortic stenosis underwent both a native and a contrast-enhanced computed tomography (CECT) scan of the aortic valve (45 in the training cohort and 20 in the validation cohort) using a standardized protocol. Aortic valve calcification was semi-automatically quantified via the Agatston score method for the native scans and was used as a reference. For contrast-enhanced computed tomography, a calcium threshold of the Hounsfield units of the aorta plus four times the standard deviation was used. Results: For the quantification of aortic valve calcification in contrast-enhanced computed tomography, a conversion formula (691 + 1.83 x AVCCECT) was derived via a linear regression model in the training cohort. The validation in the second cohort showed high agreement for this conversion formula with no significant proportional bias (Bland–Altman, p = 0.055) and with an intraclass correlation coefficient in the validation cohort of 0.915 (confidence interval 95% 0.786–0.966) p < 0.001. Conclusions: Calcium scoring in patients with aortic valve stenosis can be performed using contrast-enhanced computed tomography with high validity. Using a conversion factor led to an excellent agreement, thereby obviating an additional native computed tomography scan. This might contribute to a decrease in radiation exposure. [ABSTRACT FROM AUTHOR]

Background: Renin-angiotensin-aldosterone system inhibitor (RAASi) therapy provides cardiorenal protection but is often down-titrated or discontinued following a hyperkalemia episode. This observational study describes the extent of hyperkalemia-related RAASi reduction in patients with chronic kidney disease (CKD) and/or heart failure (HF), and estimates the number needed to treat (NNT) to avoid a first hospitalization if RAASi had been maintained at the prior dose., Methods: Healthcare registers and claims data from Germany, Spain, Sweden, and the UK were used to identify non-dialysis patients with CKD and/or HF who had a hyperkalemia episode while on RAASi. Patients whose RAASi therapy was reduced (down-titrated/discontinued) after the hyperkalemia episode were propensity score (PS)-matched to those with maintained RAASi, and their risks of a hospitalization within 6 months were estimated using the Kaplan-Meier method. Based on the absolute difference in this 6-month risk, the NNT framework was applied to estimate the number of patients who needed to have maintained instead of reduced their RAASi to avoid a first hospitalization during this period., Results: Overall, 40,059 patients from Germany, Spain, Sweden, and the UK were included. Presence of CKD at baseline was similar across countries (72%-92%), while HF was less common in Spain (18%) versus other countries (32%-71%). After the hyperkalemia episode, RAASi was reduced in 25%-57% of patients. Following PS matching, the 6-month risk of hospitalization was consistently higher in those with reduced versus maintained RAASi; the absolute risk difference ranged from 2.7% to 7.3%. Applying the NNT framework, these data suggest that a first hospitalization within 6 months could potentially have been avoided if 25 patients had maintained instead of reduced their RAASi., Conclusions: Our findings suggest a potential for avoiding a first hospitalization, even within a short time frame, by increasing adherence to guidelines to maintain instead of reduce RAASi after a hyperkalemia episode., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Nephrology.)

Aims: To determine the conditions under which early hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve implantation (TAVI) becomes haemodynamically relevant., Methods and Results: The study included 100 patients (age: 81.5 ± 5.5 years; female 63%), thereof 50 patients with HALT. After anonymization and randomization, blinded readers measured maximum thrombus thickness per prosthesis (MT&#95;pr) and movement restriction (MR&#95;pr) on electrocardiogram (ECG)-gated whole heart cycle computed tomography angiography. These measurements were compared with echocardiographic mean pressure gradient (mPG), its increase from baseline (ΔmPG), and Doppler velocity index (DVI). Haemodynamic valve deterioration (HVD) was defined as mPG > 20 mmHg. Age, body mass index, valve type, valve size, left ventricular ejection fraction, and atrial fibrillation were considered as influencing factors. Multiple regression analysis revealed that only valve size (P = 0.001) and MT&#95;pr (P = 0.02) had a significant influence on mPG. In an interaction model, valve size moderated the effect of MT&#95;pr on mPG significantly (P = 0.004). Sub-group analysis stratified by valve sizes showed a strong correlation between MT&#95;pr and echocardiographic parameters for 23 mm valves (mPG: r = 0.57, ΔmPG: r = 0.68, DVI: r = 0.55, each with P < 0.001), but neither for 26 nor 29 mm valves (r < 0.2, P > 0.2 for all correlations). Six of seven prostheses with HVD had a 23 mm valve diameter, while one had 29 mm (P = 0.02)., Conclusion: Early HALT rarely causes significant mPG increase. Our study shows that valve size is a key factor influencing the haemodynamic impact of HALT. In small valve sizes, mPG is more likely to increase. Our study is the first to offer in vivo evidence supporting previous in vitro findings on this topic., Competing Interests: Conflict of interest: F.B.: Bayer Healthcare, speakers bureau and unrestricted research grant Siemens Healthineers, speakers bureau and unrestricted research grant, unrelated to this work. C.L.S.: Siemens Healthineers, unrestricted research grant, unrelated to this work. J.T.: funding by Deutsche Forschungsgesellschaft (DFG, German Research Foundation)—TA 1438/1–2. T; speakers bureau Siemens Healthcare GmbH and speakers bureau Bayer AG, reviewer Universimed Cross Media Content GmbH and consultant Core Lab Black Forrest GmbH, all unrelated to this work. M.S.: electronic presentation sponsored by Bayer AG, unrelated to this work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: Early leaflet thrombosis (LT) is a well-described phenomenon after transcatheter aortic valve implantation (TAVI) with an incidence around 15%. Data about predictors of LT are scarce. The purpose of the study was to investigate the influence of prosthesis-related factors on the occurrence of LT., Materials and Results: Fusion imaging of pre- and post-procedural computed tomography angiography was performed in 55 TAVI patients with LT and 140 selected patients as control groups (85 patients in an unmatched and 55 in a matched control) to obtain a 3D reconstruction of the transcatheter heart valve (THV) within the native annulus region. All patients received a balloon-expandable Sapien 3 THV. The THV length above and below the native annulus was measured within the fused images to assess the implantation depth. The deployed THV area was quantified on three heights (left ventricular outflow tract end, stent centre, and aortic end) to determine the average expansion of the prosthesis as percent of the nominal area. We also calculated the extent of prosthesis waist in percent of maximum area. After multivariate adjustment, the extent of THV waist [odds ratio (OR) per 10% (confidence interval, CI) 0.636 (0.526-0.769), P < 0.001] as prosthesis-related factor and previous oral anticoagulation [OR (CI) 0.070 (0.020-0.251), P < 0.001] had significant, independent influence on the occurrence of LT. The implantation depth showed no influence on LT manifestation (P = 0.704)., Conclusion: Besides the absence of previous oral anticoagulation, a less pronounced waist of the implanted THV was a prosthesis-position-related independent predictor of LT after TAVI using the Sapien 3., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: The purpose of this study was to evaluate prosthesis position by fusion of pre- and post-transcatheter aortic valve implantation (TAVI) computed tomography angiography (CTA) images and to investigate its influence on the occurrence of new conduction disturbances (CD)., Methods and Results: We performed CTA fusion imaging in 120 TAVI patients (Edwards Sapien 3) on a standard image post-processing workstation to obtain a 3D reconstruction of the transcatheter heart valve (THV) position within the native annulus region. Optimal implantation depth of the THV was defined according to the manufacturers recommendations as 70-80% of the prosthesis above (aortic) and 20-30% below (ventricular) the native annulus plane. Pre- and post-interventional electrocardiograms (ECGs) were assessed for the development of new CD. THV position was found to be within, above, or below the prespecified margins in 32 patients (27%), 71 patients (59%), and 17 patients (14%), respectively. Interobserver reliability was high for fusion measurements [e.g. median THV position 0.983, 95% confidence interval (CI): 0.935-0.996]. Patients with low stent position were significantly more likely to develop new CD compared with patients with optimal or high stent position (P = 0.039). Independent predictors of CD in multivariate analysis were low THV position [odds ratio (CI): 1.362 (1.093-1.698), P = 0.006] and calcification of the device landing zone [odds ratio (CI): 1.149 (1.024-1.289), P = 0.018]., Conclusion: Fusion imaging of pre- and post-TAVI-CTA allows for the exact evaluation of THV position in relation to the native annulus plane. A low THV position as assessed by fusion imaging is associated with the development of new CD post-TAVI., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)