INTRODUCTION: Data on patients with small aortic annuli (SAA) undergoing transcatheter aortic valve implantation (TAVI) are limited. We aim to describe the impact of aortic annular size, particularly SAA and TAVI valve type on valve haemodynamics, durability and clinical outcomes. METHOD: All patients in National Heart Centre Singapore who underwent transfemoral TAVI for severe symptomatic native aortic stenosis from July 2012 to December 2019 were included. Outcome measures include valve haemodynamics, prosthesis-patient mismatch (PPM), structural valve degeneration (SVD) and mortality. RESULTS: A total of 244 patients were included. The mean Society of Thoracic Surgeons score was 6.22±6.08, with 52.5% patients with small aortic annulus (<23mm), 33.2% patients with medium aortic annulus (23-26mm) and 14.3% patients with large aortic annulus (>26mm). There were more patients with self-expanding valve (SEV) (65.2%) versus balloon-expandable valve (BEV) (34.8%). There were no significant differences in indexed aortic valve area (iAVA), mean pressure gradient (MPG), PPM, SVD or mortality across all aortic annular sizes. However, specific to the SAA group, patients with SEV had larger iAVA (SEV 1.19±0.35cm2/m2 vs BEV 0.88±0.15cm2/m2, P<0.01) and lower MPG (SEV 9.25±4.88 mmHg vs BEV 14.17±4.75 mmHg, P<0.01) at 1 year, without differences in PPM or mortality. Aortic annular size, TAVI valve type and PPM did not predict overall mortality up to 7 years. There was no significant difference in SVD between aortic annular sizes up to 5 years. CONCLUSION Valve haemodynamics and durability were similar across the different aortic annular sizes. In the SAA group, SEV had better haemodynamics than BEV at 1 year, but no differences in PPM or mortality. There were no significant differences in mortality between aortic annular sizes, TAVI valve types or PPM.
Humans ; Transcatheter Aortic Valve Replacement ; Heart Valve Prosthesis ; Aortic Valve Stenosis/surgery* ; Aortic Valve/surgery* ; Prosthesis Design ; Postoperative Complications/surgery* ; Treatment Outcome ; Hemodynamics

INTRODUCTION: Chronic kidney disease (CKD) is a significant comorbidity in aortic stenosis (AS) patients. We examined the impact of baseline CKD, postoperative acute kidney injury (AKI) and CKD progression on clinical outcomes in patients who underwent transcatheter aortic valve implantation (TAVI). MATERIALS AND METHODS: Consecutive patients with severe AS who underwent TAVI were classified into CKD stages 1-2 (≥60 mL/min/1.72m), 3 (30-59 mL/min/1.73m) and 4-5 (<30 mL/min/1.73m or dialysis) based on estimated glomerular filtration rate (eGFR). Primary outcome was mortality and secondary outcomes included 1-year echocardiographic data on aortic valve area (AVA), mean pressure gradient (MPG) and aortic regurgitation (AR). RESULTS: A total of 216 patients were included. Higher eGFR was associated with lower overall mortality (adjusted hazards ratio [AHR] 0.981, 95% confidence interval [CI] 0.968-0.993, = 0.002). CKD 4-5 were associated with significantly higher mortality from non-cardiovascular causes ( <0.05). Patients with CKD 3-5 had higher incidence of moderate AR than those with CKD 1-2 ( = 0.010); no difference in AVA and MPG was seen. AKI patients had higher mortality ( = 0.008), but the effect was attenuated on multivariate analysis (AHR 1.823, 95% CI 0.977-3.403, = 0.059). Patients with CKD progression also had significantly higher mortality (AHR 2.969, 95% CI 1.373-6.420, = 0.006). CONCLUSION CKD in severe AS patients undergoing TAVI portends significantly higher mortality and morbidity. Renal disease progression impacts negatively on outcomes and identifies a challenging subgroup of patients for optimal management.

INTRODUCTIONPercutaneous transcatheter aortic valve implantation (TAVI) has become an established therapy for inoperable and high-surgical-risk patients with severe aortic stenosis. Although TAVI in patients with degenerated surgical aortic bioprostheses (i.e. valve-in-valve TAVI) is increasingly reported in Western studies, such data is lacking in Asian patients. We describe the initial experience of valve-in-valve TAVI in Asia.

METHODSEight patients who underwent valve-in-valve TAVI due to degenerated aortic bioprostheses were enrolled. The mechanism of bioprosthetic valve failure was stenotic, regurgitation or mixed. All procedures were performed via transfemoral arterial access, using the self-expanding CoreValve prosthesis or balloon-expandable SAPIEN XT prosthesis.

RESULTSThe mean age of the patients was 71.6 ± 13.2 years and five were male. Mean duration to surgical bioprosthesis degeneration was 10.2 ± 4.1 years. Valve-in-valve TAVI was successfully performed in all patients. CoreValve and SAPIEN XT prostheses were used in six and two patients, respectively. There were no deaths, strokes or permanent pacemaker requirement at 30 days, with one noncardiac mortality at one year. All patients experienced New York Heart Association functional class improvement. Post-procedure mean pressure gradients were 20 ± 11 mmHg and 22 ± 8 mmHg at 30 days and one year, respectively. Residual aortic regurgitation (AR) of more than mild severity occurred in one patient at 30 days. At one year, only one patient had mild residual AR.

CONCLUSIONIn our experience of valve-in-valve TAVI, procedural success was achieved in all patients without adverse events at 30 days. Good clinical and haemodynamic outcomes were sustained at one year.

Aged ; Aged, 80 and over ; Aortic Valve ; surgery ; Aortic Valve Insufficiency ; surgery ; Aortic Valve Stenosis ; surgery ; Arteries ; Bioprosthesis ; Cardiac Catheterization ; methods ; Female ; Fluoroscopy ; Follow-Up Studies ; Heart Valve Prosthesis ; Heart Valve Prosthesis Implantation ; Hemodynamics ; Humans ; Male ; Middle Aged ; Pacemaker, Artificial ; Prosthesis Failure ; Severity of Illness Index ; Transcatheter Aortic Valve Replacement

INTRODUCTIONDoor-to-balloon (DTB) time is critical to ST elevation myocardial infarction (STEMI) patients' survival. Although DTB time is reduced with direct cardiovascular laboratory (CVL) activation by emergency physicians, concerns regarding false-positive activation remain. We evaluate false-positive rates before and after direct CVL activation and factors associated with false-positive activations.

MATERIALS AND METHODSThis is a retrospective single centre study of all emergency CVL activation 3 years before and after introduction of direct activation in July 2007. False-positive activation is defined as either: 1) absence of culprit vessel with coronary artery thrombus or ulceration, or 2) presence of chronic total occlusion of culprit vessel, with no cardiac biomarker elevations and no regional wall abnormalities. All false-positive cases were verified by reviewing their coronary angiograms and patient records.

RESULTSA total of 1809 subjects were recruited; 84 (4.64%) identified as false-positives. Incidence of false-positive before and after direct activation was 4.1% and 5.1% respectively, which was not significant (P = 0.315). In multivariate logistic regression analysis, factors associated with false-positive were: female (odds ratio (OR): 2.104 [1.247-3.548], P = 0.005), absence of chest pain (OR: 5.369 [3.024-9.531], P <0.0001) and presence of only left bundle branch block (LBBB) as indication for activation (OR: 65.691 [19.870-217.179], P <0.0001).

CONCLUSIONImprovement in DTB time with direct CVL activation by emergency physicians is not associated with increased false-positive activations. Factors associated with false-positive, especially lack of chest pain or LBBB, can be taken into account to optimise STEMI management.

Bundle-Branch Block ; epidemiology ; Cardiac Catheterization ; Chest Pain ; epidemiology ; Coronary Angiography ; Disease Management ; Emergency Medicine ; Humans ; Logistic Models ; Multivariate Analysis ; Percutaneous Coronary Intervention ; Physicians ; Retrospective Studies ; ST Elevation Myocardial Infarction ; diagnosis ; epidemiology ; therapy ; Sex Factors ; Singapore ; epidemiology ; Time-to-Treatment

INTRODUCTIONA retrospective case series of acute anterior myocardial infarction (MI) patients complicated by complete atrioventricular block (AVB) treated with acute percutaneous transluminal coronary angioplasty (PTCA).

CLINICAL PICTUREEight patients with anterior MI and complete AVB underwent acute PTCA between 2000 and 2005. Mean onset of complete AVB was 16.6 +/- 16.9 hours from chest pain onset.

TREATMENTAll patients underwent successful PTCA to the left anterior descending artery.

OUTCOMEComplete AVB resolved with PTCA in 88%; mean time of resolution was 89 +/- 144 minutes after revascularisation. One patient had permanent pacemaker implanted at Day 12 after developing an 8-second ventricular standstill during hospitalisation but not pacing-dependent on follow-up. The rhythm on discharge for the other surviving patients was normal sinus rhythm.

CONCLUSIONThis case series suggests that complete AVB complicating anterior MI is reversible with acute PTCA and survivors are not at increased risk of recurrent AVB. Nevertheless, this condition is associated with extensive myocardial damage and high mortality during the acute hospitalisation was not improved with correction of AVB with temporary pacing.

Adult ; Aged ; Angioplasty, Balloon, Coronary ; Anterior Wall Myocardial Infarction ; complications ; therapy ; Atrioventricular Block ; complications ; therapy ; Electrocardiography ; Female ; Humans ; Male ; Middle Aged ; Recovery of Function ; Retrospective Studies