The FRANCE TAVI registry provided reassuring data regarding trends in TAVR performance in an all-comers population on a national scale. Nonetheless, given that TAVR indications are likely to expand to patients at lower surgical risk, concerns remain regarding potentially life-threatening complications and pacemaker implantation. (Registry of Aortic Valve Bioprostheses Established by Catheter [FRANCE TAVI]; NCT01777828).
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Background
Venoarterial extra corporeal life support (ECLS) is the treatment of choice of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) class 1 patients, but left ventricle (LV) overload is a complication of ECLS. Unloading the LV by adding Impella 5.0 to ECLS in Impella used in combination with venoarterial extracorporeal membrane oxygenation (ECMELLA) configuration is recommended only in patients with acceptable prognosis. We investigated whether serum lactate level, a simple biological parameter, could be used as a marker to select candidates for bridging from ECLS to ECMELLA.
Methods
Forty-one consecutive INTERMACS 1 patients under ECLS were upgraded to ECMELLA using Impella 5.0 pump implantation to unload the LV and were followed-up for 30 days. Demographic, clinical, imaging, and biological parameters were collected.
Results
The time between ECLS and Impella 5.0 pump implantation was 9 [0–30] hours. Among these 41 patients, 25 died 6±6 days after implantation. They were older (53±12
vs.
43±12 years, P=0.01) with acute coronary syndrome as the primary etiology (64%
vs.
13%, P=0.0007). In univariate analysis, patients who died exhibited a lower mean arterial pressure (74±17
vs.
89±9 mmHg, P=0.01), a higher level of troponin (24,000±38,000
vs.
3,500±5,000 mg/dL, P=0.048), a higher level of serum lactate (8.3±7.4
vs.
4.2±3.8 mmol/L, P=0.05) and more frequent cardiac arrest at admission (80%
vs.
25%, P=0.03). In multivariate Cox regression analysis, a serum lactate level of >7.9 mmol/L (P=0.008) was found to be an independent predictor of mortality.
Conclusions
In INTERMACS 1 patients who require urgent ECLS for restoring hemodynamics and organ perfusion, an upgrade from ECLS to ECMELLA is relevant if the serum lactate level is ≤7.9 mmol/L.
We report the case of a 58‐year‐old female with severe postcapillary pulmonary hypertension (averaged mean pulmonary arterial pressure was 49 mmHg, pulmonary arterial wedge pressure 29 mmHg, and right atrial pressure 8 mmHg) due to heart failure with preserved ejection fraction. A left‐to‐right atrial shunt was created using an 8 mm cutting balloon, under transesophageal echocardiography guidance. Both pulmonary arterial and wedge pressure dramatically decreased after the procedure. Symptoms immediately improved and benefits were sustained at 6 months of follow‐up. This case suggests that iatrogenic septal defect using a cutting balloon could be an option to treat symptomatic postcapillary pulmonary hypertension.
Le rétrécissement aortique est la valvulopathie acquise la plus fréquente. Quand il devient serré et symptomatique, la mortalité à 2 ans est proche de 80% en l’absence de prise en charge. Le traitement repose sur le remplacement valvulaire, historiquement réalisé par voie chirurgicale. L’avènement des procédures percutanées par cathétérisme cardiaque TAVI (Trans-catheter Aortic Valve Implantation) a tout d’abord permis de traiterdes patients jugés inopérables, puis avec l’avancée des connaissances cette procédure s’est étendue aux populations à risque chirurgicale élevépuis intermédiaire, et a même été validée chez les patients à bas risque aux Etats-Unis suite à de grandes études multicentriques. Le principe consiste à implanter une bioprothèse aortique suturée sur un stent directement au sein de la valve native calcifiée, soit par un procédé de dilatation au ballonnet, soit par un procédé auto-expansé. Le TAVI présente l’avantage d’une procédure peu invasive, le plus souvent réalisée sous anesthésie locale et sédation, et une durée de séjour courte. La récupération fonctionnelle est plus rapide qu’après chirurgie cardiaque conventionnelle.Un autre avantage par rapport à la chirurgie cardiaque conventionnelle est un moindre taux de complications graves (choc cardiogénique, saignement majeure, accident vasculaire cérébrale, insuffisance rénale, décès toute cause). En revanche certaines complications sont plus spécifiques du TAVI comme l’apparition d’un trouble conduction de haut degré nécessitant la pose d’un pacemaker, et l’existence de complications vasculaires. La surveillance en soins intensifs en découlant est donc plus courte qu’après chirurgie et doit probablement être personnalisée selon le risque du patient.
L’utilisation du TAVI chez les sujets à risque et/ou âgés semble parfaitement implanté en France. L’extension des indications à des sujets à bas risque et plus jeunes n’est pas encore autorisée en France et en Europe. L’étude de la durabilité des bioprothèses implantées par voie percutanée à long terme nécessite des investigations supplémentaires.
Background
The ACURATE neo™ transcatheter heart valve (Boston Scientific, Marlborough, Massachusetts) is predominantly implanted via femoral access. Transcarotid use of this prothesis has never been reported.
Case presentation
We present the case of an 89-year-old woman referred to us for a transcatheter aortic valve replacement (TAVR). After apparatus imaging of the aortic annulus and the peripheral vascular pathway, the heart team was confronted with a triple challenge: (i) The preferable choice of a self-expanding valve because of a small aortic annulus in an obese woman. (ii) Gaining favorable access to the coronary ostia, considering multiple recent coronary stenting. (iii) Utilizing an alternative arterial access because of iliac and femoral severely calcified stenosis. Implanting the ACURATE neo™ transcatheter heart valve (THV) via carotidal access allowed us to overcome these challenges. The procedure was performed successfully without any short-term complications.
Conclusion
We report the first case of implantation of an ACURATE neo™ transcatheter heart valve (Boston Scientific, Marlborough, Massachusetts) via the right common carotid artery.
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