Mohammed Saad

Background: Patients with complex coronary artery disease, concomitant cardiovascular disease, and multiple comorbidities are classified as complex higher-risk indicated patients (CHIPs). They preclude surgical revascularization due to high perioperative morbidity and mortality. Intervention with left-ventricular assist device support using Impella CP is an alternative strategy. It may serve as a temporary circulatory support during complex intervention and cardiogenic shock and provides LV unloading, antegrade blood flow generation, infarct size limitation, and recovery promotion. However, its use in CHIPs remains a matter of debate. Case summary: A challenging case presented with CHIP. The combination of baseline comorbidities, underlying complex coronary artery disease, and evolving hemodynamics synergistically jeopardized the physiological reserve and necessitated management with innovative strategies. A stepwise bail-out approach to the challenges during the procedure is provided. Using a longer sheath to overcome advanced peripheral arterial disease, peeling the shaft of the Impella CP sheath and removal of sheath’s protection cover enables an additional 25 cm to reach the left ventricle, and a second access for PCI facilitates the standard length of the guide catheter to reach the left coronary artery. However, different plaque modification techniques did not prevent 30% of stent underexpansion. The 6-month follow-up was uneventful. Conclusions: The adoption of mechanical circulatory support in daily medical practice has been propelled more by clinically estimated risk than definitive evidence. Although ongoing innovations facilitate interventions in more complex scenarios, bailout strategies help to rescue the patient and address new insights for the next innovations.

Background: The use of interventional endovascular therapy for pulmonary embolism (PE) has become increasingly important over the last decade. In contrast to other cardiovascular interventions, these procedures carry a higher risk of access-related bleeding due to the acute clinical setting, elevated body mass index, and the frequent need for high-dose anticoagulation. However, there is still no clear consensus regarding the optimal vascular access site for endovascular PE therapy or the impact of ultrasound (US)-guided puncture on access-related complications. Methods: We treated 89 patients with intermediate- to high-risk PE using the Ekosonic endovascular system (EKOS). Group A (n = 39) underwent femoral venous puncture without US guidance, and Group B (n = 50) underwent US-guided femoral venous puncture. Results: Intraprocedural complications differed significantly between the two groups, with a higher incidence of vascular access complications in the non-US-guided group. Access-site pseudoaneurysms and retroperitoneal bleeding events occurred exclusively in the non-US-guided group (n = 6). Major (n = 3) and moderate (n = 5) bleeding events were also observed only in the non-US-guided group (p < 0.001). However, the total length of stay in the intermediate care unit and in the hospital did not differ between the groups. These findings are consistent with prior reports from other interventional settings that demonstrate fewer bleeding events among patients undergoing US-guided procedures. Conclusion: Widespread adoption of US-guided puncture in interventional PE therapy could reduce access-related complications, increase first-pass success, and reduce the number of puncture attempts, inadvertent arterial punctures, and unsuccessful access-site cannulations, particularly in patients with unfavorable access anatomy, obesity, or anatomical variations. Further education and implementation of US-guided access into training programs could improve the adoption of this technique.

Aims: Patients at high bleeding risk (HBR) and acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) are at high risk of adverse outcomes. We investigated the clinical outcomes and their consistency after biodegradable polymer sirolimus-eluting (BP-SES) or durable polymer zotarolimus-eluting stent (DP-ZES) implantation in HBR patients with or without ACS. Methods and results: The per-protocol population of the BIOFLOW-DAPT randomized control trial (RCT) consisted of HBR patients with (n = 541) or without ACS (n = 1245) who were randomized to BP-SES or DP-ZES and underwent 1 month dual antiplatelet therapy (DAPT). The primary efficacy and safety endpoints were target lesion failure (TLF), defined as the composite endpoint of cardiac death, target vessel myocardial infarction (TV-MI), or clinically driven target lesion revascularization (cd-TLR) as well as major bleeding defined as BARC 3 or 5 (according to Bleeding Academic Research Consortium classification) and definite/probable stent thrombosis (ST). At 1 year, patients with ACS suffered from higher cardiac death rates (3.4 vs. 1.3%, log-rank P = 0.004) but similar TLF (6.8 vs. 6.7%, P = 0.992), TV-MI (2.8 vs. 4.5%, P = 0.100), cd-TLR (1.4 vs. 2.1%, P = 0.300), major bleeding (4.2 vs. 3.1%, P = 0.266), and ST (0.2 vs. 0.9%, P = 0.098) compared with no ACS patients. The rate of TLF and of all secondary endpoints was consistent with BP-SES or DP-ZES across ACS strata. Conclusion: HBR patients with ACS are at higher risk of cardiac death than those without ACS and experience a consistent outcome with BP-SES or DP-ZES followed by 1 month DAPT at 1 year follow-up. Clinical Trial Registration: NCT04137510.

Objective: Self-expanding (SE) transcatheter aortic prostheses (THV) have been associated with an increased risk of new permanent pacemaker implantation (PPMI), particularly with deeper implantations in the left ventricular outflow tract (LVOT) that result in more atrioventricular conduction system damage, leading to higher rates of post-procedural conduction disturbances (CDs) and subsequently more PPMIs. The cusp-overlap technique (COT) is designed to provide better visualisation of the LVOT during implantation, aiming to achieve a shallower implantation depth (ID) and potentially reduce both post-procedural CDs and PPMIs. This study seeks to compare the traditional three-cusp coplanar view technique (3CT) with the newer COT in patients undergoing transcatheter aortic valve replacement (TAVR). Methods: From March 2018 to April 2020, a total of 586 patients underwent TAVR at the university clinic in Kiel. Among them, 226 patients who received SE prostheses were included in the study. After applying exclusion criteria, a final cohort of 203 patients was analysed. Of these, 106 patients underwent TAVR using the COT, while 97 patients underwent TAVR using the 3CT. The primary endpoints of the study were the occurrence of new CD and PPMI within 30 days post-procedure. Secondary endpoints included various post-TAVR events as defined by the Valve Academic Research Consortium 3 (VARC-3) safety criteria. A specific focus was placed on assessing the risk of high valve implantation according to VARC-3 criteria, specifically paravalvular insufficiency, valve embolisation, and coronary occlusion. Statistical analysis was conducted to compare outcomes between the COT and 3CT groups. Results: Implantation depths were significantly lower in the COT group compared to the 3CT group, with ID values from the NCC and LCC being 2.7 mm (±1.5) and 2.8 mm (±1.5) for the COT, and 5.4 mm (±3) and 6.6 mm (±2.6) for the 3CT (p < 0.001 for both). The incidence of high-grade CD, particularly Atrioventricular Block (AVB) II and III, was significantly higher in the 3CT group (26.8%) compared to the COT group (13.2%) (p = 0.023). The overall 30-day PPMI rate was 18.2% (n = 37), with a significant difference between the COT and 3CT groups (12.2% vs. 24.7%, p = 0.021). The primary indication for PPMI was permanent high-grade AVB occurring during or after TAVR, accounting for 95% of cases. No cases of TAVR embolisation, acute coronary occlusion or related syndromes were observed within the first 30 days post-procedure. There were no significant differences in 30-day mortality or post-procedural paravalvular insufficiency between the groups. In multivariable logistic regression analysis, the COT remained independently associated with lower odds of new post-procedural CD after adjustment for prior right bundle branch block (RBBB), prior first-degree AVB, predilatation, valve size and coronary artery disease (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.24–0.82, p = 0.009). For 30-day PPMI, the cusp-overlap technique demonstrated a borderline association with lower adjusted odds (OR 0.46, 95% CI 0.20–1.02, p = 0.057), while prior RBBB was independently associated with increased PPMI risk (OR 3.54, 95% CI 1.22–10.28, p = 0.020). Conclusions: The COT was associated with shallower implantation depth and lower rates of new post-procedural CD after multivariable adjustment. The association with reduced 30-day PPMI remained directionally consistent but was borderline after adjustment. These findings support the potential value of COT as a procedural strategy to reduce conduction-related complications after TAVR with self-expanding prostheses.

Background: Coronary artery perforation is a potentially life-threatening complication in 0.2–0.6% of all patients undergoing percutaneous coronary intervention. Despite the ongoing development of technical skills and coronary devices, severe recalcitrant calcified coronary lesions remain a challenge for interventional cardiologists and can carry a potential risk for life-threatening complications, including coronary perforation. Discussion and Conclusion: The algorithm for cardiac vessel perforation could be more comprehensive and cover preventive and predictive measures. It is necessary to take into consideration prompt recognition, implement actions to restabilize the hemodynamic status, understand the source and mechanism of bleeding, and classify the cause of bleeding into proximal, distal, coronary artery bypass graft and collateral vessel, pericardial, myocardial extravasation, and vessel-chamber perforation, as each causality would necessitate a different management strategy for a successful outcome. Imaging information about cardiac vessel injury is useful for a better understanding of the spatial orientation of the coronary vessels. It also helps to detect a hematoma that deteriorates the hemodynamic status without effusion “dry tamponade” and could have a particular role in cardiac interventions to predict and prevent this complication.

The circumflex (Cx) coronary artery is more vulnerable to injury than other coronary arteries during procedures such as radiofrequency ablation, left atrial appendage closure, mitral valve repair, and coronary sinus-based mitral valve intervention. Furthermore, a lower success rate was also observed in the Cx artery during chronic occlusion recanalization. Additionally, injury to the great cardiac vein during Cx artery interventions can occur due to the highly variable and often unpredictable relationship between the great cardiac vein and the Cx artery, which occurs in approximately 30% of cases. Imaging information on the Cx artery and the associated relationship with surrounding cardiac structures is crucial for understanding spatial orientation. This knowledge aids preventive measures, accurate prediction, prompt recognition, and understanding of injury mechanisms, thereby facilitating appropriate therapeutic interventions. We present a comprehensive literature review of the clinical implications, complexities, and challenges associated with the Cx artery, which could help in management strategies and improve outcomes.

Background: The third‐generation sirolimus‐eluting resorbable magnesium scaffold could be a competitive or alternative to a drug‐eluting stent in the future, in particular in iatrogenic coronary artery dissection, to avoid unnecessary metal stents to reduce restenosis and occlusion rate. Case Presentation: We report a 66‐year‐old female who presented with unstable angina. The significant medial Cx stenosis was treated with a drug‐coated balloon. A small new dissection medial Cx occurred. 8 hours later, the patient developed lateral wall ST segment elevation myocardial infarction. Coronary angiography revealed Cx with iatrogenic antegrade and retrograde propagation flow limiting dissection. After dissection modification with cuttering technique, we performed IVUS‐guided medial to distal Cx with Freesolve BRS. The 3‐month follow‐up was uneventful. Conclusion: Usage of BRS in cases of iatrogenic flow limiting coronary artery dissection, especially in small diameter vessels, may be a good indication in the future to decrease the in‐stent stenosis/occlusion rate. Large cohort studies are required.

Objective: This analysis compares new (G2) versus old (G1) generations of transcatheter heart valves (THVs) in transcatheter aortic valve replacement (TAVR) procedures, focusing on key outcomes: post-procedural conduction disturbance (CD) and permanent pacemaker implantation (PPMI). We aim to determine whether G2 valves reduce these specific complications and thereby improve patient outcomes compared with G1. Methods: From February 2015 to September 2022, 1468 patients underwent TAVR at the university clinic in Kiel. After applying exclusion criteria, a final cohort of 1182 patients were analysed. Among these, 782 patients underwent TAVR with G1, whereas 400 underwent TAVR with G2. The primary study endpoints were the occurrence of new CD and PPMI within 30 days post-procedure. The secondary endpoints included diverse post-TAVR events as defined by the safety criteria of Valve Academic Research Consortium 3 (VARC III). A statistical analysis compared outcomes between the G1 and G2 groups. Results: Out of 1182 patients, 12.1% required PPMI within 30 days. Rates showed no statistical difference between G2 and G1 for PPMI (10.3% vs. 13.0%, IPTW-weighted p = 0.31) or CD (15.3% vs. 21.48%, IPTW-weighted p = 0.08). Among G2, the Sapien 3 Ultra valve had the lowest PPMI rate (4.8%). Overall, G2 and G1 had similar post-procedural and 30-day mortality rates. Conclusion: G2 valves may reduce post-procedure CD, but the difference is not statistically significant. Differences between specific valve types—such as the Sapien 3 Ultra’s lower rates—are notable, but overall, PPMI and safety profiles remain similar between G1 and G2. Patient and procedural factors still play a significant role. Careful valve and patient selection is essential, and ongoing research will guide further improvements.

Transcatheter aortic valve implantation (TAVI) is the gold standard therapy for high‐risk patients with severe, symptomatic aortic valve stenosis, particularly in patients with impaired left ventricular systolic function or those with previous cardiac surgery. However, TAVI with non‐dedicated devices in patients with native severe AR is challenging. Patients frequently have a bicuspid aortic valve, large dimensions of the aortic annulus, and a low aortic valve calcification load. These features increase the risk of significant paravalvular regurgitation and prosthesis migration. We present two cases of severe aortic valve regurgitation due to cusp migration of previously implanted surgical aortic valves and flail cusps. After discussion with the Heart team based on the patient's clinical profile and the high risk of surgical repair, self‐expandable‐TAVI was performed using the Navitor trans‐catheter heart valve in the first case and the Accurate Neo 2 in the second case. During TAVI and before valve release, acute LM coronary artery occlusion was noted. Successful further TAVI implantation and PCI was a lifesaving strategy. The 3‐month follow‐up was uneventful. Transcatheter valve implantation expands its indications for more complex anatomy, off‐label use in severe aortic regurgitation and patient's comorbidity. In the case of flail cusp during TAVI, LM coronary artery obstruction must be considered an expected complication, and LM protection maneuvers should be considered in difficult anatomies.