Timothy Cartlidge

Background: Patients undergoing urgent transcatheter aortic valve implantation (TAVI) represent a clinically high-risk population with increased peri-procedural morbidity. Whether an early discharge strategy is feasible and safe remains unclear. We evaluated the feasibility of early discharge in patients undergoing urgent transcatheter aortic valve implantation. Methods: This single-centre observational cohort study included 279 consecutive patients undergoing urgent TAVI (mean age 81 ± 7 years; 155 [56%] male). Patients were stratified according to post-TAVI length of stay into next-day discharge or prolonged hospitalisation (>1 day). Data were prospectively collected and the primary end point was 30-day all-cause mortality. Results: Among 279 urgent TAVI patients, 62 (22%) were discharged the next day and 217 (78%) had prolonged hospitalisation. Baseline clinical and echocardiographic characteristics were similar between the two groups. Among the 279 patients surviving to discharge assessment, 30-day mortality was 0.4%, with no significant difference between the next-day and longer-stay groups. Patients in the short hospital stay group had an 11% complication rate compared to 30% in the long stay one. Unlike stroke or pacemaker implantation, vascular complication was an independent predictor of extended in-hospital length of stay [Beta coefficient 3.41, 95% CI (0.98 to 5.85), p = 0.006]. Conclusions: Next-day discharge appears feasible in carefully selected patients undergoing urgent TAVI and was not associated with excess 30-day mortality in this observational cohort. Prospective multi-centre studies are required to validate these findings and establish standardised discharge criteria.

Background: Single-access transfemoral transcatheter aortic valve implantation (TAVI) reduces the need for multiple vascular access and therefore, the related risk of related complications. However, the impact of patient age on its clinical outcomes remains uncertain. Methods: This is a secondary analysis of previously reported propensity score matched study comparing clinical outcomes of single- versus dual-access transfemoral TAVI using SAPIEN-3-Ultra. We examined the relation between patient age, access strategy and outcomes—specifically, 30-day safety endpoint according to the Valve Academic Research Consortium 3 (VARC-3) and major adverse cardiovascular events (MACE), defined as death, permanent pacemaker, neurological or vascular complications—using logistic regression interaction analyses, and restricted cubic spline modelling. Results: A total of 204 patients (propensity score-matched cohort) were included in the study. The elderly group were more likely to have hypertension, peripheral vascular disease or stroke. The use of single access was comparable. The elderly cohort demonstrated a tendency toward longer fluoroscopy and procedural times compared with the non-elderly group. This pattern likely reflects the greater technical complexity and heightened procedural caution often associated with older patients, including more challenging vascular anatomy and the need for careful device handling. Although not statistically significant, these findings remain clinically meaningful and are consistent with the notion that procedures in elderly patients frequently require more meticulous planning and execution. There was a significant interaction between access strategy and age in reducing MACE, but not in VARC-3 safety outcomes. Single access was associated with a significant reduction in MACE (5.4% vs. 26.7%, p = 0.015) with comparable technical and safety outcomes when compared with elderly patients who underwent dual-access TAVI. Conclusions: Single-access TAVI was linked to favourable early outcomes, maintained procedural success, and suggested a possible age-dependent pattern in the occurrence of MACE. Our findings support the need for randomised studies to demonstrate superiority of single- versus dual-access TAVI, particularly in the elderly population.

Background and Objectives: Recent studies have focused on evaluating the hemodynamic results in patients undergoing transcatheter aortic valve implantation (TAVI) with small aortic annuli. There is limited data on the incidence, clinical characteristics, and mortality of prosthesis–patient mismatch (PPM) in patients undergoing TAVI with large aortic annuli. Materials and Methods: This is a retrospective analysis of consecutive patients with severe aortic stenosis and large annuli who underwent TAVI at a single UK center. PPM was defined according to the Valve Academic Research Consortium (VARC-3) criteria and identified using echocardiography within 4–6 weeks following TAVI. Measurements were analyzed by an experienced operator who was blinded to the type of valve platform and clinical outcomes. Results: A total of 447 patients were screened, of whom 353 patients were included in the analysis. The incidence of any PPM or severe PPM was 38% and 15% of patients, respectively. Patients with severe PPM were younger, had larger body surface area, and were more likely to receive a balloon-expandable valve (BEV). At a mean follow-up of 35 months, mortality was numerically higher in patients with severe PPM (46% vs. 36%, p = 0.20) but this did not reach statistical significance. Similar mortality rates were observed among patients with or without severe PPM in those who received SEV as well as BEV. There was a differential role of body surface area in mortality in patients who developed severe PPM versus non-severe PPM. Conclusions: Severe PPM was evident in patients with large aortic annuli undergoing TAVI, particularly those who received BEV. Nonetheless, severe PPM did not impact mortality rate at three-year follow-up. Longer-term follow-up may be required to assess the impact of severe PPM on mortality.

Background: Left bundle branch block (LBBB) following trans-catheter aortic valve implantation (TAVI) has been excluded from same-day discharge. Early identification of patients with stable LBBB can help facilitate same-day discharge. We aim to assess the role of 6-hour ECG to determine development of LBBB in patients undergoing TAVI. Methods: This is a prospective single-centre study of patients who have LBBB following elective TAVI procedures. All patients underwent ECGs pre-TAVI, as well as immediately, 6 h, and 24 h post-TAVI. Changes in ECG were compared at 6 and 24 h with the one immediately post TAVI. Results: The study included 115 patients with uncomplicated procedures. The mean age was 81 ± 7 years, with 54% male. A self-expanding valve was used in 67% of patients. Following TAVI, prolongations of PR interval and QRS duration were dynamic and reduced at 6 h. The change in PR interval at 6 and 24 h was comparable [−11 (−20 to 3) vs. −2 (−24 to 16) ms, p = 0.18]. Similarly, there was no statistical difference in the change of QRS duration at 6 and 24 h compared to the ECG immediately post-TAVI [−10 (−40 to −2) vs. −7 (−34 to 0) ms, p = 0.055]. Changes in ECG were also comparable in patients undergoing balloon-expandable and self-expanding valves. Conclusions: The current study supports that 6-hour ECG has the potential to reduce the need for prolonged continuous monitoring post-TAVI. ECG at 6 h can help optimise patient flow and facilitate early discharge. Future studies with larger sample sizes are required to confirm our findings.

Optimal myocardial reperfusion during primary percutaneous coronary intervention (pPCI) is increasingly recognized to be beyond restoring epicardial coronary flow. Both invasive and non-invasive tools have highlighted the limitation of using this metric, and more efforts are focused towards achieving optimal reperfusion at the level of the microcirculation. Recent data highlighted the close relationship between thrombus burden and impaired microcirculation in patients presenting with ST-segment elevation myocardial infarction (STEMI). Moreover, distal embolization was an independent predictor of mortality in patients with STEMI. Likewise, the development of no-reflow phenomenon has been directly linked with worse clinical outcomes. Adjunctive thrombus aspiration during pPCI is intuitively intended to remove atherothrombotic material to mitigate the risk of distal embolization and the no-reflow phenomenon (NRP). However, prior trials on the use of thrombectomy during pPCI did not support its routine use, with comparable clinical endpoints to patients who underwent PCI alone. This article aims to review the existing literature highlighting the limitation on the use of thrombectomy and provide future insights into trials investigating the role of thrombectomy in contemporary pPCI.

Microvascular obstruction (MVO) is a recognised phenomenon following mechanical reperfusion in patients presenting with ST-segment elevation myocardial infarction (STEMI). Invasive and non-invasive modalities to detect and measure the extent of MVO vary in their accuracy, suggesting that this phenomenon may reflect a spectrum of pathophysiological changes at the level of coronary microcirculation. The importance of detecting MVO lies in the observation that its presence adds incremental risk to patients following STEMI treatment. This increased risk is associated with adverse cardiac remodelling seen on cardiac imaging, increased infarct size, and worse patient outcomes. This review provides an outline of the pathophysiology, clinical implications, and prognosis of MVO in STEMI. It describes historic and novel pharmacological and non-pharmacological therapies to address this phenomenon in conjunction with primary PCI.