Publications by authors named "Nilesh Sutaria"

29 Publications

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COVID-19 and its impact on the cardiovascular system.

Open Heart 2021 03;8(1)

Cardiology, Imperial College Healthcare NHS Trust, London, UK.

Objectives: The clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascular manifestations. We review the cardiac presentations, in-hospital outcomes and development of cardiovascular complications in the initial cohort of SARS-CoV-2 positive patients at Imperial College Healthcare National Health Service Trust, UK.

Methods: We retrospectively analysed 498 COVID-19 positive adult admissions to our institute from 7 March to 7 April 2020. Patient data were collected for baseline demographics, comorbidities and in-hospital outcomes, especially relating to cardiovascular intervention.

Results: Mean age was 67.4±16.1 years and 62.2% (n=310) were male. 64.1% (n=319) of our cohort had underlying cardiovascular disease (CVD) with 53.4% (n=266) having hypertension. 43.2%(n=215) developed acute myocardial injury. Mortality was significantly increased in those patients with myocardial injury (47.4% vs 18.4%, p<0.001). Only four COVID-19 patients had invasive coronary angiography, two underwent percutaneous coronary intervention and one required a permanent pacemaker implantation. 7.0% (n=35) of patients had an inpatient echocardiogram. Acute myocardial injury (OR 2.39, 95% CI 1.31 to 4.40, p=0.005) and history of hypertension (OR 1.88, 95% CI 1.01 to 3.55, p=0.049) approximately doubled the odds of in-hospital mortality in patients admitted with COVID-19 after other variables had been controlled for.

Conclusion: Hypertension, pre-existing CVD and acute myocardial injury were associated with increased in-hospital mortality in our cohort of COVID-19 patients. However, only a low number of patients required invasive cardiac intervention.
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http://dx.doi.org/10.1136/openhrt-2020-001472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969760PMC
March 2021

Adapting the role of handheld echocardiography during the COVID-19 pandemic: A practical guide.

Perfusion 2021 Jan 9:267659120986532. Epub 2021 Jan 9.

Department of Cardiology, Imperial College Healthcare NHS Foundation Trust, London, UK.

The COVID-19 pandemic has altered our approach to inpatient echocardiography delivery. There is now a greater focus to address key clinical questions likely to make an immediate impact in management, particularly during the period of widespread infection. Handheld echocardiography (HHE) can be used as a first-line assessment tool, limiting scanning time and exposure to high viral load. This article describes a potential role for HHE during a pandemic. We propose a protocol with a reporting template for a focused core dataset necessary in delivering an acute echocardiography service in the setting of a highly contagious disease, minimising risk to the operator. We cover the scenarios typically encountered in the acute cardiology setting and how an expert trained echocardiography team can identify such pathologies using a limited imaging format and include cardiac presentations encountered in those patients acutely unwell with COVID-19.
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http://dx.doi.org/10.1177/0267659120986532DOI Listing
January 2021

Prevalence, predictors, and outcomes of patient prosthesis mismatch in women undergoing TAVI for severe aortic stenosis: Insights from the WIN-TAVI registry.

Catheter Cardiovasc Interv 2021 Feb 31;97(3):516-526. Epub 2020 Aug 31.

Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, New York, Box 1030, USA.

Objective: To evaluate the incidence, predictors and outcomes of female patients with patient-prosthesis mismatch (PPM) following transcatheter aortic valve intervention (TAVI) for severe aortic stenosis (AS).

Background: Female AS TAVI recipients have a significantly lower mortality than surgical aortic valve replacement (SAVR) recipients, which could be attributed to the potentially lower PPM rates. TAVI has been associated with lower rates of PPM compared to SAVR. PPM in females post TAVI has not been investigated to date.

Methods: The WIN-TAVI (Women's INternational Transcatheter Aortic Valve Implantation) registry is a multicenter registry of women undergoing TAVR for severe symptomatic AS. Two hundred and fifty patients with detailed periprocedural and follow-up echocardiographic investigations were included in the WIN-TAVI echocardiographic sub-study. PPM was defined as per European guidelines stratified by the presence of obesity.

Results: The incidence of PPM in our population was 32.8%. Patients with PPM had significantly higher BMI (27.4 ± 6.1 vs. 25.2 ± 5.0, p = .002), smaller sized valves implanted (percentage of TAVI ≤23 mm 61% vs. 29.2%, PPM vs. no PPM, p < .001) and were more often treated with balloon expandable valves (48.3 vs. 32.5%, p < .001) rather than self expanding ones (26.3 vs. 52.8%, <.001). BMI (OR = 1.08; 95%CI 1.02-1.14, p = .011) and valve size ≤23 mm (OR = 3.00 95%CI 1.14-7.94, p = .027) were the only independent predictors of PPM. There was no significant interaction between valve size and valve type (p = .203). No significant differences were observed in 1-year mortality or major adverse cardiovascular events.

Conclusions: PPM in females undergoing TAVI occurs in one third of patients. BMI and valve size ≤23 mm are independent predictors. Larger registries are required to determine the impact of PPM on future clinical outcomes.
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http://dx.doi.org/10.1002/ccd.29227DOI Listing
February 2021

Improving ultrasound video classification: an evaluation of novel deep learning methods in echocardiography.

J Med Artif Intell 2020 Mar;3

National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK.

Echocardiography is the commonest medical ultrasound examination, but automated interpretation is challenging and hinges on correct recognition of the 'view' (imaging plane and orientation). Current state-of-the-art methods for identifying the view computationally involve 2-dimensional convolutional neural networks (CNNs), but these merely classify individual frames of a video in isolation, and ignore information describing the movement of structures throughout the cardiac cycle. Here we explore the efficacy of novel CNN architectures, including time-distributed networks and two-stream networks, which are inspired by advances in human action recognition. We demonstrate that these new architectures more than halve the error rate of traditional CNNs from 8.1% to 3.9%. These advances in accuracy may be due to these networks' ability to track the movement of specific structures such as heart valves throughout the cardiac cycle. Finally, we show the accuracies of these new state-of-the-art networks are approaching expert agreement (3.6% discordance), with a similar pattern of discordance between views.
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http://dx.doi.org/10.21037/jmai.2019.10.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7100611PMC
March 2020

Double Utility of a Buddy Wire in Transseptal Transcatheter Mitral Intervention.

JACC Cardiovasc Interv 2019 12;12(24):2555-2557

Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2019.08.048DOI Listing
December 2019

Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses: A Multicenter Study Using Intracoronary Pressure and Flow.

Circ Cardiovasc Interv 2019 12 22;12(12):e008263. Epub 2019 Nov 22.

National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.).

Background: Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation.

Methods: Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with percutaneous coronary intervention were included. Coronary pressure and flow were measured at rest and during hyperemia in both groups, before and after TAVI (group 1) and before and after percutaneous coronary intervention (group 2).

Results: Microvascular resistance over the wave-free period of diastole increased significantly post-TAVI (pre-TAVI, 2.71±1.4 mm Hg·cm·s versus post-TAVI 3.04±1.6 mm Hg·cm·s [=0.03]). Microvascular reserve over the wave-free period of diastole significantly improved post-TAVI (pre-TAVI 1.88±1.0 versus post-TAVI 2.09±0.8 [=0.003]); this was independent of the severity of the underlying coronary stenosis. The change in microvascular resistance post-TAVI was equivalent to that produced by stenting a coronary lesion with an instantaneous wave-free ratio of ≤0.74.

Conclusions: TAVI improves microcirculatory function regardless of the severity of underlying coronary disease. TAVI for severe AS produces a coronary hemodynamic improvement equivalent to the hemodynamic benefit of stenting coronary stenoses with instantaneous wave-free ratio values <0.74. Future trials of physiology-guided revascularization in severe AS may consider using this value to guide treatment of concomitant coronary artery disease.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6924937PMC
December 2019

Coronary Hemodynamics in Patients With Severe Aortic Stenosis and Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement: Implications for Clinical Indices of Coronary Stenosis Severity.

JACC Cardiovasc Interv 2018 10 25;11(20):2019-2031. Epub 2018 Aug 25.

National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, London, United Kingdom. Electronic address:

Objectives: In this study, a systematic analysis was conducted of phasic intracoronary pressure and flow velocity in patients with severe aortic stenosis (AS) and coronary artery disease, undergoing transcatheter aortic valve replacement (TAVR), to determine how AS affects: 1) phasic coronary flow; 2) hyperemic coronary flow; and 3) the most common clinically used indices of coronary stenosis severity, instantaneous wave-free ratio and fractional flow reserve.

Background: A significant proportion of patients with severe aortic stenosis (AS) have concomitant coronary artery disease. The effect of the valve on coronary pressure, flow, and the established invasive clinical indices of stenosis severity have not been studied.

Methods: Twenty-eight patients (30 lesions, 50.0% men, mean age 82.1 ± 6.5 years) with severe AS and coronary artery disease were included. Intracoronary pressure and flow assessments were performed at rest and during hyperemia immediately before and after TAVR.

Results: Flow during the wave-free period of diastole did not change post-TAVR (29.78 ± 14.9 cm/s vs. 30.81 ± 19.6 cm/s; p = 0.64). Whole-cycle hyperemic flow increased significantly post-TAVR (33.44 ± 13.4 cm/s pre-TAVR vs. 40.33 ± 17.4 cm/s post-TAVR; p = 0.006); this was secondary to significant increases in systolic hyperemic flow post-TAVR (27.67 ± 12.1 cm/s pre-TAVR vs. 34.15 ± 17.5 cm/s post-TAVR; p = 0.02). Instantaneous wave-free ratio values did not change post-TAVR (0.88 ± 0.09 pre-TAVR vs. 0.88 ± 0.09 post-TAVR; p = 0.73), whereas fractional flow reserve decreased significantly post-TAVR (0.87 ± 0.08 pre-TAVR vs. 0.85 ± 0.09 post-TAVR; p = 0.001).

Conclusions: Systolic and hyperemic coronary flow increased significantly post-TAVR; consequently, hyperemic indices that include systole underestimated coronary stenosis severity in patients with severe AS. Flow during the wave-free period of diastole did not change post-TAVR, suggesting that indices calculated during this period are not vulnerable to the confounding effect of the stenotic aortic valve.
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http://dx.doi.org/10.1016/j.jcin.2018.07.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197079PMC
October 2018

Transcatheter mitral valve replacement in severe mitral annular calcification and atrial septal defect closure.

Cardiovasc Revasc Med 2019 03 7;20(3):194-196. Epub 2018 Apr 7.

Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.

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http://dx.doi.org/10.1016/j.carrev.2018.03.022DOI Listing
March 2019

Patent foramen ovale closure vs. medical therapy for cryptogenic stroke: a meta-analysis of randomized controlled trials.

Eur Heart J 2018 05;39(18):1638-1649

National Heart and Lung Institute, 2nd Floor B Block, Hammersmith Hospital, Imperial College London W12 0HS, UK.

Aims: The efficacy of patent foramen ovale (PFO) closure for cryptogenic stroke has been controversial. We undertook a meta-analysis of randomized controlled trials (RCTs) comparing device closure with medical therapy to prevent recurrent stroke for patients with PFO.

Methods And Results: We systematically identified all RCTs comparing device closure to medical therapy for cryptogenic stroke in patients with PFO. The primary efficacy endpoint was recurrent stroke, analysed on an intention-to-treat basis. The primary safety endpoint was new onset atrial fibrillation (AF). Five studies (3440 patients) were included. In all, 1829 patients were randomized to device closure and 1611 to medical therapy. Across all patients, PFO closure was superior to medical therapy for prevention of stroke [hazard ratio (HR) 0.32, 95% confidence interval (95% CI) 0.13-0.82; P = 0.018, I2 = 73.4%]. The risk of AF was significantly increased with device closure [risk ratio (RR) 4.68, 95% CI 2.19-10.00, P<0.001, heterogeneity I2 = 27.5%)]. In patients with large shunts, PFO closure was associated with a significant reduction in stroke (HR 0.33, 95% CI 0.16-0.72; P = 0.005), whilst there was no significant reduction in stroke in patients with a small shunt (HR 0.90, 95% CI 0.50-1.60; P = 0.712). There was no effect from the presence or absence of an atrial septal aneurysm on outcomes (P = 0.994).

Conclusion: In selected patients with cryptogenic stroke, PFO closure is superior to medical therapy for the prevention of further stroke: this is particularly true for patients with moderate-to-large shunts. Guidelines should be updated to reflect this.
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http://dx.doi.org/10.1093/eurheartj/ehy121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946888PMC
May 2018

Optimal antiplatelet strategy after transcatheter aortic valve implantation: a meta-analysis.

Open Heart 2018;5(1):e000748. Epub 2018 Jan 26.

International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK.

Objective: International guidelines recommend the use of dual antiplatelet therapy (DAPT) after transcatheter aortic valve implantation (TAVI). The recommended duration of DAPT varies between guidelines. In this two-part study, we (1) performed a structured survey of 45 TAVI centres from around the world to determine if there is consensus among clinicians regarding antiplatelet therapy after TAVI; and then (2) performed a systematic review of all suitable studies (randomised controlled trials (RCTs) and registries) to determine if aspirin monotherapy can be used instead of DAPT.

Methods: A structured electronic survey regarding antiplatelet use after TAVI was completed by 45 TAVI centres across Europe, Australasia and the USA. A systematic review of TAVI RCTs and registries was then performed comparing DAPT duration and incidence of stroke, bleeding and death. A variance weighted least squared metaregression was then performed to determine the relationship of antiplatelet therapy and adverse events.

Results: 82.2% of centres routinely used DAPT after TAVI. Median duration was 3 months. 13.3% based their practice on guidelines. 11 781 patients (26 studies) were eligible for the metaregression. There was no benefit of DAPT over aspirin monotherapy for stroke (P=0.49), death (P=0.72) or bleeding (P=0.91).

Discussion: Aspirin monotherapy appears to be as safe and effective as DAPT after TAVI.
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http://dx.doi.org/10.1136/openhrt-2017-000748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786926PMC
January 2018

Doppler assessment of aortic stenosis: a 25-operator study demonstrating why reading the peak velocity is superior to velocity time integral.

Eur Heart J Cardiovasc Imaging 2018 12;19(12):1380-1389

Imperial College London, NHLI-Cardiovascular Science, Du Cane Road, London, UK.

Aims: Measurements with superior reproducibility are useful clinically and research purposes. Previous reproducibility studies of Doppler assessment of aortic stenosis (AS) have compared only a pair of observers and have not explored the mechanism by which disagreement between operators occurs. Using custom-designed software which stored operators' traces, we investigated the reproducibility of peak and velocity time integral (VTI) measurements across a much larger group of operators and explored the mechanisms by which disagreement arose.

Methods And Results: Twenty-five observers reviewed continuous wave (CW) aortic valve (AV) and pulsed wave (PW) left ventricular outflow tract (LVOT) Doppler traces from 20 sequential cases of AS in random order. Each operator unknowingly measured each peak velocity and VTI twice. VTI tracings were stored for comparison. Measuring the peak is much more reproducible than VTI for both PW (coefficient of variation 10.1 vs. 18.0%; P < 0.001) and CW traces (coefficient of variation 4.0 vs. 10.2%; P < 0.001). VTI is inferior because the steep early and late parts of the envelope are difficult to trace reproducibly. Dimensionless index improves reproducibility because operators tended to consistently over-read or under-read on LVOT and AV traces from the same patient (coefficient of variation 9.3 vs. 17.1%; P < 0.001).

Conclusion: It is far more reproducible to measure the peak of a Doppler trace than the VTI, a strategy that reduces measurement variance by approximately six-fold. Peak measurements are superior to VTI because tracing the steep slopes in the early and late part of the VTI envelope is difficult to achieve reproducibly.
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http://dx.doi.org/10.1093/ehjci/jex218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6247666PMC
December 2018

Female-specific survival advantage from transcatheter aortic valve implantation over surgical aortic valve replacement: Meta-analysis of the gender subgroups of randomised controlled trials including 3758 patients.

Int J Cardiol 2018 Jan;250:66-72

Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, UK; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.

Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) is the first area of interventional cardiology where women are treated as often as men. In this analysis of the gender specific results of randomised controlled trials (RCTs) comparing TAVI with surgical aortic valve replacement (SAVR) we aimed to determine whether gender affects the survival comparison between TAVI and SAVR. We identified all RCTs comparing TAVI versus SAVR for severe AS and reporting 1 and/or 2year survival. Summary odds ratios (ORs) were obtained using a random-effects model. Heterogeneity was assessed using the Q statistic and I. Four RCTs met the criteria, totalling 3758 patients, 1706 women and 2052 men. Amongst females, TAVI recipients had a significantly lower mortality than SAVR recipients, at 1year (OR 0.68; 95%CI 0.50 to 0.94) and at 2years (OR 0.74; 95%CI 0.58 to 0.95). Amongst males there was no difference in mortality between TAVI and SAVR, at 1year (OR 1.09; 95%CI 0.86 to 1.39) or 2years (OR 1.05; 95%CI 0.85 to 1.3). The difference in treatment effect between genders was significant at both 1year (p=0.02) and 2years (p=0.04). In women TAVI has a 26 to 31% lower mortality odds than SAVR. In men, there is no difference in mortality between TAVI and SAVR.
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http://dx.doi.org/10.1016/j.ijcard.2017.05.047DOI Listing
January 2018

The Impact of Gender on Outcomes Following Transcatheter Aortic Valve Implantation: True Effect or Bias?

J Heart Valve Dis 2016 09;25(5):552-556

Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, UK.

Transcatheter aortic valve implantation (TAVI) is currently the treatment of choice for patients with severe aortic stenosis (AS) who are unsuitable for surgical aortic valve replacement (SAVR), and is an acceptable alternative for those at high and intermediate surgical risk. In published TAVI registries and meta-analyses, whilst women are significantly older they present with fewer comorbidities compared to men (including coronary artery disease, peripheral vascular disease, diabetes and chronic obstructive pulmonary disease). In response to chronic pressure overload from AS, women have been shown to develop greater levels of left ventricular hypertrophy than men, as well as having a greater preservation of LV ejection fraction (LVEF) and less fibrosis. Following aortic valve replacement, women have been shown to have a faster regression of myocardial hypertrophy, with a significant improvement in LVEF. Following TAVI, female gender seems to be associated with a significantly lower one-year mortality. In the current viewpoint, it is discussed whether these findings reflect a true differential treatment response to TAVI among women, or simply the higher comorbidity burden among males undergoing TAVI.
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September 2016

Successful Treatment of Very Early Thrombosis of SAPIEN 3 Valve with Direct Oral Anticoagulant Therapy.

J Heart Valve Dis 2016 03;25(2):211-213

Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.

Thrombosis of transcatheter aortic valve implantation (TAVI) is an uncommon complication that commonly occurs weeks to months following the procedure. Herein are described the details of a patient who presented with a recurrence of symptoms days after intervention with a bioprosthesis thrombosis that was successfully treated with direct oral anticoagulant (DOAC) therapy and resulted in hemodynamic improvement and resolution of symptoms. Whilst a previous trial of DOAC therapy with mechanical valves was stopped due to elevated events in comparison to warfarin, a TAVI valve may be different, and the rapid onset of action and reduced bleeding risk may be beneficial in this patient group.
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March 2016

Impact of clinical and procedural factors upon C reactive protein dynamics following transcatheter aortic valve implantation.

World J Cardiol 2016 Jul;8(7):425-31

Neil Ruparelia, Vasileios F Panoulas, Angela Frame, Ben Ariff, Nilesh Sutaria, Michael Fertleman, Jonathan Cousins, Jon Anderson, Colin Bicknell, Andrew Chukwuemeka, Sayan Sen, Iqbal S Malik, Ghada W Mikhail, Department of Cardiology, Hammersmith Hospital, Imperial NHS Healthcare Trust, London W12 0HS, United Kingdom.

Aim: To determine the effect of procedural and clinical factors upon C reactive protein (CRP) dynamics following transcatheter aortic valve implantation (TAVI).

Methods: Two hundred and eight consecutive patients that underwent transfemoral TAVI at two hospitals (Imperial, College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom and San Raffaele Scientific Institute, Milan, Italy) were included. Daily venous plasma CRP levels were measured for up to 7 d following the procedure (or up to discharge). Procedural factors and 30-d safety outcomes according to the Valve Academic Research Consortium 2 definition were collected.

Results: Following TAVI, CRP significantly increased reaching a peak on day 3 of 87.6 ± 5.5 mg/dL, P < 0.001. Patients who developed clinical signs and symptoms of sepsis had significantly increased levels of CRP (P < 0.001). The presence of diabetes mellitus was associated with a significantly higher peak CRP level at day 3 (78.4 ± 3.2 vs 92.2 ± 4.4, P < 0.001). There was no difference in peak CRP release following balloon-expandable or self-expandable TAVI implantation (94.8 ± 9.1 vs 81.9 ± 6.9, P = 0.34) or if post-dilatation was required (86.9 ± 6.3 vs 96.6 ± 5.3, P = 0.42), however, when pre-TAVI balloon aortic valvuloplasty was performed this resulted in a significant increase in the peak CRP (110.1 ± 8.9 vs 51.6 ± 3.7, P < 0.001). The development of a major vascular complication did result in a significantly increased maximal CRP release (153.7 ± 11.9 vs 83.3 ± 7.4, P = 0.02) and there was a trend toward a higher peak CRP following major/life-threatening bleeding (113.2 ± 9.3 vs 82.7 ± 7.5, P = 0.12) although this did not reach statistical significance. CRP was not found to be a predictor of 30-d mortality on univariate analysis.

Conclusion: Careful attention should be paid to baseline clinical characteristics and procedural factors when interpreting CRP following TAVI to determine their future management.
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http://dx.doi.org/10.4330/wjc.v8.i7.425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958693PMC
July 2016

Transfemoral Valve-in-Valve Transcatheter Aortic Valve Implantation (TAVI) in a Patient With Previous Endovascular Aortic Repair (EVAR).

J Invasive Cardiol 2016 Jul;28(7):E69-70

Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, United Kingdom.

A 90-year-old man presented with increasing exertional breathlessness. He had previous implantation of a Perimount bioprosthetic aortic valve (Edwards Lifesciences) and coronary artery bypass graft surgery. Due to severe transvalvular bioprosthetic regurgitation with preserved left ventricular dimensions and ejection fraction, the heart team decided on valve-in- valve transcatheter aortic valve implantation via the transfemoral route in view of the patient's prohibitively high surgical and anesthetic risk. The patient had an uncomplicated recovery and was symptomatically much improved at 3-month follow-up.
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July 2016

Transcatheter aortic valve implantation in the young.

Int J Cardiol 2016 Jan 5;203:626-8. Epub 2015 Nov 5.

Cardiovascular Sciences, Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.

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http://dx.doi.org/10.1016/j.ijcard.2015.10.243DOI Listing
January 2016

Balloon aortic valvuloplasty as a treatment option in the era of transcatheter aortic valve implantation.

Expert Rev Cardiovasc Ther 2015 May 12;13(5):457-60. Epub 2015 Apr 12.

Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK.

Aortic valve stenosis is the commonest encountered valvular pathology and a frequent cause of morbidity and mortality in cases of severe stenosis. Definitive treatment has traditionally been offered in the form of surgical aortic valve replacement in patients with an acceptable surgical risk and more recently with the less invasive transcatheter aortic valve implantation (TAVI) in those where surgery is not a viable option. Prior to the introduction of TAVI, inoperable patients were treated medically and where appropriate with balloon aortic valvuloplasty, a procedure which although effective only provided short-term relief and was associated with high complication rates especially during its infancy. Here we discuss whether balloon aortic valvuloplasty continues to have a role in contemporary clinical practice in an era where significant advances have been achieved in the fields of surgical aortic valve replacement, TAVI and postoperative care.
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http://dx.doi.org/10.1586/14779072.2015.1036742DOI Listing
May 2015

CT coronary angiography in the investigation of chest pain--beyond coronary artery atherosclerosis; a pictorial review.

Int J Cardiol 2014 Oct 13;176(3):618-29. Epub 2014 Aug 13.

Imperial College Healthcare Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, United Kingdom.

Obstructive coronary artery disease due to atherosclerosis remains the commonest cause of chest pain, although several other conditions involving the coronary arteries, cardiac and non-cardiac structures can also result in chest pain syndromes. CT coronary angiography (CTCA) provides a non-invasive method for anatomical imaging of coronary artery disease. Whilst it does not replace diagnostic angiography, it provides a reliable 'rule out' of significant coronary artery disease in at least low to intermediate risk groups. The ability of CTCA to provide volumetric data with a large field of view also facilitates its use in the diagnosis of patients presenting with chest pain. The purpose of this pictorial review is to describe non-atherosclerotic pathologies which may present with chest pain identifiable on CTCA.
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http://dx.doi.org/10.1016/j.ijcard.2014.08.035DOI Listing
October 2014

Influence of gender on clinical outcomes following transcatheter aortic valve implantation from the UK transcatheter aortic valve implantation registry and the National Institute for Cardiovascular Outcomes Research.

Am J Cardiol 2014 Feb 9;113(3):522-8. Epub 2013 Nov 9.

Imperial College Healthcare NHS Trust, London, United Kingdom.

Gender differences exist in outcomes after percutaneous coronary intervention and coronary artery bypass graft surgery but have yet to be fully explored after transcatheter aortic valve implantation. We aimed to investigate gender differences after transcatheter aortic valve implantation in the UK National Institute for Cardiovascular Outcomes Research registry. A retrospective analysis was performed of Medtronic CoreValve and Edwards SAPIEN implantation in 1,627 patients (756 women) from January 2007 to December 2010. Men had more risk factors: poor left ventricular systolic function (11.9% vs 5.5%, p <0.001), 3-vessel disease (19.4% vs 9.2%, p <0.001), previous myocardial infarction (29.5% vs 13.0%, p <0.001), peripheral vascular disease (32.4% vs 23.3%, p <0.001), and higher logistic EuroSCORE (21.8 ± 14.2% vs 21.0 ± 13.4%, p = 0.046). Thirty-day mortality was 6.3% (confidence interval 4.3% to 7.9%) in women and 7.4% (5.6% to 9.2%) in men and at 1 year, 21.9% (18.7% to 25.1%) and 22.4% (19.4% to 25.4%), respectively. There was no mortality difference: p = 0.331 by log-rank test; hazard ratio for women 0.91 (0.75 to 1.10). Procedural success (96.6% in women vs 96.4% in men, p = 0.889) and 30-day cerebrovascular event rates (3.8% vs 3.7%, p = 0.962) did not differ. Women had more major vascular complications (7.5% vs 4.2%, p = 0.004) and less moderate or severe postprocedural aortic regurgitation (7.5% vs 12.5%, p = 0.001). In conclusion, despite a higher risk profile in men, there was no gender-related mortality difference; however, women had more major vascular complications and less postprocedural moderate or severe aortic regurgitation.
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http://dx.doi.org/10.1016/j.amjcard.2013.10.024DOI Listing
February 2014

Saphenous vein graft aneurysm mimicking right atrial mass.

Eur Heart J Cardiovasc Imaging 2013 Jan 19;14(1):90. Epub 2012 Aug 19.

Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK.

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http://dx.doi.org/10.1093/ehjci/jes167DOI Listing
January 2013

Choosing between velocity-time-integral ratio and peak velocity ratio for calculation of the dimensionless index (or aortic valve area) in serial follow-up of aortic stenosis.

Int J Cardiol 2013 Aug 8;167(4):1524-31. Epub 2012 May 8.

International Centre for Circulatory Health, National Heart and Lung Institute, London, UK.

Background: It remains unclear which echocardiographic measure is most suitable for serial measurement in real-world aortic stenosis (AS) follow-up. We determine whether the dimensionless index (DI) between aortic valve and left ventricular outflow tract velocities is measured more consistently using velocity-time-integral (VTI) or peak velocities (V(peak)) in real life.

Methods: Serial echocardiograms acquired within 6 months in subjects with AS were analysed with blinding, to compare the variability over time of DI calculated using V(peak), with that of DI calculated using VTI.

Results: Paired echocardiograms, acquired on average 72 days apart, were analysed from 70 patients with a range of severities of AS (59% severe). DI, calculated using either V(peak) or VTI, did not significantly change over this short time. Coefficient of variation was significantly better when DI was calculated using V(peak) than VTI (12.6 versus 25.4%, p<0.0001). The variabilities of mean and peak trans-aortic valve 4v(2) and left ventricular outflow tract VTI were no better: 26.9%, 19.1% and 22.1% respectively.

Conclusions: Serially-followed variables require minimal noise to maximise detection of genuine change. For AS surveillance, calculating DI--or effective orifice area--from the ratio of V(peak) rather than VTIs would reduce 95% confidence intervals from ± 51% to a still-disappointing ± 25%. Guidelines recommend noisy surveillance measures, causing conscientious echocardiographers to 'peek' at previous values, and impairing clinicians' faith in echocardiographically-observed changes when making clinical decisions. For us in echocardiography to improve our ability to contribute to AS follow-up requires us to first acknowledge and discuss this honestly.
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http://dx.doi.org/10.1016/j.ijcard.2012.04.105DOI Listing
August 2013

Successful placement of left atrial appendage closure device is heavily dependent on 3-dimensional transesophageal imaging.

J Am Coll Cardiol 2011 Sep;58(12):1283

International Centre for Circulatory Health, National Heart & Lung Institute, Imperial College, London, United Kingdom.

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http://dx.doi.org/10.1016/j.jacc.2010.11.089DOI Listing
September 2011

A surgeon's eye view noninvasively.

J Am Coll Cardiol 2010 Jul;56(5):e9

Imperial College Healthcare National Health Service Trust, St. Mary's Hospital Campus, London, United Kingdom.

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http://dx.doi.org/10.1016/j.jacc.2009.06.074DOI Listing
July 2010

A rare case of suture material obstructing the closure mechanism of a prosthetic aortic valve: a case report.

Cases J 2009 Dec 2;2:9126. Epub 2009 Dec 2.

Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London, W2 1NY, UK.

Prosthetic aortic valve dysfunction presenting as aortic regurgitation is a complication of mechanical valve replacement. We describe a case of late valve dysfunction caused by an annular suture of excessive length obstructing the closure mechanism of a bileaflet prosthetic valve.We present this rare cause of valve dysfunction in an 80-year-old male patient who presented with haemolysis and dyspnoea. At the time of operation it was found that a long vertically positioned annular valve suture was interfering with the normal closure mechanism of one of the prosthetic leaflets causing eccentric regurgitation jets. These findings were misdiagnosed as paravalvular leaks on the preoperative transoesophageal echo. No paravalvular leak was identified intraoperatively. After removal of the responsible suture normal prosthetic valve function was restored.Whilst early aortic valve dysfunction caused by suture material has previously been reported, this is the first report of suture material causing late dysfunction.
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http://dx.doi.org/10.1186/1757-1626-2-9126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2803923PMC
December 2009

Treatment of unprotected left main coronary artery stenosis in the drug-eluting stent era.

J Interv Cardiol 2005 Dec;18(6):455-65

Cardiology, 1st Department of Internal Medicine, Osaka Medical College, Osaka, Japan.

Coronary angiography is often inadequate for estimating the severity of ambiguous left main coronary artery (LMCA) stenoses. Our assessment of these lesions can be improved by the techniques of intravascular ultrasound and fractional flow reserve which provide indices of stenosis severity to enable the prediction of future events and planning of treatment. For patients requiring LMCA revascularization, coronary artery bypass graft (CABG) surgery has been gold standard for decades. However, this technique continues to be limited by factors such as periprocedural mortality, prolonged hospital stay and rehabilitation, and long-term graft patency. LMCA stenosis remains one of the few serious challenges for the interventional cardiologists and, in the bare metal stent era, the long-term results were not sufficient to replace CABG surgery, mainly because of the high restenosis rate. Drug-eluting stents (DES) have dramatically reduced the restenosis rate and early results in small series (approximately 300 patients in total) treated with DES in LMCA have been encouraging, especially for lesions at the ostium and in the left main shaft. Before changes are made in the guidelines for treatment, we must wait for a refinement in the technique and stent design used for bifurcational left main lesion and the results of randomized, specific multicenter studies (SYNTAX trial). It is likely that, for selected patients, LMCA stenosis will be regarded as an indication for PCI.
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http://dx.doi.org/10.1111/j.1540-8183.2005.00086.xDOI Listing
December 2005