Publications by authors named "Richard J Jabbour"

90 Publications

Cardiac MRI in cardiomyopathies.

Future Cardiol 2021 Apr 22. Epub 2021 Apr 22.

Department of Medicine, Faculty of Medicine, Imperial College London, London, UK.

Heart failure affects 1-2% of the adult population and one of the main contributors to its development is cardiomyopathy. Assessing a patient's risk for adverse events in heart failure is challenging and made more difficult by the heterogenous phenotypic expression of the disease. Cardiac MRI has long been a gold standard measure of myocardial function and anatomy due to its high spatial and temporal resolution. More recently, it has been posited to play a more critical role in the diagnosis and prognosis of cardiomyopathy-related heart failure. Given the limitations of more commonly used imaging modalities, increasing the clinical use of cardiac magnetic resonance imaging could potentially improve the prognosis of specific subgroups of patients at risk of adverse cardiac events.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2217/fca-2020-0233DOI Listing
April 2021

Remodelling of adult cardiac tissue subjected to physiological and pathological mechanical load in vitro.

Cardiovasc Res 2021 Mar 16. Epub 2021 Mar 16.

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

Aims: Cardiac remodelling is the process by which the heart adapts to its environment. Mechanical load is a major driver of remodelling. Cardiac tissue culture has been frequently employed for in vitro studies of load-induced remodelling; however, current in vitro protocols (e.g. cyclic stretch, isometric load, auxotonic load) are oversimplified and do not accurately capture the dynamic sequence of mechanical conformational changes experienced by the heart in vivo. This limits translational scope and relevance of findings.

Methods And Results: We developed a novel methodology to study chronic load in vitro. We first developed a bioreactor that can recreate the electromechanical events of in vivo pressure-volume loops as in vitro force-length loops. We then used the bioreactor to culture rat living myocardial slices (LMS) for 3 days. The bioreactor operated on the basis of a 3-Element Windkessel circulatory model enabling tissue mechanical loading based on physiologically relevant parameters of afterload and preload. LMS were continuously stretched/relaxed during culture simulating conditions of physiological load (normal preload & afterload), pressure-overload (normal preload & high afterload), or volume-overload (high preload & normal afterload). At the end of culture, functional, structural, and molecular assays were performed to determine load-induced remodelling.Both pressure- and volume-overloaded LMS showed significantly decreased contractility that was more pronounced in the latter compared with physiological load p < 0.0001). Overloaded groups also showed cardiomyocyte hypertrophy; RNAseq identified shared and unique genes expressed in each overload group. The PI3K-Akt pathway was dysregulated in volume-overload while inflammatory pathways were mostly associated with remodelling in pressure-overloaded LMS.

Conclusion: We have developed a proof-of-concept platform and methodology to recreate remodelling under pathophysiological load in vitro. We show that LMS cultured in our bioreactor remodel as a function of the type of mechanical load applied to them.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/cvr/cvab084DOI Listing
March 2021

Natural Biomaterials for Cardiac Tissue Engineering: A Highly Biocompatible Solution.

Front Cardiovasc Med 2020 23;7:554597. Epub 2020 Oct 23.

Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom.

Cardiovascular diseases (CVD) constitute a major fraction of the current major global diseases and lead to about 30% of the deaths, i.e., 17.9 million deaths per year. CVD include coronary artery disease (CAD), myocardial infarction (MI), arrhythmias, heart failure, heart valve diseases, congenital heart disease, and cardiomyopathy. Cardiac Tissue Engineering (CTE) aims to address these conditions, the overall goal being the efficient regeneration of diseased cardiac tissue using an ideal combination of biomaterials and cells. Various cells have thus far been utilized in pre-clinical studies for CTE. These include adult stem cell populations (mesenchymal stem cells) and pluripotent stem cells (including autologous human induced pluripotent stem cells or allogenic human embryonic stem cells) with the latter undergoing differentiation to form functional cardiac cells. The ideal biomaterial for cardiac tissue engineering needs to have suitable material properties with the ability to support efficient attachment, growth, and differentiation of the cardiac cells, leading to the formation of functional cardiac tissue. In this review, we have focused on the use of biomaterials of natural origin for CTE. Natural biomaterials are generally known to be highly biocompatible and in addition are sustainable in nature. We have focused on those that have been widely explored in CTE and describe the original work and the current state of art. These include fibrinogen (in the context of Engineered Heart Tissue, EHT), collagen, alginate, silk, and Polyhydroxyalkanoates (PHAs). Amongst these, fibrinogen, collagen, alginate, and silk are isolated from natural sources whereas PHAs are produced via bacterial fermentation. Overall, these biomaterials have proven to be highly promising, displaying robust biocompatibility and, when combined with cells, an ability to enhance post-MI cardiac function in pre-clinical models. As such, CTE has great potential for future clinical solutions and hence can lead to a considerable reduction in mortality rates due to CVD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fcvm.2020.554597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644890PMC
October 2020

COVID-19 pandemic and STEMI: pathway activation and outcomes from the pan-London heart attack group.

Open Heart 2020 10;7(2)

Department of Cardiology, Royal Free London NHS Foundation Trust, London, United Kingdom.

Objectives: To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19.

Methods: We systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomes RESULTS: There was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62-118) min in 2020 vs 75 (57-95) min in 2019, p<0.001), but that this was not associated with a delays in achieving revascularisation once in hospital (48 (34-65) min in 2020 vs 48 (35-70) min in 2019, p=0.35) or increased mortality (10.9% (38) in 2020 vs 8.6% (38) in 2019, p=0.28). 46 patients with active COVID-19 were more thrombotic and more likely to have intensive care unit admissions (32.6% (15) vs 9.3% (28), OR 5.74 (95%CI 2.24 to 9.89), p<0.001). They also had increased length of stay (4 (3-9) days vs 3 (2-4) days, p<0.001) and a higher mortality (21.7% (10) vs 9.3% (28), OR 2.72 (95% CI 1.25 to 5.82), p=0.012) compared with patients having PPCI without COVID-19.

Conclusion: These findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/openhrt-2020-001432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592245PMC
October 2020

Development of a pro-arrhythmic ex vivo intact human and porcine model: cardiac electrophysiological changes associated with cellular uncoupling.

Pflugers Arch 2020 10 1;472(10):1435-1446. Epub 2020 Sep 1.

Faculty of Medicine, National Heart and Lung Institute, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.

We describe a human and large animal Langendorff experimental apparatus for live electrophysiological studies and measure the electrophysiological changes due to gap junction uncoupling in human and porcine hearts. The resultant ex vivo intact human and porcine model can bridge the translational gap between smaller simple laboratory models and clinical research. In particular, electrophysiological models would benefit from the greater myocardial mass of a large heart due to its effects on far-field signal, electrode contact issues and motion artefacts, consequently more closely mimicking the clinical setting. Porcine (n = 9) and human (n = 4) donor hearts were perfused on a custom-designed Langendorff apparatus. Epicardial electrograms were collected at 16 sites across the left atrium and left ventricle. A total of 1 mM of carbenoxolone was administered at 5 ml/min to induce cellular uncoupling, and then recordings were repeated at the same sites. Changes in electrogram characteristics were analysed. We demonstrate the viability of a controlled ex vivo model of intact porcine and human hearts for electrophysiology with pharmacological modulation. Carbenoxolone reduces cellular coupling and changes contact electrogram features. The time from stimulus artefact to (-dV/dt) increased between baseline and carbenoxolone (47.9 ± 4.1-67.2 ± 2.7 ms) indicating conduction slowing. The features with the largest percentage change between baseline and carbenoxolone were fractionation + 185.3%, endpoint amplitude - 106.9%, S-endpoint gradient + 54.9%, S point - 39.4%, RS ratio + 38.6% and (-dV/dt) - 20.9%. The physiological relevance of this methodological tool is that it provides a model to further investigate pharmacologically induced pro-arrhythmic substrates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00424-020-02446-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476990PMC
October 2020

Rescue Valve-in-Valve-in-Valve TAVR for Acute Transvalvular Aortic Regurgitation.

Cardiovasc Revasc Med 2020 Nov 6;21(11S):11-13. Epub 2020 Jul 6.

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

Transcatheter aortic valve replacement (TAVR) is a well-established treatment option for severe symptomatic aortic stenosis (Leon et al., 2016), and recently has also been utilised for bioprosthetic surgical aortic valve (sAVR) failure (valve-in-valve TAVR (ViV-TAVR)) (Yoon et al., 2017; Nalluri et al., 2018). Data supporting ViV-TAVR are limited to observational studies but suggest similar outcomes to re-do sAVR in high risk patients (Barbanti et al., n.d.). Whilst bioprosthetic SAVR failure is well documented, TAVR failure is less well described (Barbanti et al., n.d.). Here, we describe a case of TAVR failure in a previous sAVR resulting in the need for emergent valve-in-valve-in-valve TAVR (ViViV-TAVR).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.carrev.2020.07.002DOI Listing
November 2020

Balloon-Assisted Tracking (BAT) of an Uncrossable Aortic Valve During Transcatheter Aortic Valve Implantation.

Cardiovasc Revasc Med 2020 Nov 19;21(11S):33-35. Epub 2020 Mar 19.

Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.carrev.2020.03.024DOI Listing
November 2020

Ventricular fibrillation mechanism and global fibrillatory organization are determined by gap junction coupling and fibrosis pattern.

Cardiovasc Res 2021 Mar;117(4):1078-1090

National Heart & Lung Institute, Imperial College London, 4th Floor, ICTEM Building, 72 Du Cane Road, London W12 0NN, UK.

Aims: Conflicting data exist supporting differing mechanisms for sustaining ventricular fibrillation (VF), ranging from disorganized multiple-wavelet activation to organized rotational activities (RAs). Abnormal gap junction (GJ) coupling and fibrosis are important in initiation and maintenance of VF. We investigated whether differing ventricular fibrosis patterns and the degree of GJ coupling affected the underlying VF mechanism.

Methods And Results: Optical mapping of 65 Langendorff-perfused rat hearts was performed to study VF mechanisms in control hearts with acute GJ modulation, and separately in three differing chronic ventricular fibrosis models; compact fibrosis (CF), diffuse fibrosis (DiF), and patchy fibrosis (PF). VF dynamics were quantified with phase mapping and frequency dominance index (FDI) analysis, a power ratio of the highest amplitude dominant frequency in the cardiac frequency spectrum. Enhanced GJ coupling with rotigaptide (n = 10) progressively organized fibrillation in a concentration-dependent manner; increasing FDI (0 nM: 0.53 ± 0.04, 80 nM: 0.78 ± 0.03, P < 0.001), increasing RA-sustained VF time (0 nM: 44 ± 6%, 80 nM: 94 ± 2%, P < 0.001), and stabilized RAs (maximum rotations for an RA; 0 nM: 5.4 ± 0.5, 80 nM: 48.2 ± 12.3, P < 0.001). GJ uncoupling with carbenoxolone progressively disorganized VF; the FDI decreased (0 µM: 0.60 ± 0.05, 50 µM: 0.17 ± 0.03, P < 0.001) and RA-sustained VF time decreased (0 µM: 61 ± 9%, 50 µM: 3 ± 2%, P < 0.001). In CF, VF activity was disorganized and the RA-sustained VF time was the lowest (CF: 27 ± 7% vs. PF: 75 ± 5%, P < 0.001). Global fibrillatory organization measured by FDI was highest in PF (PF: 0.67 ± 0.05 vs. CF: 0.33 ± 0.03, P < 0.001). PF harboured the longest duration and most spatially stable RAs (patchy: 1411 ± 266 ms vs. compact: 354 ± 38 ms, P < 0.001). DiF (n = 11) exhibited an intermediately organized VF pattern, sustained by a combination of multiple-wavelets and short-lived RAs.

Conclusion: The degree of GJ coupling and pattern of fibrosis influences the mechanism sustaining VF. There is a continuous spectrum of organization in VF, ranging between globally organized fibrillation sustained by stable RAs and disorganized, possibly multiple-wavelet driven fibrillation with no RAs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/cvr/cvaa141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983010PMC
March 2021

Looking Toward the Post-TAVR Period and Keeping Options Open for Easy Coronary Access.

JACC Cardiovasc Interv 2020 04 12;13(8):951-953. Epub 2020 Feb 12.

Division of Cardiology, Montefiore Medical Center, New York, New York.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcin.2019.12.012DOI Listing
April 2020

Future potential of engineered heart tissue patches for repairing the damage caused by heart attacks.

Expert Rev Med Devices 2020 01 6;17(1):1-3. Epub 2019 Dec 6.

Department of translational medicine, Imperial College London, London, UK.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/17434440.2020.1700793DOI Listing
January 2020

Comparison of warfarin versus DOACs in patients with concomitant indication for oral anticoagulation undergoing TAVI; results from the ATLAS registry.

J Thromb Thrombolysis 2020 Jul;50(1):82-89

Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Hill End Road, Harefield, Middlesex, London, UB9 6JH, UK.

The optimal antithrombotic therapy for patients undergoing TAVI with concomitant indication for oral anticoagulation remains unclear. In this high-risk population group, there is a paucity of data with regards to the use of DOACs. In the present study we compared long-term clinical outcomes of TAVI patients requiring anticoagulation, treated with warfarin versus DOACs. Consecutive patients, who underwent TAVI with indication for oral anticoagulation from the multicenter ATLAS registry were studied and divided in two groups depending on the chosen anticoagulation regimen, warfarin vs. DOACs. 30-day survival, as well as estimated 1 and 2-year all-cause mortality were compared between groups. The secondary endpoint included in-hospital major or life-threatening bleeding. The study group included 217 patients (102 treated with warfarin; 115 treated with DOACs). Kaplan-Meier estimated survival was found to be statistically similar in the warfarin and DOAC groups (90.6% vs. 93.7% for 1-year and 84.5% vs. 88.5%, for 2-year survival, respectively, P = 0.984). Adjusted hazard ratio for all cause mortality was similar between the two groups (HR = 1.15; 95% CI 0.33 to 4.04, p = 0.829). Propensity matching revealed similar results. At 30-days, all-cause mortality was found to be comparable between the two groups. With regards to BARC defined bleeding complications, major and life-threatening complications did not differ between the two anticoagulation groups (6% vs. 8% for warfarin and DOACs respectively, p = 0.857). DOACs seem to demonstrate a similar safety and efficacy profile compared to warfarin in TAVI patients with a concomitant indication for oral anticoagulation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11239-019-01968-wDOI Listing
July 2020

What are the remaining lessons to be learnt from 1st-generation bioresorbable scaffolds?

Int J Cardiol 2019 10 22;293:103-104. Epub 2019 Jul 22.

Interventional Cardiology Unit, EMO-GVM, Centro Cuore Columbus, Milan, Italy; Villa Maria Cecilia Hospital GVM, Lugo, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2019.07.037DOI Listing
October 2019

The changing landscape of interventional cardiology.

Aging (Albany NY) 2019 05;11(10):2914-2915

Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.18632/aging.102005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6555454PMC
May 2019

Biomimetic electromechanical stimulation to maintain adult myocardial slices in vitro.

Nat Commun 2019 05 15;10(1):2168. Epub 2019 May 15.

National Heart & Lung Institute, Imperial College London, London, W12 0NN, UK.

Adult cardiac tissue undergoes a rapid process of dedifferentiation when cultured outside the body. The in vivo environment, particularly constant electromechanical stimulation, is fundamental to the regulation of cardiac structure and function. We investigated the role of electromechanical stimulation in preventing culture-induced dedifferentiation of adult cardiac tissue using rat, rabbit and human heart failure myocardial slices. Here we report that the application of a preload equivalent to sarcomere length (SL) = 2.2 μm is optimal for the maintenance of rat myocardial slice structural, functional and transcriptional properties at 24 h. Gene sets associated with the preservation of structure and function are activated, while gene sets involved in dedifferentiation are suppressed. The maximum contractility of human heart failure myocardial slices at 24 h is also optimally maintained at SL = 2.2 μm. Rabbit myocardial slices cultured at SL = 2.2 μm remain stable for 5 days. This approach substantially prolongs the culture of adult cardiac tissue in vitro.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41467-019-10175-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520377PMC
May 2019

Incidence, Technical Safety, and Feasibility of Coronary Angiography and Intervention Following Self-expanding Transcatheter Aortic Valve Replacement.

Cardiovasc Revasc Med 2019 05 14;20(5):371-375. Epub 2019 Feb 14.

Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy; Division of Cardiology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Department of Cardiology, Montefiore Medical Center, New York, USA. Electronic address:

Background: Transcatheter aortic valve replacement (TAVR) is a well-established treatment option for severe aortic stenosis (AS). AS and coronary artery disease frequently coincide, and therefore some patients may require coronary angiography (CAG) and/or intervention (PCI) post-TAVR. Due to valve stent design, most self-expanding prostheses always cover the coronary ostium, and therefore may hinder future access. The objective of this research was to evaluate the incidence, safety and feasibility of CAG/PCI in patients with prior self-expanding TAVR valves.

Methods: Among 2170 patients (age 82 ± 6 years, 43% male) who underwent TAVR with Corevalve or Evolut prostheses, as part of the Italian CoreValve ClinicalService® framework (data from 13 Italian centers), the occurrence of CAG/PCI following TAVR and periprocedural characteristics were examined.

Results: During median follow-up of 379 days, 41 patients (1.9%) required CAG and/or PCI (total 46; 16 CAG, 14 PCI, 16 both PCI/CAG). 56.5% of the procedures were performed under emergency/urgency settings. Left system coronary angiography was successfully performed in most cases (28/32, 87.5%), while right coronary angiography was successful only in 50.0% (16/32). PCI procedures (20 for left system, 3 for right system, 4 for graft) were successfully performed in 93.3% (28/30) of the procedures. No CAG/PCI procedure-related complications including prosthesis dislodgment or coronary ostium dissection occurred.

Conclusions: CAG and PCI procedures following CoreValve TAVR is safe and mostly feasible, although the success rate of selective right coronary angiography was relatively low when compared to the left system. Further investigations are required to explore this issue.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.carrev.2019.01.026DOI Listing
May 2019

Valve durability - is this the Achilles' heel of TAVI?

EuroIntervention 2019 Feb 8;14(15):e1544-e1547. Epub 2019 Feb 8.

Imperial College Healthcare Trust, London, United Kingdom.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4244/EIJV14I15A263DOI Listing
February 2019

Delayed Coronary Occlusion After Transcatheter Aortic Valve Implantation: Implications for New Transcatheter Heart Valve Design and Patient Management.

Interv Cardiol 2018 Sep;13(3):137-139

EMO-GVM Centro Cuore Columbus Milan, Italy.

Transcatheter aortic valve implantation has revolutionised the treatment of patients with severe aortic stenosis and is the preferred treatment option for patients with elevated surgical risk. Outcomes have continually improved, but because of the nature of the procedure infrequent catastrophic complications, such as coronary obstruction, persist. Recently, data were published regarding delayed coronary obstruction (DCO), a phenomenon in which the obstruction occurs after the index procedure. DCO has important consequences for future research. In this article we will explore the implications for new transcatheter heart valve design and approaches to patient management to minimise the risk of DCO occurring.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.15420/icr.2018.24.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234488PMC
September 2018

The "new" syndrome of delayed coronary obstruction after transcatheter aortic valve replacement.

Cardiovasc Revasc Med 2019 01 4;20(1):81-83. Epub 2018 Oct 4.

Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy; Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy; Division of Cardiology, Department of Medicine, University of Cape Town, Cape Town, South Africa. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.carrev.2018.10.004DOI Listing
January 2019

Bioresorbable vascular scaffold implantation for severely calcified lesions after excimer laser lesion preparation.

Catheter Cardiovasc Interv 2018 12 30;92(7):1283-1288. Epub 2018 Sep 30.

Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy.

Bioresorbable vascular scaffolds (Absorb BVS, Abbott Vascular, Santa Clara, CA) temporarily elute antiproliferative drugs and provide vessel support, which then subsequently resorb to allow restoration of normal vessel function and architecture. To attain the best possible results with BVS, a dedicated implantation technique (PSP: adequate lesion preparation, proper sizing, postdilatation) is considered mandatory, and calcified lesions are one of the most challenging lesion subsets for BVS implantation. In five cases with severe calcifications refractory to balloon predilatation, we performed excimer laser catheter ablation (ELCA: Turbo Elite catheter; Spectranetics Corporation, Colorado Springs, CO, USA), which facilitated adequate lesion expansion with high-pressure noncompliant balloon inflation and BVS implantation. During the follow-up period (481 days [interquartile range: 445-579]), all patients continued dual antiplatelet therapy (DAPT) and there were no cases of cardiac death, myocardial infarction, or scaffold thrombosis. For treatment of severely calcified lesions with bioresorbable scaffolds, ELCA could be considered an effective potential strategy. After the procedure, prolonged DAPT was prescribed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.27704DOI Listing
December 2018

Predictors of Advanced Conduction Disturbances Requiring a Late (≥48 H) Permanent Pacemaker Following Transcatheter Aortic Valve Replacement.

JACC Cardiovasc Interv 2018 08;11(15):1519-1526

IRCCS San Raffaele Scientific Institute, Milan, Italy; Division of Cardiology, Department of Medicine, University of Cape Town, Cape Town, South Africa. Electronic address:

Objectives: This study sought to determine predictors of advanced conduction disturbances requiring late (≥48 h) permanent pacemaker replacement (PPM) after transcatheter aortic valve replacement (TAVR).

Methods: Data of consecutive patients were identified by retrospective review of a TAVR database of a single center in Milan, Italy, between October 2007 and July 2015. We defined delta PR (ΔPR) and delta QRS (ΔQRS) interval as the difference between the last PR and QRS length available 48 h after TAVR and the baseline PR and QRS length.

Results: Overall population included 740 patients. We excluded 78 patients who already had a PPM and 51 patients who received a PPM <48 h after TAVR. The final analysis included 611 patients. Fifty-four patients (8.8%) developed an advanced conduction disturbance requiring PPM ≥48 h following TAVR. Patients who required a late PPM implant had a wider QRS width (113 ± 25 ms vs. 105 ± 23 ms; p = 0.009) and a higher prevalence of baseline right bundle branch block (12.9% vs. 5.3%; p = 0.026) and were more likely to have a self-expandable valve implanted (51.8% vs. 31.9%; p = 0.003). The ΔPR was 40 ± 51 ms (p = 0.0001) and the ΔQRS was 22 ± 61 ms (p = 0.001). Multivariable analysis revealed that baseline right bundle branch block (odds ratio: 3.56; 95% confidence interval: 1.07 to 11.77; p = 0.037) and ΔPR (odds ratio for each 10-ms increase: 1.31; 95% confidence interval: 1.18 to 1.45; p = 0.0001) are independent predictors of delayed advanced conduction disturbances.

Conclusions: This analysis showed that baseline right bundle branch block and the amount of increase of PR length after TAVR are independent predictors of late (≥48 h) advanced conduction disturbances requiring PPM replacement after TAVR in this cohort. A simple ECG analysis could help in detecting potentially lethal advanced conduction disturbances that could occur more than 48 h after TAVR.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcin.2018.06.014DOI Listing
August 2018

Percutaneous left atrial appendage occlusion with the Amulet device: The impact of device disc position upon periprocedural and long-term outcomes.

Catheter Cardiovasc Interv 2019 01 5;93(1):120-127. Epub 2018 Aug 5.

Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.

Objective: To investigate the effect of left atrial appendage (LAA) occlusion device positioning upon periprocedural and long-term outcomes.

Background: The Amulet device is designed to cover the ostium of the LAA. Prolapse of the device into the neck of the LAA is not uncommon resulting in incomplete coverage of the ostium. The clinical consequences of this remain uncertain.

Methods: Outcomes of 87 patients with successful LAA closure were analyzed according to Amulet disc position: group A (n = 45) had complete LAA ostium coverage; group B (n = 42) had incomplete ostium coverage because of disc prolapse. Periprocedural major adverse events (MAE) (composite of all cause death, tamponade, device/air embolization, cerebrovascular events, myocardial infarction, and major bleeding not related to vascular access complications) and total device-related periprocedural adverse events (defined as MAE and pericardial effusion) were evaluated. All patients were followed up longitudinally with long-term events defined as a composite of: cardiovascular death, cerebrovascular events, systemic embolization, and major bleeding requiring transfusion or intervention.

Results: Median follow-up was 234 days (IQR 150-436 days). There was a trend toward more periprocedural MAE in group B (P = 0.07) with deep implantation of the Amulet device associated with significantly more periprocedural adverse events (P = 0.03). There were no differences in reposition attempts (P = 0.9) or long-term events (P = 0.57).

Conclusions: Our data suggest that suboptimal device positioning may be associated with worse periprocedural outcomes but no difference in long-term clinical outcomes. The results of this relatively small cohort does not seem to be affected by repositioning attempts during the index procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.27727DOI Listing
January 2019

Variation in vessel healing response after implantation of two different poly-L-lactic acid bioresorbable scaffolds: insights from optical coherence tomography.

EuroIntervention 2018 Dec 20;14(12):e1304-e1305. Epub 2018 Dec 20.

Cardiovascular Interventions Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4244/EIJ-D-18-00456DOI Listing
December 2018

Mid-term clinical outcomes after bailout drug-eluting stenting for suboptimal drug-coated balloon results: Insights from a Milan registry.

Int J Cardiol 2018 07 13;263:17-23. Epub 2018 Apr 13.

Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy. Electronic address:

Background: Drug-coated balloon (DCB) is an alternative to drug-eluting stent (DES) for the treatment of small vessel or in-stent restenosis (ISR) lesions, with bailout stenting reserved for poor results after DCB inflation (residual stenosis or dissection). Data regarding bailout stenting with DES are limited. The aim of this study was to evaluate clinical outcomes after bailout stenting with DES for suboptimal DCB results.

Methods: From June 2009 to December 2015, patients who underwent bailout DES implantation for suboptimal results after DCB (residual stenosis > 30% or type C-F dissection) in 2 high-volume centers in Italy were analyzed. The primary endpoint was target lesion failure (TLF) defined as composite of cardiac mortality, target vessel myocardial infarction (MI) and target lesion revascularization (TLR).

Results: A total of 103 patients (125 lesions) were analyzed. Mean age was 68.8 ± 9.5 years, 21.4% were diabetic, and 92.2% underwent PCI for stable angina. The left anterior descending artery was most commonly treated (35.2%), followed by right coronary artery (17.6%) and left circumflex artery (17.6%). Lesion complexity was high (type B2/C: 88.8%) and 24.8% were ISR lesions. During the follow-up period (median: 858 days [interquartile range: 467-1665]), the TLF rate was 4.3% at 1 year and 15.4% at 2 years, and mainly driven by TLR (3.3% at 1 year, 14.5% at 2 years, respectively). There were no target vessel MI or definite/probable stent thrombosis events.

Conclusions: Bailout stenting with DES for suboptimal DCB results is a feasible and safe strategy at mid-term follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2018.04.050DOI Listing
July 2018

Coronary Sinus Reducer Implantation for the Treatment of Chronic Refractory Angina: A Single-Center Experience.

JACC Cardiovasc Interv 2018 04;11(8):784-792

Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy.

Objectives: The aim of this study was to assess the safety and efficacy of the Reducer in a real-world cohort of patients presenting with refractory angina.

Background: The coronary sinus Reducer is a novel device to aid in the management of patients with severe angina symptoms refractory to optimal medical therapy and not amenable to further revascularization.

Methods: Fifty patients with refractory angina and objective evidence of myocardial ischemia who were judged unsuitable for revascularization were treated with coronary sinus Reducer implantation at a single center between March 2015 and August 2016. Safety endpoints were procedural success and the absence of device-related adverse events. Efficacy endpoints, assessed at 4- and 12-month follow-up, were a reduction in Canadian Cardiovascular Society angina class, improvement in quality of life assessed using the Seattle Angina Questionnaire, improvement in exercise tolerance assessed using the 6-min walk test, and reduction in pharmacological antianginal therapy.

Results: Procedural success was achieved in all patients, with no device-related adverse effects during the procedure or at follow-up. Regarding the efficacy endpoint, 40 patients (80%) had at least 1 reduction in Canadian Cardiovascular Society class, and 20 patients (40%) had at least 2 class reductions, with a mean class reduction to 1.67 ± 0.83 vs. 2.98 ± 0.52 (p < 0.001) at 4-month follow-up. All Seattle Angina Questionnaire items improved significantly (p < 0.001 for all). A significant increment in 6-min walk distance to 388.6 ± 119.7 m vs. 287.0 ± 138.9 m (p = 0.004) was observed. Sixteen patients (32%) and 3 patients (6%) demonstrated reductions of at least 1 or 2 antianginal drugs, respectively. The benefit of Reducer implantation observed at 4-month follow-up was maintained at 1 year.

Conclusions: In this real-world, single-center experience, implantation of the coronary sinus Reducer appeared safe and was associated with reduction in anginal symptoms and improvement in quality of life in patients with refractory angina who were not candidates for further revascularization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcin.2018.01.251DOI Listing
April 2018

Delayed Coronary Obstruction After Transcatheter Aortic Valve Replacement.

J Am Coll Cardiol 2018 04;71(14):1513-1524

Quebec Heart and Lung Institute, Quebec City, Quebec, Canada.

Background: Delayed coronary obstruction (DCO) is an uncommon and barely reported complication following transcatheter aortic valve replacement (TAVR).

Objectives: The aim of this study was to describe the incidence and pathophysiological features of DCO after TAVR, obtained from a large international multicenter registry.

Methods: Data were retrospectively collected from an international multicenter registry consisting of 18 centers between November 2005 and December 2016.

Results: During the study period, 38 DCO (incidence 0.22%) cases were identified from a total of 17,092 TAVR procedures. DCO occurred more commonly after valve-in-valve procedures (0.89% vs. 0.18%; p < 0.001) and if self-expandable valves were used during the index procedure (0.36% vs. 0.11% balloon expandable; p < 0.01). DCO was most likely to occur ≤24 h after the TAVR procedure (47.4%; n = 18); 6 (15.8%) cases occurred between 24 h and ≤7 days, with the remaining 14 (36.8%) at ≥60 days. The most frequent presentation was cardiac arrest (31.6%; n = 12), followed by ST-segment elevation myocardial infarction (23.7%; n = 9). The left coronary artery was obstructed in most cases (92.1%; n = 35). Percutaneous coronary intervention was attempted in the majority of cases (74.3% left main; 60% right coronary), and stent implantation was successful in 68.8%. The overall in-hospital death rate was 50% (n = 19), and was higher if DCO occurred ≤7 days from the index procedure (62.5% vs. 28.6%; p = 0.09).

Conclusions: DCO following TAVR is a rare phenomenon that is associated with a high in-hospital mortality rate. Clinicians should be aware that coronary obstruction can occur after the original TAVR procedure and have a low threshold for performing coronary angiography when clinically suspected.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2018.01.066DOI Listing
April 2018

Comparison of mid-term clinical outcomes after treatment of ostial right coronary artery lesions with early and new generation drug-eluting stents: Insights from an international multicenter registry.

Int J Cardiol 2018 03 28;254:53-58. Epub 2018 Jan 28.

Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy. Electronic address:

Background: There are only a limited number of studies comparing clinical outcomes after treatment of right coronary artery (RCA) aorto-ostial (AO) lesions with early (E-) and new (N-) generation drug-eluting stents (DES).

Methods: From January 2005 to December 2013, 334 de novo RCA AO lesions treated with DES (E-:142 lesions, N-:192 lesions) at 2 high-volume centers (Italy and Japan) were included in this study. The primary endpoint was target lesion failure (TLF) defined as composite of cardiac mortality, target vessel myocardial infarction, and target lesion revascularization (TLR).

Results: Baseline and lesion characteristics were well balanced between the 2 groups. The size of the stents deployed (3.35±0.37mm vs 3.39±0.33mm, p=0.29) and non-compliant balloons used for post-dilatation (3.55±0.38mm vs 3.62±0.47mm, p=0.21) were similar between the two groups. The median follow-up period was 1432 (IQR: 703-2197) days in total population. The cumulative rate of TLF at 3years was significantly higher in E-DES group when compared with N-DES group (37.7% vs 14.2%, p<0.001), which was mainly driven by TLR (38.0% vs 11.0%, p<0.001). Multivariable analysis revealed that N-DES [HR 0.22 (0.13-0.38), p<0.001], stent underexpansion [HR 10.59 (6.23-17.97), p<0.001], excessive aortic stent protrusion [HR 3.12 (1.87-5.23), p<0.001], and proximal stent overlap [HR 1.74 (1.03-2.95), p=0.03] were independent predictors of TLF.

Conclusion: For the treatment of RCA AO lesions, N-DES were associated with a lower incidence of TLF at 3years when compared with E-DES. N-DES use and suboptimal implantation characteristics were independent predictors of TLF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2017.10.066DOI Listing
March 2018

Definite stent thrombosis after drug-eluting stent implantation in coronary bifurcation lesions: A meta-analysis of 3,107 patients from 14 randomized trials.

Catheter Cardiovasc Interv 2018 10 7;92(4):680-691. Epub 2017 Dec 7.

Institution of Cardiovascular Research, Xinqiao Hospital, Third Military Medical University, Chongqing, China.

Background: Bifurcation percutaneous coronary intervention (PCI) is a challenging procedure, but there are currently inadequate data about definite stent thrombosis (ST) rates of single-stent versus double-stent strategies (SS and DS, respectively).

Methods And Results: Randomized clinical trials (RCTs) comparing SS and DS strategies were searched through PubMed, Embase, and the Cochrane Central Register of Controlled Trials. Fourteen RCTs involving 3,107 patients were analyzed. Owing to the high crossover rate (16.49%), both intention-to-treat (ITT) and as-treated (AT) analyses were performed. In the ITT population, there was a significantly lower rate of early definite ST in the SS group (0.26%; DS group 1.14%; P = 0.021). Similarly, in the AT population, there was a significantly lower rate of early definite ST in the SS group (0.23%, DS group 1.07%; P = 0.042). True bifurcation subgroup analysis also showed a significantly lower early definite ST in the SS group (OR = 0.36, 95% CI = 0.15-0.86, P = 0.042) in the ITT population. There was no significant difference of overall, acute, subacute, and late definite ST between the 2 groups.

Conclusions: Early definite ST is reduced when a SS strategy is used in bifurcation lesions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.27443DOI Listing
October 2018

Impact of Mitral Annular Calcium on Outcomes after Transcatheter Aortic Valve Implantation.

Am J Cardiol 2017 Dec 18;120(12):2233-2240. Epub 2017 Sep 18.

Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy. Electronic address:

A high prevalence of mitral annular calcium (MAC) is expected in patients undergoing transcatheter aortic valve implantation (TAVI); however, data regarding the prevalence of MAC and impact on risk of cardiovascular events are lacking. To determine the prevalence of MAC and its association with clinical outcomes in patients undergoing TAVI, we retrospectively analyzed 424 patients who underwent transfemoral TAVI from 2007 to 2015 and whose preoperative computed tomography images were available for assessment of MAC. Severe circumferential MAC (SC-MAC) was defined as calcification involving at least the whole posterior annulus alone or with the attachment of the anterior leaflet. Clinical outcomes were examined according to Valve Academic Research Consortium-2 criteria up to 2 years. SC-MAC was found in 17.7% of patients. Patients with SC-MAC were more likely to be female, with a higher prevalence of atrial fibrillation and peripheral artery disease. There were no differences between the groups regarding age, functional class, prevalence of diabetes, kidney disease, and operative risk. Female gender and peripheral artery disease were independent predictors of SC-MAC. SC-MAC did not appear to be associated with periprocedural and 30-day outcomes. At 2 years' follow-up, patients with SC-MAC had significantly higher cardiovascular and all-cause mortality rates. SC-MAC was an independent predictor of cardiovascular mortality during follow-up. In conclusion, SC-MAC is a frequent finding in the TAVI population and appears to be an independent predictor of cardiovascular mortality at 2 years' follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjcard.2017.09.006DOI Listing
December 2017