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TAVI is an established therapy for patients with severe aortic stenosis. Rapid or control pacing is necessary for TAVI, and most centers are familiar with right ventricular (RV) pacing. Although there are several reports on the efficacy and safety of LV pacing, they are still few. In addition, LV pacing has not been studied for different LV guidewires. Our aim is to study the effectiveness of left ventricular (LV) pacing and the thresholds of LV guidewires in patients who underwent transcatheter aortic valve implantation (TAVI). We retrospectively analyzed 252 consecutive patients who underwent trans-femoral TAVI (TF-TAVI) with LV pacing in our institute between December 2017 and November 2020. We excluded 48 patients from the total cohort due to TAVI with RV pacing, and the remaining 204 patients were analyzed (52 males, mean age 85 ± 5 years). Among them, 202 patients (99.0%) had successful LV pacing. In the two patients with failed LV pacing, SAFARI2™ Small was used. The CONFIDA™ group ( n  = 34) showed a significantly lower threshold than the SAFARI2™ group ( n  = 163) (median 3.0 vs. 5.0 V; P  = 1.1 × 10 –7 ). LV pacing with Lunderquist® was successful in all patients ( n  = 7). LV pacing in TAVI was an effective and safe strategy. CONFIDA™ wire may be particularly well suited for LV pacing in TAVI.

•Subclinical hemolysis after TAVI has occasionally been documented.•Decompensated hemolytic anemia requiring specific treatment has been rare.•The incidence of hemolytic anemia after TAVI using S3UR was not negligible.•PVL ≥ mild was associated with an increased risk of hemolytic anemia. Decompensated hemolytic anemia after transcatheter aortic valve implantation (TAVI) requiring specific treatment is rarely encountered in actual clinical practice. Nevertheless, there have been several cases of clinically relevant hemolytic anemia following implantation of the recently launched SAPIEN 3 Ultra RESILIA (S3UR). This study aimed to elucidate the clinical features of hemolytic anemia following S3UR implantation. Patients who underwent TAVI using S3UR from the end of March 2023 to November 2023 were enrolled from the Japanese multicenter OCEAN (Optimized CathEter vAlvular iNtervention)–TAVI registry. Hemolytic anemia was defined as (1) a drop in hemoglobin level by >2.0 g/dL within 3 months after the index TAVI procedure and (2) the diagnosis of mechanical hemolysis as the cause of anemia made by the attending physician and hematologist based on the presence of any 2 of the following criteria: (1) serum lactate dehydrogenase level >220 IU/L; (2) haptoglobin level <0.5 g/L; and (3) reticulocyte count ≥2%. Of the 1,070 patients, 18 (1.7%) patients developed hemolytic anemia after TAVI. These patients had a significantly lower prosthesis oversizing relative to native annulus (−3.7% [−5.9% to 0.1%] vs 7.5% [0.6% to 14.0%], p <0.001) and a higher prevalence of paravalvular leakage (PVL) ≥mild (mild PVL: 61.1% vs 12.4%; moderate-to-severe PVL: 16.7% vs 0.2%; p <0.001) than those without hemolytic anemia. PVL ≥mild was associated with a higher incidence of hemolytic anemia particularly in patients with oversizing of <−5% (33.3% vs 1.3%, p <0.001) and in those with −5%≤ oversizing <10% (8.3% vs 0.7%, p <0.001). In conclusion, the incidence of decompensated hemolytic anemia after S3UR implantation was not negligible, and the results of the present study support the importance of selecting a prosthesis size with a sufficient oversizing relative to native annulus to minimize residual PVL ≥mild leading to hemolytic anemia after TAVI. [Display omitted]

Therapeutic devices for acute myocardial infarction (AMI) have evolved dramatically in recent years. However, the impact of the Killip classification of AMI outcomes in patients undergoing aggressive percutaneous coronary intervention remains unclear. We performed a 10-year retrospective review of 2062 patients diagnosed with AMI, and divided the data into two 5-year intervals: 2005–2009 ( n  = 1071), and 2010–2014 ( n  = 991). No difference was observed in in-hospital mortality rate between the two periods (first period, 11.5% vs second period, 9.7%; P  = 0.19). The incidence of stent thrombosis was not significantly different between the two periods, and very few thrombi occurred in patients who received second-generation drug-eluting stents (DES) (0.98%: 5/511). In-hospital mortality due to stent thrombosis was high in the full cohort (15%). During the second period, in-hospital mortality was lower in Killip class 4 patients, although the difference was not significant (59.1 vs 47.5%, P  = 0.07). Multivariable logistic regression identified several factors that significantly affected in-hospital mortality, including age [odds ratio (OR) 1.07], left main trunk (OR 2.47), peak CPK value above 5000 IU/L (OR 3.18), and Killip class 4 (OR 15.63). We evaluated trends in in-hospital mortality among patients with AMI over a 10-year period. New DES and the frequent use of mechanical support in patients with hemodynamic compromise tended to improve in-hospital mortality, but the effect was not significant. Notably, Killip class 4 on admission was associated with an estimated 16-fold increased risk of in-hospital death.

Spontaneous coronary artery dissection (SCAD) is diagnosed in a very small percentage of patients with suspected acute coronary syndromes who undergo emergency coronary angiography. Although fibromuscular dysplasia (FMD) is known to coexist in patients with SCAD, the vascular sites of FMD and their frequency have not yet been clarified. We retrospectively reviewed the medical records of 16 patients who were diagnosed with and treated for SCAD at our hospital between 1 January 2011 and 31 January 2023. We have summarized their baseline and clinical characteristics and medical variables, including coronary and upper extremity angiography and in-hospital outcomes. One of our patients had concurrent cardiac tamponade requiring pericardial drainage, and another went into hemorrhage shock the following day from dissection of the gastric retroperitoneal artery. Characteristic angiographic features of partial or diffuse nonatherosclerotic stenosis were observed mainly in the distal parts of the coronary arteries or their branches. Notably, in six patients with SCAD who underwent upper extremity angiography, FMD of the brachial artery was revealed. For the first time, to our knowledge, we found a high prevalence of multifocal FMD of the brachial artery in patients with SCAD.

A 60-year-old man was referred to our hospital because of dyspnea on exertion. He was diagnosed with heart failure due to an old myocardial infarction. Myocardial stress perfusion scintigraphy revealed inducible myocardial ischemia. Coronary angiography revealed hazy slit lesions in both the left anterior descending (LAD) and right coronary arteries (RCA). We first performed percutaneous coronary intervention (PCI) on the LAD lesion. Subsequently, we performed PCI for the RCA lesion using multiple imaging modalities. We observed a lotus root-like appearance in both the LAD and RCA, and PCI was successful for both vessels. We describe this rare case in detail.

Data concerning the clinical effect of the latest-generation self-expandable transcatheter heart valve (Evolut FX) remain limited. We aimed to assess the in-hospital outcomes of 3 bioprosthetic valves (Evolut EPO, PRO+, and FX). We analyzed data from a Japanese multicenter registry involving 634 consecutive patients who underwent transcatheter aortic valve replacement with Evolut FX up until October 2023. Patients who underwent transcatheter aortic valve replacement with Evolut EPO between 2018 and 2020 (n = 1,128), and those with Evolut EPO+ between 2020 and 2023 (n = 1,696) served as the control groups. The exclusion criteria comprised patients on dialysis with a history of infective endocarditis or with insufficient data. Unmatched comparisons among the 3 valves were conducted, followed by a propensity score–matched comparison between Evolut EPO+ and FX. In the unmatched cohort, among the Evolut EPO, PRO+, and FX groups, all vascular complications (7.8% vs 5.2% vs 4.5%, respectively, p <0.01) and new pacemaker implantation rates (11.2% vs 6.1% vs 7.7%, respectively, p <0.01) differed significantly. In the propensity score–matched analysis, the rate of all bleeding events was significantly higher in the Evolut EPO+ group (11.0%) than in the FX group (7.0%) (p = 0.02), whereas all vascular complications (4.6% vs 4.6%, respectively, p = 1.00) and new pacemaker implantation (5.9% vs 7.6%, respectively, p = 0.28) rates were comparable. The incidence of stroke in the FX group was approximately half that of the EP+ group (3.7% vs 1.9%, p = 0.095), without statistical significance. In conclusion, compared with the Evolut EPO+, Evolut FX was associated with a lower incidence of in-hospital bleeding complications and may reduce the incidence of in-hospital stroke.

Abstract Background Determining the treatment strategy for cardiogenic shock following ST-elevation myocardial infarction in a patient with severe aortic stenosis remains challenging and is a matter of debate. Case summary An 84-year-old man with chest pain was transferred to our institute and subsequently diagnosed with ST-elevation myocardial infarction and Killip class III heart failure. The patient was intubated, and urgent coronary angiography revealed severe tandem stenosis from the proximal to mid-left anterior descending coronary artery. We performed a primary percutaneous coronary intervention (PCI) and deployed drug-eluting stents from the left main trunk to mid-left anterior descending coronary artery. Although the procedure was successful, the patient went into cardiogenic shock a few hours later. Transthoracic echocardiography revealed low cardiac function and severe aortic stenosis. We decided to perform transcatheter aortic valve implantation using a self-expandable valve, followed by the insertion of a left ventricular assist device. The combination of procedures achieved haemodynamic stability. Discussion It is difficult to treat cardiogenic shock that develops in patients with severe aortic stenosis and ST-elevation myocardial infarction. This case report demonstrates that combined transcatheter aortic valve replacement using a self-expanding valve and left ventricular assist device placement can be safe and effective after a primary PCI.