Post Dilatation Research Articles

Outcomes of Direct Transcatheter Aortic Valve Replacement Without Balloon Aortic Valvuloplasty Using a New Generation Valve.

We investigated the outcomes of patients who underwent Transcatheter Aortic Valve Replacement (TAVR) with and without Balloon Aortic Valvuloplasty (BAV) using the SAPIEN 3 (S3) valve. All patients who underwent TAVR using S3 valve were included. The primary outcomes were the incidence of stroke and significant paravalvular leak (PVL). Secondary outcomes were the incidence of mortality, balloon post dilation, and need for permanent pacemaker. From July-2014 to April-2018, 34 (9%) patients underwent BAV prior to TAVR and 344 (91%) patients underwent direct TAVR without BAV using the S3 valve. The Society of Thoracic Surgeons (STS) risk score was similar between two groups; 5.8 ± 3.5 in no BAV group and 5.4 ± 3.3 in BAV group, p = 0.53. After TAVR, 6 (1.7%) patients in no BAV group but no patient in BAV group developed stroke (p = 1.0). No patient had severe PVL and only 5 patients (1.3%) had moderate PVL at 30-day; 4 (1.2%) in no BAV group and 1 (2.9%) in BAV group (p = 0.38). Forty-six patients (13.4%) in the no BAV group and 4 (11.8%) patients in the BAV group needed balloon post dilation (p = 1.0). Six (1.6%) patients died during hospitalization, all in the no BAV group (p = 1.0). Forty-five (11.9%) patients needed new pacemaker implantation; 44 (12.8%) patients in no BAV group and 1 (2.9%) patient in BAV group (p = 0.1). Two-year survival rate was 85% in no BAV group and 84% in BAV group (p = 0.46). TAVR using S3 valves is associated with very low rates of post-TAVR stroke and significant PVL. Outcomes of direct TAVR are similar to the outcomes of TAVR with BAV, without an increased rate of stroke, significant PVL, or balloon post dilation.

Insights into permanent pacemaker implantation following TAVR in a real-world cohort.

BackgroundPermanent pacemaker implantation (PPI) following TAVR is a frequent post interventional complication and its management remains controversial.ObjectiveWe sought to elucidate the electrophysiological, procedural, and clinical baseline parameters that are associated with and perhaps predict the need for PPI after TAVR in a heterogeneous-valve-type real-world cohort.MethodsOverall, 494 patients receiving TAVR at our center from April 2009 to August 2015 were screened. ECG analyses and clinical parameters were collected prospectively.ResultsOverall, 401 patients in this all-comers real-world TAVR cohort with a PPI rate of 16% were included. The mean age was 82 years, and the mean duration to PPI was 5.5 days. A large proportion of Edwards SAPIEN valves (81%), DirectFlow, CoreValve, and Portico were implanted. The main indications for PPI were atrioventricular (AV) block III, AV-block Mobitz type II, bradycardic atrial fibrillation and persistent sinus bradycardia. Between groups with and without PPI, significant differences were noted in the prevalence of post TAVR balloon dilatation, resting heart rate, QRS interval, PR interval with a cut-off of >178 ms, left anterior fascicular block and RBBB in univariate analyses. In the subsequent multiple regression analysis, post TAVR balloon dilatation and a PR interval with a cut-off of >178 ms were significant predictors of PPI.ConclusionThis real-world cohort differs from others in its size and heterogeneous valve selection, and indicates for the first time that patients with post balloon dilatation or prolonged PR interval are at a higher risk for pacemaker dependency after TAVR.

Plummer Vinson Syndrome in a Young African American Female: A Rare Entity

Plummer Vinson syndrome (PVS), also known as Paterson-Brown-Kelly syndrome, is a rare clinical condition characterized by a triad of iron deficiency anemia, esophageal webs, and dysphagia. PVS has been rarely reported in African American females. In this case, however, we report a 26-year-old African American female with a 10-year history of iron deficiency anemia, who presented with severe fatigue and dysphagia. Her work-up revealed severe iron deficiency anemia, and upper endoscopy showed two esophageal rings. A 26-year-old African American female presented with severe fatigue, headache, and dysphagia for 5 months. The dysphagia was predominantly to solid foods compared to liquids. Patient also has a 10-year history of iron deficiency anemia and has stopped taking iron supplementations for the last 2 years. Physical examination revealed severe conjunctival pallor but was otherwise normal. Routine investigations revealed severe microcytic anemia with hemoglobin of 4.2 g/dL, mean corpuscular volume of 62.5 fL, and a ferritin level of 2 ng/dL. A modified barium swallow study showed two esophageal impressions in the cervical region, which were concerning for esophageal webs. Patient later underwent an esophagogastroduodenoscopy (EGD) which showed two upper esophageal rings; one semi-circumferential at 15 cm and a second circumferential at 17 cm from the incisors. A pediatric size scope was used to bypass the rings. She was initiated on iron replacement therapy with no symptomatic improvement of her dysphagia after 6 months of treatment. She then had a follow up EGD with wire-guided savary dilation with 8 mm dilator which resulted in an immediate improvement of her symptoms. Patient remained symptom free in her 2 months follow-up. PVS is characterized by iron deficiency anemia, esophageal webs, and dysphagia. It is predominantly seen in middle aged Caucasian females. Our case is unique because only a few cases of PVS have been reported in African American females. PVS is also a precancerous condition. Therefore, patients with this syndrome are at increased risk of developing gastrointestinal squamous cell carcinomas. Since nutritional deficiency is one of the major causes of iron deficiency anemia, the improvement in nutritional status of populations worldwide has led to a decreased incidence of PVS. Dysphagia in PVS usually responds to iron supplementation. However, resistant cases may require endoscopic dilatation of the webs as in our patient.1776_A Figure 1. EGD image Showing the first upper esophageal web, 15 cm from the incisors.1776_B Figure 2. EGD image Showing the second esophageal web, 17 cm from the incisors.1776_C Figure 3. Esophageal ring post wire-guided savary dilation with a satisfactory mucosal tear shown.

TCT-497 Predictors of Post-Dilatation after Self-Expanding Transcatheter Aortic Valve Replacement: Large Single Center Experience

Post-dilatation (PD) for self-expanding transcatheter aortic valve replacement (TAVR) demands a distinct procedural strategy and availability of an appropriate sheath and balloon and the identification of patients requiring PD for TAVR has other implications, such as case selection for

TCT-649 Impact of postdilatation on long-term outcome and valve durability in TAVR patients

Transcatheter aortic valve replacement (TAVR) has become the standard of care in high-risk patients and patients that are not suitable for surgery. Postdilatation (PD) is mainly performed due to remaining paravalvular aortic regurgitation (AR). However, there are concerns regarding leaflet function

PS01.086: TRANSGASTRIC VACUUM DRAINAGE FOR OESOPHAGEAL PERFORATIONS: A SIMPLE TECHNIQUE FOR A COMPLEX PROBLEM

Abstract Background We present an updated case series of patients treated with a novel Transgastric (TG) drainage technique, previously published by the senior author in 2008 [Ref], which has now been used in 6 hospitals across United Kingdom and Ireland. The technique establishes vacuum drainage of the lumen of the injured oesophagus whilst maintaining its patency, effectively exteriorizing complex oesophageal perforations to allow healing. Methods Patients presenting with Boerhaave or iatrogenic rupture, undergo an initial decontamination of the chest with drainage as required. A 32–36 Fr Chest drain is inserted in a PEG guided technique, where the proximal end of the drain is positioned 5 cm above the perforation site within the oesophagus, whilst the distal end is pulled out through the stomach and abdominal wall. Continuous low-pressure suction at -10 cm water is applied. Patients continue to drink water. Further intervention is not required until the leak has healed and the drain removed. Results We have used this technique in 20 patients in our institution (3 iatrogenic perforations, 17 Boerhaave), with a median age of 72 (range; 55–85). Perforation length ranged from 1–15 cms. Three cases were performed after stenting failed to control the leak. Pleural decontamination required thoracotomy (n = 12), VATS (n = 2); in 6 cases, no pleural decontamination was required. There were four in-hospital deaths. Median duration from surgery to removal of TG drain was 31 days (range; 10 - 71). Two patients required post discharge dilatation for stricture and are currently asymptomatic. Conclusion TG drainage in effect exteriorizes the oesophageal lumen at the site of oesophageal perforation, encouraging the perforated edges to appose and allow healing by secondary intention. Mediastinal sepsis drains through the transgastric drain (on suction) and intercostal drains placed at decontamination (off suction). Patients tolerate it well, drinking while their perforation heals, avoiding nasogastric intubation. [Ref] Berrisford RG, Krishnadas R, Froeschle P, Wajed S. European Journal of Cardiothoracic Surgery 33(2008):742–744. Disclosure All authors have declared no conflicts of interest.

A modified procedure for percutaneous pulmonary valve implantation of the SAPIEN 3 valve using a delivery sheath

The SAPIEN 3 valve (S3) is the latest iteration of the SAPIEN valve family. It is deployed using a low profile flexible Commander delivery system. Hemodynamic outcomes and device durability are promising with SAPIEN valves, but percutaneous pulmonary valve implantation (PPVI) remains difficult. Moreover, the lack of valve covering increases the risk of tricuspid valve injury. To described the early results of a modified procedure for PPVI of the SAPIEN S3 valve using a delivery sheath. We report the first consecutive cases of a modified procedure for PPVI of the SAPIEN S3 valve using a DryGore Seal 26French 65 cm delivery sheath. The sheath was used to stent the right ventricular outflow tract and then for the valve implantation. PPVI was performed using the modified technique in 15 patients (mean age 31 yo; mean weight 72.5 kg). The most common diagnoses were conotruncal defect (53.3%) and congenital aortic valve disease with Ross surgery (13.3%). A right-ventricle-to-pulmonary-artery tube had been inserted in 20.0% and a homograft or bioprosthesis implanted in 13.3% and 17.7% of patients, respectively. PPVI was performed on the native or patched RVOT in 73.3% of patients. Prestenting was performed in 12 cases with Andrastent XXL in 11 cases and eV3 LD max in 1 case. Prestenting was performed during the same procedure in all cases. While advancing the sheath through the stent, stent embolization occurred in one case. The stent was impacted and moved back with post dilatation and implantation of a second stent. SAPIEN 3 No. 23, No. 26 and No. 29 were implanted in 2, 3 and 10 cases. Valves were successfully implanted in all cases using the delivery sheath. Mean post valve gradient was 3 mmHg. Minor paravalvular leak was reported in 2 cases. Mean fluoroscopy time was 26.8 min. Groin hematoma were reported in 4 cases (26.7%). A delivery sheath allows a fast and safe PPVI of SAPIEN S3 valve.

Echocardiography in transcatheter aortic (Core)Valve implantation: Part 2-Transesophageal echocardiography.

Transesophageal echocardiography (TEE) plays a significant role during transcatheter aortic valve implantation (TAVR). 2DTEE allows assessment of anatomy of the aortic valve, aortic root, left ventricular (LV) outflow tract, severity of the aortic valve stenosis (AS), and the presence and severity of other valve stenosis and regurgitation. Left and right ventricular size and global function as well as cardiac hemodynamics pre and post TAVR and LV regional wall motion can be assessed. Three-dimensional (3D) imaging adds significantly via accurate measurement of aortic annulus that helps select the appropriate valve size. Biplane imaging allows simultaneous assessment of target cardiac structure in two orthogonal views and provides a rapid assessment during and immediately post valve deployment by evaluating stent height, leaflet motion, and the presence and severity of paravalvular leak (PVL). 2DTEE and 3DTEE allow evaluation of mechanism of PVL that helps guide the decision regarding need for balloon post dilation of the implanted valve or valve in valve implantation.

Aortic valve and left ventricular outflow tract calcium volume and distribution in transcatheter aortic valve replacement: Influence on the risk of significant paravalvular regurgitation

ObjectivesWe sought to determine the impact of aortic root calcium on the risk of significant paravalvular regurgitation (sPAR) in transcatheter aortic valve replacement (TAVR). MethodsIn 302 consecutive patients from 3 centers, aortic root calcium was quantified volumetrically on pre-TAVR multidetector computed tomography (MDCT) in three regions: 1) the aortic valve region, 2) the overall left ventricular outflow tract (LVOT) and 3) the upper LVOT. Transcathether heart valve (THV) oversizing was calculated as (THV nominal area/MDCT annular area−1) × 100. The study endpoint sPAR was a composite of post-dilatation (PD) and PAR > mild. ResultssPAR occurred in 15% (46/302) of patients. Upper LVOT calcium volume was more predictive of sPAR than overall LVOT calcium volume, with an area under the receiver operating curve (AUC) (95% confidence interval [CI]) of 0.80 (0.67–0.89) vs. 0.60 (0.51–0.70); p = 0.0001. The optimal cut-off calcium volume thresholds determined from receiver operating curves were 21 mm3 and 30 mm3 for upper LVOT and overall LVOT calcium, respectively. Upper LVOT calcium ≥ 21 mm3, but not overall LVOT calcium ≥ 30 mm3, independently predicted sPAR, odds ratio (95%CI): 9.5 (4.1–22.3) vs 1.6 (0.6–2.7). Upper LVOT calcium was more predictive of sPAR in patients with THV oversizing ≥ 13% compared to patients with THV oversizing <13%, AUC (95% CI): 0.83 (0.72–0.93) vs. 0.67 (0.51–0.74); p < 0.0001. ConclusionsUpper LVOT calcium predicts more-than-mild paravalvular regurgitation following TAVR or the need for postdilatation. Upper LVOT calcium is most predictive of paravalvular regurgitation in the event of THV oversizing ≥ 13%.

Salvage of the Unsalvageable: V-A ECMO Bridging the Treatment of Acute Stent Thrombosis of the Left Main in a 29-Year-Old Male

A 29-year-old male with no risk factors presented with anterior ST elevation. RRA access coronary angiography revealed an occluded left anterior descending (LAD). Glycoprotein IIb/IIIa inhibition was withheld due to initial distal LAD wire dissection. An intravascular ultrasound (IVUS)-guided single DES strategy was complicated by distal edge dissection requiring further mid-LAD DES insertion. Repeat IVUS revealed thrombus at proximal edge of the initial LAD stent requiring ostial stenting back into the distal left main with post dilatation to high pressure. The final angiographic and clinical result was acceptable.

Clinical and procedural outcomes with the SAPIEN 3 versus the SAPIEN XT prosthetic valves in transcatheter aortic valve replacement: A systematic review and meta‐analysis

The SAPIEN 3 valve (S3V) was designed to overcome the shortcomings of its predecessor, the SAPIEN XT (SXT) valve. We conducted a meta-analysis to compare their clinical outcomes and procedural characteristics. PUBMED, EMBASE, and Cochrane CENTRAL were searched by two independent reviewers. The clinical outcomes of interest were paravalvular leakage (PVL), major vascular complications (MVC), bleeding, acute kidney injury (AKI), device success, need for post dilation all-cause mortality and procedural details. Fifteen observational cohort studies were included in the analysis involving a total of 4,496 patients. Of these, 1,700 were S3V recipients and 2,796 were SXT recipients. The S3V group showed fewer complications compared to the SXT group with respect to PVL (5.58% vs. 19.35%, OR: 0.27, P: 0.000), MVC (4.07% vs. 9.13%, OR: 0.44, P: 0.002), bleeding (6.40% vs. 12.03%, OR: 0.50, P: 0.003), 30-day mortality (3.29% vs. 5.68%, OR: 0.51, P: 0.000), and stroke (1.48% vs. 2.86%, OR: 0.49, P: 0.014). Device success was higher in the S3V (98.18% vs. 93.76%, OR: 3.14, P: 0.000). Cardiovascular mortality, myocardial infarction, AKI and post-dilatation were not significantly different. Permanent pacemaker implantation (PPI) was higher in S3V recipients (13.29% vs. 9.23%, OR: 1.58, P: 0.000). Procedure time was shorter for the S3V (71.94 vs. 86.85, P: 0.016) and used less contrast volume (129.36 vs. 161.18, P: 0.049). Patients receiving the S3V had lower risk of PVL, MVC, bleeding, mortality, and stroke. PPI was somewhat higher in the S3V group. S3V implantation was faster and used less contrast.

Disparity in Coronary Artery Diameter in Diabetic and Nondiabetic Subjects undergoing Percutaneous Coronary Intervention in Bangladesh: A 2-Year Retrospective Analysis

Objective: Coronary arteries in diabetic patients were found to be narrower than in non-diabetic subjects. The aim of the study was to compare the coronary arteries diameter between diabetic and non-diabetic patients undergoing percutaneous coronary intervention (PCI) using stent diameter for greater accuracy.Methods: This was a randomized observational study. From a dedicated database, we retrospectively analysed all consecutive patients of both gender who underwent PCI in the cardiac catheterization laboratory of Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh, from January 2011 to December 2012. Patients who required left main coronary artery stenting were excluded from this study. Patients were divided into two groups; diabetics and non-diabetics. We calculated the coronary artery diameter according to the diameter of the stent, achieved at the final pressure at which the stent was deployed. The diameter which was achieved at a given atmospheric pressure was taken from the attached booklet provided with the stent packaging. If post dilatation was required then the diameter achieved by the non-compliant balloon after post dilatation was taken as the reference diameter of the artery.Results: A total of 571 patients, 333 in diabetic and 238 in non-diabetic group were included in the study. Proximal segments of left anterior descending (LAD) coronary artery in diabetics and non-diabetics were 2.99±0.44 vs 3.14±0.50 mm (p=0.00) while mid and distal segments were 2.90±0.38 vs 3.10±0.42 mm (p=0.00) and 2.25±0.39 vs 2.42±0.45 mm (p=0.00) respectively. Various segments of proximal left Circumflex (LCx) coronary artery in diabetics and non-diabetics were 2.98±0.21 vs 3.01±0.25 mm (p=0.39) while distal circumflex were 2.35±0.40 vs 2.49±0.43 mm (p=0.00) respectively. Proximal segments of right coronary artery (RCA) in diabetic and nondiabetics were 3.0±0.28 vs 3.28±0.25 mm (p=0.00) while mid and distal segments were 2.97±0.26 vs 3.19±0.25 mm (p=0.00) and 2.43±0.51 vs 2.87±0.32 mm (p=0.00) respectively. The number of stents (1.34±0.87 vs 1.30±0.65; p=0.40) and type of stent utilized (DES &amp; non DES: 87.3 &amp; 12.7% vs 85.2 &amp; 14.8%; p=0.50) between diabetic &amp; non-diabetic groups were not significantly different; however the total stent length (23.1±13.3 vs 21.5±9.52 mm; p=0.03) in diabetic group was significantly longer.Conclusions: The diameter of LAD, distal circumflex and right coronary arteries were significantly narrower in diabetic than non-diabetic subjects.Bangladesh Heart Journal 2017; 32(1) : 23-28

Pneumatic Balloon Dilation is a Safe and Effective Treatment for Severe Dysphagia Post-Fundoplication

Introduction: Fundoplication is a common surgical treatment for refractory gastroesophageal reflux disease or following myotomy for achalasia. Although transient postoperative dysphagia often related to postoperative edema and inflammation is common, the rate of severe or persistent dysphagia lasting more than 3 months is reported 3% to 24% post fundoplication for GERD. Dysphagia recurs in about 10% of cases post successful myotomy and fundoplication. Its pathophysiology is unclear, but esophageal dysmotility or functional obstruction at GE junction due to the wrap may be important. Our aim was to evaluate the efficacy and safety of pneumatic balloon dilation for refractory dysphagia following fundoplication. The role of EndoFLIP study in pre and post dilation was also assessed. Methods: Retrospective review was performed of all patients who underwent pneumatic dilation over 3 years. Patients in whom pneumatic dilation was performed for primary achalasia were excluded. Demographic details, esophageal motility studies, symptoms pre and post dilation, and esophageal imaging studies were reviewed. Results: 10 patients met the inclusion criteria. All patients had fundoplication from 3 to 20 years prior to presentation and had symptoms of dysphagia unresponsive to multiple (>3) Savary or balloon dilations. Mean age was 57.1 years with M/F=3/7. 6 patients had fundoplication with myotomy for achalasia. 4 patients had fundoplication for GERD. All pneumatic dilations were with either 30 mm or 35 mm Boston Scientific Rigiflex balloons performed under fluoroscopy with confirmation of waist obliteration. The esophageal manometry showed elevated IRP and IBP (mean of 20 and 18.4) along with poor bolus transit (mean bolus transit failure of 77%). All patients tolerated the pneumatic dilation well without complications. All had significant symptom improvement shown either with esophageal symptoms scores reduction or post dilation Eckardt scores of <3. 2 patients had EndoFLIP study pre and post pneumatic balloon dilation showing three-fold increase in distensibility index (0.4 to 1.2 and 0.7 to 2.8). Conclusion: Refractory dysphagia post fundoplication is a rare, but disabling complication. In patients who failed bougie dilation, and with proven GE junction functional obstruction (high IRP, low distensibility index), pneumatic balloon dilation appears to be a safe and effective option. High resolution esophageal manometry and EndoFlip assessment are useful tools for assessment and adequacy of treatment.Table: No Caption availableFigure: EndoFLIP evaluation before and after pneumatic balloon dilation.

Empiric Dilation in Patients With Unexplained Dysphagia

Introduction: Patients with subjective dysphagia with normal findings on both the High Resolution Manometry (HRM) and Esophagogastroduodenoscopy (EGD) represent a challenging cohort to treat. There is a paucity of data on efficacy and safety of the empirical dilation in patients with unexplained dysphagia. The aim of our study is to determine the efficacy and safety of esophageal dilation as empiric therapy for patients with cryptogenic dysphagia.FigureMethods: This is a retrospective cohort study that included patients who met the criteria for unexplained dysphagia, i.e. underlying cause of the dysphagia cannot be determined both on the HRM and EGD between April 2015 and August 2016. Each patient received esophageal dilation with bougie dilators. Post dilation, patients were contacted by telephone and asked about their symptom severity and symptom frequency using the Brief Esophageal Dysphagia Questionnaire* and overall treatment satisfaction (measured on a scale of 1 to 10: 1 being not pleased with current symptoms, 10 being very satisfied. Results: Twenty seven patients (seven male/ twenty female) with dysphagia were dilated with esophageal dilators with a goal of 18mm. Using a questionnaire post dilation, seventeen patients (62.96%%) had improvement of their dysphagia symptoms (i.e. total dysphagia score <3). Seven patients (25.9%) reported symptoms of food stuck in the esophagus for more than 30 minutes; none of the empirically dilated patients had an emergency visit for globus or dysphagia. Conclusion: Empirical esophageal dilation is safe and effective in improving the symptoms of dysphagia in patients without obvious structural lesions or functional disorders. Empirical dilation may improve dysphagia symptoms because subtle structural lesions such as small strictures, webs, rings capable of decreasing the esophageal lumen diameter might go unnoticed on endoscopy. These subtle structural lesions are countered by the empirical esophageal dilation, eventually improve symptoms of dysphagia.

Impact of post-dilatation on the reduction of paravalvular leak and mortality after transcatheter aortic valve implantation.

Post-implantation paravalvular leak (PVL) remains a significant complication of transcatheter aortic valve implantation (TAVI). More importantly, its occurrence may impact long-term mortality. We sought to evaluate the effects of balloon post-dilatation (PD) on the reduction of PVL and mortality in patients undergoing TAVI. A total of 101 consecutive patients undergoing TAVI were enrolled. Angiography, echocardiography, and the aortic regurgitation index (ARI) were used to assess the severity of PVL before and after balloon PD. Patients were divided into two groups based whether or not PD after TAVI was performed. Reduction of PVL, change of ARI, and clinical outcomes were assessed. Balloon post-dilatation was performed in 23 (22.8%) patients. In 95.6%, PVL reduction was successful (no or mild PVL). PD increased the ARI from 23.4% (22.4-24.0) to 27.1% (26.1-28.3); p < 0.001. Thirty-day mortality rate was 14.1% in the PD (-) group vs. 0.0% in the PD (+) group; p = 0.07. One-year mortality (21.8% vs. 4.3%, p = 0.97) and procedural stroke rate (7.7% vs. 8.7%, p = 0.99) were not different between the groups. Balloon post-dilatation may be a safe and effective technique to reduce moderate to severe PVL after TAVI.

P2353Advantage and accuracy of a new jailed pressure wire technique using an optical fiber for coronary bifurcation lesions after post dilatation of stent by high pressure

P2353Advantage and accuracy of a new jailed pressure wire technique using an optical fiber for coronary bifurcation lesions after post dilatation of stent by high pressure

The Acute Effect of Aerobic and Resistance Training on Arterial Diameter

A positive chronic effect of different exercise modalities on vascular endothelial diameter and function has been reported; however, little is known about the arterial vascular response to acute bouts of exercise. PURPOSE: The purpose of the study was to investigate the acute response of two exercise modes (aerobic and resistance training) on the endothelium vascular diameter. METHODS: A meta-analysis was planned where the inclusion criteria for studies were: 1) experimental trials; 2) only one exercise session (acute treatment); 3) aerobic (AE) or resistance training (RT) interventions; 4) studies in human adults with no heart disease; 5) studies published only in English language; and 6) studies with pre and post flow-mediated dilation (FMD) measurement. The electronic search was performed in six databases (PubMed, Springer Link, Science Direct, SAGE Journals, Sport Discus and Nature), cross-referencing, and hand searching, using the following combinations of words “Acute exercise FMD”, “endothelial exercise function”, “vascular exercise endothelium”, and “FMD exercise”. Hedge’s standardized mean difference effect size (ES) was calculated for each result; then, ESs pooled using random-effects models. Non-overlapping 95% confidence intervals (CI95%) were considered statistically significant. Heterogeneity was assessed using Q and I2, while funnel plots and Egger’s regression test were used to assess small-study effects (potential bias). RESULTS: A total of 13 studies were meta-analyzed and 40 ESs computed from 378 (245 men and 133 women) participants. Of the 40 ESs, 27 were on AE, 9 on RT and 4 on control groups (no exercise). The AE training revealed no significant effect on artery diameter (ES= 0.26; CI95%= 0.00, 0.52; Q= 14.2; p= 0.11; I2= 0%). The RT interventions indicated no significant effect (ES= 0.29; CI95%= -0.08, 0.66; Q 0.38; p= 0.25; I2= 0%). CONCLUSIONS: Neither aerobic or resistance training elicited an acute response on vascular function. More research is needed to better understand the physiological mechanisms responsible for this response.

22 Single centre experience of incorporating knowledge-based reconstruction for right ventricular volumetry into clinical practice

Knowledge-based reconstruction (KBR) is a new technique for calculating the volume of cardiac chambers accurately. The technique can be applied to 3D datasets (eg, MRI scans), but can also be used with conventional 2D echocardiography by tracking the probe position and orientation in 3D space. It is particularly useful for assessing the volume of the right ventricle without having to undergo an MRI scan. We acquired a KBR system in March 2015, and have been putting it into practice. We have performed 69 studies in 45 patients over an 18 month period, ages between 5 and 70 years average 18.9 years, 28 patients (62%) were between 5–12 years and 37 patients (82%) were below 18 years of age. Indications mainly for post surgical Tetralogy of Fallot variants or post pulmonary valve dilation resulting in free pulmonary regurgitation or mixed valve disease with resulting significant right ventricular volume loading . In a subset we have performed analysis on 13 patients who underwent pulmonary valve replacement, giving pre- and post- surgical RV volume and function analysis, all 13 patients had Cardiac MRI pre surgery, that was comparable to the pre-surgical KBR analysis. Conclusion Knowledge based reconstruction of right and left ventricle volumetric data can be preformed with good reliability and good alternative to MRI.

Post-dilation in transcatheter aortic valve replacement: A systematic review and meta-analysis.

The aim of this study was to perform a meta-analysis to compare the outcomes of patients undergoing TAVR with and without balloon post-dilation (PD). PD is a commonly used technique in TAVR to minimize paravalvular regurgitation (PVR), albeit supported by little evidence. Systematic review and meta-analysis of 6 studies comparing 889 patients who had PD compared to 4118 patients without PD. Patients undergoing PD were more likely male (OR 1.92; 95% CI, 1.41-2.61; P < 0.001) and to have coronary artery disease (OR 1.31; 95% CI, 1.03-1.68; P = 0.03) than those patients not requiring PD. There were no significant differences in 30-day mortality (OR 1.24; 95% CI, 0.88-1.74; P = 0.22) and myocardial infarction (OR 0.93; 95% CI, 0.46-1.90; P = 0.85). Patients undergoing TAVR did not have higher 1-year mortality rates (OR 0.98; 95% CI, 0.61-1.56; P = 0.92). The incidence of stroke was significantly greater in patients with PD (OR, 1.71; 95% CI, 1.10-2.66). PD was able to reduce the incidence of moderate-severe PVR by 15 fold (OR 15.0; 95% CI, 4.2-54.5; P < 0.001), although rates of moderate-severe PVR were still higher after PD than patients who did not require PD (OR 3.64; 95% CI, 1.96-6.75; P < 0.001). PD significantly improves rates of PVR, however careful patient selection is needed to minimize increased risk of strokes.

Self-expanding STENTYS stents in daily routine use.

In the era of modern interventional cardiology, implantation of a balloon expandable stent is the finishing touch of almost every coronary angioplasty. However, sometimes we face a clinical situation in which the decision regarding the stent diameter is complicated, especially in the ectatic part of arteries, in situations when the artery lumen is obscured with the thrombus, or when the reference diameter of the proximal and distal part of the lesion vary greatly. That is why the idea of a self-apposing stent similar to the one used in peripheral vascular interventions was adopted into cardiology. The aim of this study was to present a single-centre registry of STENTYS® stent implantation in 40 selected patients with acute coronary syndromes (ACS) or with stable angina (coronary artery disease [CAD]) treated with this self-expandable stent. The device was successfully implanted in all patients. During in-hospital observation and 30-day follow-up there were two cases of death, but none of the patients had acute stent thrombosis or ACS ST elevation myocardial infarction. In one case ACS type 4b was diagnosed. In all patients the stent was delivered in the target lesion. In two cases the procedure was performed in patients with multivessel CAD extending into the left main stem in a state of cardiogenic shock. These patients died immediately after the procedure. There were two procedure complications: in one case dissection after post dilatation occurred distally to the stent, and in one patient the calcified proximal part of the left anterior descending artery was dissected with system passage. Thirty-eight patients survived the 12-month follow-up period, and three (7.8%) patients underwent repeated target-lesion revascularisation. In the presented single-centre registry the STENTYS® stent was used with a high delivery and procedural success rate. Satisfactory clinical long-term outcome both in stable patients and ACS patients with a repeated revascularisation ratio of 7.8% was observed. The stent design allowed successful treatment of bifurcation lesions.