BACKGROUND
Due to nitinol stent properties, self-expanding transcatheter heart valves (THVs) have the potential to adapt their frames to native annular dimension excursions during the cardiac cycle and therefore to maintain the physiological relevance of this behaviour.
AIMS
To assess the in-vivo variations of THV frame dimensions during the cardiac cycle.
METHODS
Patients undergoing transcatheter aortic valve replacement (TAVR) with self-expanding THV platforms enrolled in the RE-ACCESS 2 study were considered. Patients with post-TAVR four-dimensional computed tomography (4-D CT) assessment not eligible for stent frame analysis were excluded from the analysis. The THV frame dimensions were assessed at three levels: inflow edge, native virtual basal ring (VBR) and bioprosthetic leaflets plane (BLP). Measurements were performed in systolic (30° of the cardiac cycle) and diastolic (70° of the cardiac cycle) phase acquisitions for each patient. Stent expansion was reported as the difference among systolic and diastolic measurements.
RESULTS
Among a total of 127 patients, 83 patients were considered eligible for the present analysis. Forty-nine and 34 patients received Evolut and Acurate Neo2 THV, respectively. Stent frame expansion across the cardiac cycle was encountered at VBR (median perimeter variability 0.30 mm) and BLP (median perimeter variability 0.25 mm) levels, but not at the inflow level (median perimeter variability -0.05 mm). Acurate Neo2 had greater variability compared to Evolut THVs (VBR median perimeter variability 0.50 mm vs. 0.10 mm, p = 0.02; BLP median perimeter variability 0.60 mm vs. 0.20 mm, p = 0.05).
CONCLUSIONS
Self-expanding THVs exhibited dynamic behavior throughout the cardiac cycle, with stent expansion during systole at both VBR and BLP levels. Stent design influenced this dynamicity, as Acurate Neo2 had greater stent variability compared to Evolut THV. Whether these features affect long-term THV durability remains to be determined.
M. Calì, Sofia Sammartino, L. La Rosa et al.· Catheterization and cardiova...· 0 citations
Anticoagulant therapy is the cornerstone of stroke prevention in atrial fibrillation (AF), yet its management in elderly and frail patients remains particularly challenging. This review aims to summarize current evidence, guideline recommendations, and future perspectives regarding the optimal anticoagulant strategy in this vulnerable population. Main findings A narrative review of pivotal randomized clinical trials and major real-world registries was conducted, focusing on outcomes of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients aged ≥75 years or meeting frailty criteria. Across studies, DOACs consistently demonstrated similar or superior efficacy compared with VKAs for the prevention of stroke and systemic embolism, with a substantially lower risk of intracranial hemorrhage. Apixaban and edoxaban, particularly at adjusted doses, showed the most favorable balance between thromboembolic protection and bleeding risk. Conversely, switching stable elderly patients from long-term VKAs to DOACs, as in the FRAIL-AF trial, was associated with an early excess of clinically relevant non-major bleeding. Frailty, multimorbidity, renal impairment, and polypharmacy remain critical modifiers of both efficacy and safety, underlining the need for individualized dosing and regular renal function monitoring. Recent European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) and the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines recommend DOACs as the preferred treatment for non-valvular AF, emphasizing comprehensive risk assessment and shared decision-making. Emerging agents, such as factor XI inhibitors, offer a promising approach to minimizing bleeding risk in the elderly, though confirmation of their efficacy against ischemic events remains to be fully established. Conclusions In elderly and frail patients with AF, DOACs represent the first-line anticoagulant therapy when appropriately dosed and monitored. A personalized, multidisciplinary approach incorporating frailty assessment, renal evaluation, and patient preference is essential to optimize outcomes. Future trials specifically enrolling very old and severely frail patients are urgently needed to close existing evidence gaps.
Lorenzo Scalia, Laura Gatto, Federica Agnello et al.· American Journal of Cardiolo...· 1 citation
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