Editorial

AsiaIntervention: marking the beginning of a new era in scientific publications in Asia

23 November inEditorial, Issue

Huay Cheem Tan
AsiaIntervention 2017;3:93-94, DOI: 10.4244/AIJV3I2A18

As President of the Asian-Pacific Society of Interventional Cardiology (APSIC) and one of the Chief Editors of this journal, it is a great pleasure to introduce this latest edition of AsiaIntervention. Our young journal is growing rapidly and with this new edition we are entering a watershed period, where the rigorous development of our first issues is beginning to bear fruit in terms of the influence and recognition we receive from you our readers throughout Asia and internationally as well.

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The evolution of percutaneous coronary intervention in Asia: in celebration of the 40th anniversary of percutaneous transluminal coronary angioplasty

23 November inEditorial, Issue

Runlin Gao
AsiaIntervention 2017;3:95-96, DOI: 10.4244/AIJV3I2A19

Forty years ago, in September 1977, Dr Andreas Grüntzig heralded the era of interventional cardiology by successfully performing the first percutaneous transluminal coronary angioplasty (PTCA) in Zurich, Switzerland1. Through live demonstration courses, he went on to train cardiologists from around the world, leading to the rapid introduction of PTCA into clinical practice in the rest of Europe, the United States and beyond.

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Role of professional medical writing in high-quality publications

23 November inEditorial, Issue

Peter Barlis, Ojas Mehta, Vikas Thondapu
AsiaIntervention 2017;3:97-98, DOI: 10.4244/AIJV3I2A20

Whilst central and western Europe have witnessed declines in absolute numbers of cardiovascular deaths between 1990 and 2013, regions such as South and East Asia have witnessed the largest increases1. Despite these observations, Asian countries remain under-represented in cardiovascular research and scientific output. The reasons for this are complex and multifactorial, but there can be little doubt that, moving forward, the Asian region is a crucial element in the effort to understand and treat cardiovascular disease better, and AsiaIntervention will continue to work tirelessly to promote the region globally.

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Dengue fever, thrombocytopaenia and management issues in post-coronary stenting patients

23 November inEditorial, Issue

Vineet Bhatia, Upendra Kaul
AsiaIntervention 2017;3:99-102, DOI: 10.4244/AIJV3I2A21

Severe thrombocytopaenia is a rare finding, particularly in patients with coronary artery disease. Percutaneous coronary intervention (PCI) is best avoided in such patients because of the increased risk of bleeding complications that may result due to the mandatory use of periprocedural anticoagulation and post-procedural antiplatelet therapy. This concern is reinforced by data which has revealed an inverse relation between in-hospital death, major adverse cardiac events and major bleeding rates in PCI patients and platelet counts.

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Restenosis after drug-eluting stenting – a call for action

23 November inEditorial, Issue

Robert A. Byrne, Roisin Colleran
AsiaIntervention 2017;3:103-105, DOI: 10.4244/AIJV3I2A22

Percutaneous coronary intervention (PCI) has become the dominant revascularisation modality for patients with obstructive coronary artery disease. This development has been facilitated by advances in catheterisation techniques, antithrombotic therapy, and stent technology1-3. Drug-eluting stents (DES) in particular were a breakthrough technology. The high efficacy of DES enabled the expansion of transcatheter treatment to patients with complex disease patterns, such as multivessel and left main stem disease.

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Stenting or bypass grafting for left main coronary artery disease: considering short- and long-term trade-offs of each procedure for individualised patient care

23 November inEditorial, Issue

Pil Hyung Lee, Duk-Woo Park, Seung-Jung Park
AsiaIntervention 2017;3:107-109, DOI: 10.4244/AIJV3I2A23

It is universally accepted that patients with significant left main coronary artery (LMCA) disease should receive coronary revascularisation regardless of the spectrum of clinical presentation. However, the optimal revascularisation strategy for such patients has been the subject of intense investigation for decades. Although coronary artery bypass graft (CABG) surgery has been the standard of care for the treatment of LMCA disease for nearly 40 years, percutaneous coronary intervention (PCI) treatment has undergone considerable therapeutic evolution over time and has changed the therapeutic paradigm in the field. Particularly since the widespread use of drug-eluting stents (DES), PCI for LMCA disease has become much more technically feasible and has shown favourable short- and long-term clinical outcomes.

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National society presentation

The Japanese Circulation Society (JCS)

22 November inNational society presentation

AsiaIntervention 2017;3:110, DOI: 10.4244/AIJV3I2A24

The JCS is recognised as one of the most influential medical associations in Japan with 26,065 members including 14,000 cardiovascular specialists certified by the society as of June 2017.

The JCS has a long history stretching back over 80 years. The Journal entitled “The Nippon Journal of Clinical Angio-Cardiology” was first published in 1935, and the first general meeting was held in the following year, 1936, which was the beginning of the JCS. For cardiovascular interventionists, we now also have the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT), which is considered a sister association of the JCS. Many collaborative activities in the field of cardiovascular intervention are organised jointly by both societies.

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Coronary Interventions

Defining optimal stent overexpansion strategies for left main stenting: insights from bench testing

22 November inCoronary Interventions, Issue

Jiang Ming Fam, Peter Mortier, et al
AsiaIntervention 2017;3:111-120, DOI: 10.4244/AIJ-D-16-00012

Abstract
Aims: Left main stenting frequently requires overexpansion of stents which can be performed by proximal optimisation technique (POT) or final kissing balloon dilation (FKBD). Yet, there are limited data concerning the effect of post-dilation of metallic stents beyond the overexpansion limit. The objectives of this study were to evaluate stent performance after overexpansion using POT or FKBD.

Methods and results: We deployed 4.00 mm drug-eluting platinum-chromium stents in silicone models of 6.00 mm diameter. We compared stent expansion and apposition using: 1) POT with 6.00 mm balloons using low, standard and high pressures (LP, SP and HP, respectively), and 2) final kissing balloon dilation (FKBD) using undersized (US) balloons at SP and optimally sized (OS) balloons at LP and SP. The platinum-chromium 4.00 mm stent can be expanded to an outer diameter of 5.10 mm by POT using a 6.00 mm balloon at LP. Further post-dilatation at higher pressures (SP, HP) resulted in an outer diameter of 6.00 mm. FKBD with US balloons resulted in a high ellipticity index and malapposition; with OS balloons, stent area improved but ellipticity and malapposition were still higher compared to POT. After overexpansion, the radial strength of metallic stents was maintained.

Conclusions: In PCI involving relatively larger vessel diameters such as left main stenting, POT but not FKBD can safely expand the platinum-chromium 4.00 mm stent beyond the overexpansion limit to 6.00 mm with optimal stent apposition and performance. POT may be the technique of first choice to achieve optimal stent expansion in left main stenting but requires higher pressures.

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Stent versus bypass grafting for the treatment of left main stem disease: a meta-analysis of six randomised controlled trials

23 November inCoronary Interventions, Issue

Javaid Iqbal, Jin-Zan Cai, et al
AsiaIntervention 2017;3:121-130, DOI: 10.4244/AIJ-D-17-00021

Abstract
Aims: We performed a meta-analysis of all randomised controlled trials to compare percutaneous coronary intervention (PCI) with stents versus coronary artery bypass grafting (CABG) for the treatment of left main stem disease.

Methods and results: We searched PubMed, the Cochrane Library, ClinicalTrials.gov, and major cardiovascular congresses for articles comparing PCI versus CABG for the treatment of left main stem disease. We utilised either fixed or random effects models to calculate the pooled risk ratio (RR) and 95% confidence interval (CI). Six trials with a total of 4,717 patients treated with either PCI (n=2,355) or CABG (n=2,362) were eligible and included. There were no differences in all-cause (RR: 1.03, 95% CI: 0.84-1.25, p=0.78) and cardiac mortality (RR: 1.03, 95% CI: 0.78-1.37, p=0.83) between PCI- and CABG-treated patients at the longest available follow-up. PCI-treated patients had a higher incidence of repeat revascularisation (RR: 1.65, 95% CI: 1.40-1.94, p<0.0001). However, there was no difference in myocardial infarction (RR: 1.36, 95% CI: 0.87-2.12, p=0.17) and stroke (RR: 0.86, 95% CI: 0.44-1.69, p=0.66).

Conclusions: There are no differences in mortality, myocardial infarction and stroke in PCI- or CABGtreated patients with left main stem disease. However, PCI-treated patients are more likely to need repeat revascularisation.

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Early and late restenosis of drug-eluting stents: an observational study about predictors, clinical presentation and response to treatment (the LATE DES study)

23 November inCoronary Interventions, Issue, Table of content TOP

Flavia Belloni, Francesco Fracassi, et al
AsiaIntervention 2017;3:131-138, DOI: 10.4244/AIJ-D-16-00021

Abstract
Aims: The aim of the study was to evaluate differences in clinical presentation, angiographic and clinical predictors, and response to treatment of early (<9 months) vs. late (≥9 months) in-stent restenosis (ISR) of drug-eluting stents (DES).

Methods and results: One hundred and twenty-nine patients with DES restenosis (defined by angiography as diameter stenosis >50% at the stent segment or its edges) were enrolled: 79 (61%) had early DES restenosis (6±2 months) and 50 (39%) late DES restenosis (18±8 months). ISR treatment strategy was left to the operator’s choice: DES or drug-eluting balloon (DEB). The primary endpoint was the incidence of major adverse cardiovascular events (MACE) at follow-up. Patients with early DES restenosis more frequently had an acute coronary syndrome as clinical presentation at the index procedure as compared to those with late DES restenosis (OR 2.63, 95% CI: 1.12-6.25; p=0.027). The treatment of DES restenosis was DES implantation in 78 (60%) patients and DEB in 51 (40%) patients, without differences between early and late DES ISR. MACE after ISR treatment occurred in 25 (19%) patients, without differences between early and late DES ISR (16 [20%] vs. 9 [18%]; p=0.75, respectively). Diabetes mellitus was the only independent predictor of MACE at follow-up (OR 4.6, 95% CI: 1.3-19.3; p=0.03). MACE-free survival was similar after treatment in early or late ISR (p=0.097) and according to ISR treatment (p=0.73).

Conclusions: Early DES restenosis occurred more frequently after DES implantation for ACS compared with late DES restenosis. This, however, did not translate into a difference in MACE rate after ISR treatment at follow-up. Treatment choice for ISR did not affect prognosis. Diabetes mellitus remains the only independent predictor of MACE after treatment of DES ISR.

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Impact of target lesion coronary calcium score on outcomes following drug-eluting stent implantation

23 November inCoronary Interventions, Issue

Tatsuyuki Sato, Satoru Kishi, et al
AsiaIntervention 2017;3:139-146, DOI: 10.4244/AIJ-D-17-00006

Abstract
Aims: The aim of this study was to evaluate the impact of computed tomography scan-based coronary artery calcium scoring of the target lesion on outcomes following percutaneous coronary intervention using second-generation drug-eluting stents.

Methods and results: We retrospectively investigated 124 consecutive patients who underwent coronary artery calcium scoring prior to cobalt-chromium everolimus-eluting stent implantation. Eight-month clinical and angiographic outcomes were evaluated. Target vessel failure (TVF) was defined as a composite of cardiac death, target vessel myocardial infarction, and target vessel revascularisation. A significant difference in lesion calcium score was observed between patients with and without TVF (median 216.7 vs. 42.8, p=0.025). The area under the receiver operating characteristic curve for prediction using lesion calcium scoring was 0.74 (95% confidence interval [CI]: 0.53-0.94) for TVF. When using a cut-off value of 140, the sensitivity and specificity of the lesion calcium score for predicting TVF were 87.5% and 69.8%, respectively. Among the 103 patients with either no or mild angiographic calcification, 24 patients (23.3%) had a lesion calcium score ≥140 and they were at higher risk for TVF (20.8% vs. 1.3%, p=0.002).

Conclusions: Computed tomography-based detection of coronary artery calcification of the target lesion was associated with poor prognosis after cobalt-chromium everolimus-eluting stent implantation.

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Two-year outcomes of a bioresorbable everolimus-eluting scaffold using a strategy of meticulous lesion preparation and routine post-dilation: the Australian ESHC-BVS registry

23 November inCoronary Interventions, Issue

Daniel Robaei, Liam Back, et al
AsiaIntervention 2017;3:147-155, DOI: 10.4244/AIJ-D-17-00014

Abstract
Aims: The Absorb bioresorbable vascular scaffold (BVS) was the first commercially available coronary stent to provide vessel scaffolding of a temporary nature following percutaneous coronary intervention. While results in clinical trials have varied, outcomes using a BVS-specific implantation strategy have not been well studied. We report two-year real-world data on the Absorb BVS implanted following meticulous lesion preparation and with a strategy of routine post-dilation.

Methods and results: Absorb BVS implantation was attempted in 152 lesions in 100 patients at two Sydney hospitals as part of the prospective ESHC-BVS registry. Lesions treated included complex lesions reflective of real-world practice with lesion length being >20 mm in 24%, and 16% featuring moderate/severe calcification. In total, type C lesions made up 37% of all lesions treated. A BVS-dedicated implantation strategy was utilised encompassing meticulous lesion preparation and routine post-dilation. Predilation was performed in 100% of lesions and post-dilation in 95% of scaffolds to a mean of 19.6±4.6 atm. Two-year clinical follow-up data were available for 99% of patients. At two years, the rate of all-cause mortality was 3% and cardiac death 1%. The cumulative incidence of target lesion revascularisation at two years was 4%, while the incidence of myocardial infarction was 2% and scaffold thrombosis 1%.

Conclusions: Using a strategy of meticulous lesion preparation and routine post-dilation, the Absorb BVS was associated with good clinical outcomes at long-term follow-up with low rates of target lesion revascularisation, myocardial infarction and scaffold thrombosis at two years. These findings support the dedicated scaffold implantation technique employed in this registry.

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Imaging comparisons of bioresorbable scaffolds as seen by optical coherence tomography

23 November inCoronary Interventions, Issue

Chee Yang Chin, Khung Keong Yeo, et al
AsiaIntervention 2017;3:156-157, DOI: 10.4244/AIJ-D-17-00017

Intracoronary imaging is recommended to guide bioresorbable scaffold (BRS) deployment. Here, we describe the distinguishing features of three CE-marked BRS – Absorb™ (Abbott Vascular, Santa Clara, CA, USA), DESolve® (Elixir Medical, Sunnyvale, CA, USA) and Magmaris™ (Biotronik, Berlin, Germany) – as imaged by optical coherence tomography (OCT) immediately post implantation.

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Potential risk of deflecting stent struts after side branch dilation with inappropriate guidewire recrossing in a coronary bifurcation lesion

23 November inCoronary Interventions, Issue, Table of content TOP

Yoshinobu Murasato, Nicolas Foin
AsiaIntervention 2017;3:158-159, DOI: 10.4244/AIJ-D-16-00020

A 64-year-old male underwent percutaneous coronary intervention (PCI) for a 1,1,1 lesion in the left anterior descending artery (LAD)-diagonal (Dx) bifurcation (Panel Aa). A biolimus-eluting 3.5/24 mm stent (Nobori®; Terumo Corp., Tokyo, Japan) was implanted in the middle LAD (Panel Ab) followed by respective sequential dilations of Dx and LAD with 2.0 mm (Panel Ac) and 3.5 mm balloons (Maverick²™; Boston Scientific Corp., Marlborough, MA, USA, and Raiden 3; Kaneka Medix, Osaka, Japan, respectively) (Panel Ad) after guidewire (GW) recrossing (Panel Ae).

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Unsuccessful confirmation of rewiring position with three-dimensional optical coherence tomography caused by thrombus formation on jailed struts

23 November inCoronary Interventions, Issue

Fumiaki Nakao
AsiaIntervention 2017;3:160-161, DOI: 10.4244/AIJ-D-16-00028

An 80-year-old man had culotte stenting performed for a left main (LM) true bifurcation lesion (Panel A). He underwent implantation of a first stent on the LM-left circumflex artery (LCx) with an Ultimaster® 2.5×18 mm (Terumo, Tokyo, Japan). After opening the jailed struts, he underwent a second stent implantation on the LM-left anterior descending artery (LAD) with an Ultimaster 3.0×24 mm. After rewiring to the LCx, using three-dimensional optical coherence tomography (3DOCT) with the OPTIS™ Metallic Stent Optimization Software™ (St. Jude Medical, St. Paul, MN, USA), no links connecting to a carina were confirmed, but the guidewire recrossed to the LCx through some tissue on the LCx ostium, and the distal cell rewiring could not be confirmed (Panel B).

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Angiographic and optical coherence tomography features of positive arterial remodelling causing very late thrombosis in a first-generation sirolimus-eluting stent

23 November inCoronary Interventions, Issue, Table of content TOP

Chee Yang Chin, Swee Leng Kui, et al
AsiaIntervention 2017;3:162-163, DOI: 10.4244/AIJ-D-16-00029

A 45-year-old man presented with acute anterior ST-elevation myocardial infarction four years after the implantation of two 3.0 mm diameter first-generation sirolimus-eluting CYPHER® (Cordis, Johnson & Johnson, Warren, NJ, USA) stents in his left anterior descending coronary artery. Emergent angiography (Moving image 1) now revealed a thrombotic occlusion of the distal stented segment (Panel A, yellow arrow), with peri-stent contrast staining in the proximal stented segment (Panel A, red arrows). Following thrombus aspiration, optical coherence tomography (OCT) (Moving image 2) showed positive arterial remodelling throughout the previously stented segments causing vessel evaginations (Panel B [blue arrows], Panel C) and malapposed stent struts (Panel B, Panel C [white arrows]), with occasional uncovered stent struts (Panel C, green arrow) and residual thrombus (Panel B, *).

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Intraprocedural rupture of neoatherosclerosis causing extensive neointimal dissection: use of optical frequency domain imaging to evaluate the mechanism and guide intervention

23 November inCoronary Interventions, Issue

Umihiko Kaneko, Yoshifumi Kashima, et al
AsiaIntervention 2017;3:164-165, DOI: 10.4244/AIJ-D-16-00031

A 75-year-old woman who was implanted with a 3.0×28 mm biolimus-eluting stent in the proximal right coronary artery two years previously presented with unstable angina due to focal in-stent restenosis (Panel A). Optical frequency domain imaging (OFDI) (Terumo Corp., Tokyo, Japan) revealed a normal pattern of homogeneous neointimal hyperplasia (Panel B, Panel C) and neoatherosclerosis with a lipid-laden neointima and large lipid pool at the most stenotic lesion (Panel D, Moving image 1). After excimer laser coronary angioplasty (1.4 mm concentric) with concomitant saline flushing, angiography revealed sudden extended multilayered haziness (Panel E, Moving image 2). OFDI clearly demonstrated extensive neointimal dissection (Panel F-Panel H, yellow asterisks, Moving image 3), some mural thrombus (Panel G, plus signs), disruption of the neointima (Panel H, arrowhead), and a mobile flap at the lasing site (Panel H, arrow), confirming neoatherosclerosis rupture complicated by extensive neointimal dissection. After angioplasty with a 3.5×13 mm scoring balloon at 20 atm and a 3.5×30 mm paclitaxel-coated balloon at 12 atm, reentry between the true lumen and dissected lumen was successfully obtained (Panel I, Moving image 4). OFDI revealed remarkable decompression of the dissected lumen (Panel J-Panel L, asterisks, Moving image 5) and several incisions (Panel L, arrowheads) created by scoring balloon angioplasty.

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Interventions for vascular disease and heart failure

Wire pull-through technique using a double lumen sheath during transapical transcatheter aortic valve implantation

23 November inInterventions for vascular disease and heart failure, Issue

Takashi Muramatsu, Masato Tochii, et al
AsiaIntervention 2017;3:166-170, DOI: 10.4244/AIJ-D-17-00002

Abstract
Transapical transcatheter aortic valve implantation (TA-TAVI) with the wire pull-through technique using a double lumen sheath via the brachial or radial artery is a new therapeutic approach to aortic stenosis patients having shaggy aortic arch. The risk of systemic embolisation of atherothrombotic material can theoretically be reduced by avoiding any manipulations of stiff guidewires or catheters across the diseased segments based on the “non-touch” method. We report a case series of three patients undergoing the wire pull-through technique during TA-TAVI using the SAPIEN XT transcatheter heart valve. The rationale, technical considerations and clinical implications of this technique are described.

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Balloon post-dilation of the mechanically expanded LOTUS transcatheter aortic valve

23 November inInterventions for vascular disease and heart failure, Issue

Sarah Zaman, Robert Gooley, et al
AsiaIntervention 2017;3:171-176, DOI: 10.4244/AIJ-D-16-00024

Abstract
Aims: The aim of this study was to describe the technique and assess the feasibility of balloon post-dilation (BPD) within the mechanically expanded LOTUS transcatheter aortic valve.

Methods and results: Consecutive patients with severe aortic stenosis who underwent LOTUS valve implantation at a single centre were prospectively followed with pre-discharge and 30-day echocardiography. BPD was performed in limited cases of significant procedural paravalvular aortic regurgitation (AR) where mitigation by initial device repositioning had been unsuccessful. BPD success was defined as a reduction of paravalvular AR to a severity of mild or less. Safety was determined by 30-day occurrence of major adverse events defined according to VARC-2 criteria. BPD was performed in four patients for significant post-implant paravalvular AR (n=4) and/or prosthesis frame deformation (n=2). BPD was successful in achieving a reduction of procedural paravalvular AR in three out of four patients and in pre-discharge AR in all patients. There were no 30-day deaths, cerebrovascular events or new pacemaker requirement in patients who received BPD.

Conclusions: This is the first study to describe the technique of BPD within the mechanically expanded LOTUS transcatheter aortic valve. An acceptable success rate with no complications was observed with the use of BPD in a small number of LOTUS valve recipients.

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First-in-man study of transcatheter aortic valve implantations in aortic stenosis using the Hydra self-expanding bioprosthesis

23 November inInterventions for vascular disease and heart failure, Issue, Table of content BOTTOM

Suphot Srimahachota, Wacin Buddhari, et al
AsiaIntervention 2017;3:177-182, DOI: 10.4244/AIJ-D-17-00007

Abstract
Aims: The aim of this study was to document the initial experience with transcatheter aortic valve implantations with the Hydra self-expanding aortic bioprosthetic valve.

Methods and results: Implantation of the Hydra aortic valve was performed in patients with symptomatic, severe aortic stenosis at the King Chulalongkorn Memorial Hospital, Thailand. Surgical treatment was deferred based on Heart Team assessment of an estimated high surgical risk. The Hydra valve was implanted in 15 patients with mean STS score 6.2%, mean age 82 years, mean aortic valve area 0.68 cm2, mean aortic pressure gradient 49 mmHg. All procedures were performed under general anaesthesia. Percutaneous transfemoral access was used in 13 patients, whereas the remainder had a transaxillary approach. There was one procedural death due to a major vascular complication. At 30-day follow-up, the median aortic valve area and pressure gradient were 1.53 cm2 and 9 mmHg, respectively. The prevalence of more than mild paravalvular leakage and new permanent pacemaker implantation was 7.7% and 14.3%, respectively. No patient suffered from stroke or TIA.

Conclusions: The Hydra aortic bioprosthetic valve is useful for transcatheter treatment of severe aortic stenosis. Initial results indicate a high haemodynamic performance and complication rates similar to those reported for second-generation transcatheter aortic bioprostheses.

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