Hemorrhages represent one of the most frequent complications during TAVI. Their rapid recognition and a prompt treatment are necessary to avoid hemorrhagic shock, which can lead the patient to death in a short time. We report the case of a 79-year-old woman affected by severe and symptomatic aortic stenosis, who underwent TAVI in our Cath-lab. Through a right femoral echo-guided arterial access, implantation of a 26 mm self-expandable aortic bio-prosthesis and hemostasis in the site of puncture with 18F Manta vascular closure device were performed. At the end of the procedure, through radial artery, a femoral angiography was performed, showing an important leak of contrast medium upper the site of puncture, without any change in arterial pressure or heart rate. After echo-guided cannulation of left femoral artery with 8F sheath, implantation of endoprosthesis in the site of hemorrhage and hemostasis of left femoral artery with 8F AngioSeal VIP vascular closure device were performed. In cardiac intensive care unit (CICU) low dosage of vasoactive agents and blood were administered, guaranteeing a good arterial pressure. Computed tomography (CT) was performed after two days and confirmed the presence of a retroperitoneal hematoma, without active bleeding. After six days, the patient left CICU and was admitted to the cardiological ward, starting a gradual mobilization. However, after 48 hours she reported abdominal pain and became rapidly hypotensive, tachycardic and asthenic, requiring readmission in CICU. Serum exams showed low hemoglobin concentration, an abdominal CT was perfomed, showing an active bleeding from left femoral artery and a homolateral retroperitoneal hematoma. The patient was rapidly lead in the cath lab. Angiography confirmed the hemorrage and an endoprosthesis was successfully implanted in the left femoral artery. Blood and vasoactive agents were administered with a progressive improvement in hemodynamic and clinical conditions of the patients. Post-operative course was complicated by fever and empiric antiobiotic therapy was administered until blood culture revealed no bacterial growth. A third CT showed the stability of the hematomas and the absence of active bleeding, allowing hospital discharge of the patient. Vascular complications are frequent and sneaky during TAVI procedures. A prompt treatment is of paramount importance to prevent hemorrhagic shock. TAVI operators should have experience in the field of peripheral intervention for the management of vascular complications.

Aims patients with severe aortic stenosis (AS) experience an increase in left ventricular filling pressure. This leads to changes in the structure and a deterioration in the function of the left (LA) and right (RA) atrium. Patients undergoing TAVI usually experience a reduction in the filling pressure of the left ventricle, thereby decreasing the wall tension of the atria in a retrograde way. The aim of this study was to demonstrate that patients with severe AS, undergoing TAVI, experience a positive remodeling of left and right atrium, with an improvement of their function. Methods and results we enrolled 38 symptomatic patients with severe AS (mean age 84,75 ± 12 years, 60% male, and pre-TAVI aortic valve area 0.75 ± 0.25 cm2 and mean gradient 47,96 ± 23 mmHg). 2D transthoracic echocardiography and 2D speckle tracking echocardiography at baseline and 12 months of follow up were performed. The variation of continuous variables was evaluated using a Student's T test for paired data. P values < 0.05 were considered significant. When compared to baseline, at 12 months a statistically significant improvement was observed for RA strain (p < 0.001) and LA (biplane) strain reservoir, conduction and contraction (p < 0.001, p < 0.012 and p < 0.001, respectively). The LA FE increased significantly (26.01 ± 9.16 vs 32.66 ± 10.95; p < 0.001). After TAVI, the LA (biplane) strain reservoir/end systolic volume ratio increased by 0.33 ± 0.18 to 0.49 ± 0.26 (p > 0.001). Left atrial end-systolic and end-diastolic volume decreased significantly (p > 0.001). Conclusion within 12 months after TAVI, there was a reverse LA and RA remodeling and an improvement in strain reservoir, condunction and contraction function. Also, there was a significant improvement of LA (biplane) strain reservoir/end systolic volume ratio.

An 87-year-old male patient with worsening dyspnea was admitted to our institution. The patient had a history of acute myocardial infarction treated with coronary stenting of the left descending artery (LAD), diagonal (Diag), right coronary artery (RCA), and chronic kidney disease. For acute pulmonary edema, the patient was admitted to our cardiac intensive care unit and rapidly treated with non-invasive positive-pressure ventilation with continuous positive airway pressure (C-PAP), IV high dosage diuretic therapy, inotropes, and vasoactive agents. Chest X-ray revealed cardiomegaly (cardiothoracic ratio, 56%) and pulmonary congestion. Electrocardiogram revealed sinus tachycardia and diffuse ST-segment abnormalities. An echocardiogram demonstrated left ventricular apical akinesia, with a left ventricular ejection fraction (LVEF) of 25% and severe mitral regurgitation. Blood tests revealed very high levels of NT-pro-brain natriuretic peptide (NT-proBNP) (>30000 pg/ml) and myocardial necrosis markers (hs-Trop 5055 ng/l; CK-MB 72 ng/ml). After 24 hours, the patient was placed on intra-aortic balloon pump (IABP) support to further hemodynamic support through the right femoral artery, nonetheless, he showed no improvement in symptoms or urine output. Because of a state of hypoxemic and hypercapnic respiratory failure, non-invasive ventilation (NIV) was given to the patient with a gradual improvement in blood gas analysis. The optimization of diuretic therapy allowed to treat the state of acute oliguric kidney disease, avoiding dialytic treatment. After 48 hours, because of a new worsening in hemodynamic state, we decided for a percutaneous left ventricular assist device (Impella CP, Denver, Massachusetts, USA). After placing the Impella device, coronary angiography was performed, showing critical stenosis of the left main (LM), involving the origin of the left anterior descending artery and a collateralized chronic occlusion of the circumflex artery and the LAD, after the origin of a large first diagonal branch. Because of the high procedural risk, we decided to perform only percutaneous coronary intervention and stent implantation of LM. After 3 days his symptoms improved, the required dose of inotropic agents and furosemide decreased and Impella was removed. After 12 days the patient was admitted to the cardiological ward and discharged after 21 days because of a urinary infection requiring antibiotic therapy. The management of acute heart failure in very old patients is challenging, limiting in many cases the use of invasive procedures such as coronary angiography or left ventricular assist devices. In this case, although the patient presented a very high-risk profile considering age and comorbidities, the use of Impella resulted to be safe and guaranteed hemodynamic support during the procedure of revascularization and in the immediate post-operative phase.