Face to Face: on ACS, aortic valve, bifurcations

Unless a patient is brought to the cathlab directly from admission, we advocate upfront use of GPIIb/IIIa in high risk ACS patients.

Upfront, because the results of several trials with these drugs show a trend for best results when GPIIB/IIIa antagonists are started earlier. According to these results, GPIIB/IIIa should be started before the patient reaches the cathlab. The results are not the same with different drugs, so the choice of the drug is also important.

One option. The data are very strong but of course we do not know how Bivalirudin would compare to heparin only, or against a reduced dose of a low molecular weight heparin

Horizons-AMI showed very favourable results to the Bivalirudin arm in almost all the endpoints and these results were sustained during the follow-up. So I think this is a favourable approach regarding the patient population evaluated in this trial and should bring up changes in clinical practice.

No dogmas! And good judgement and patient selection is essential for our practice. However, in the majority of cases I would follow the "keep it simple" principle and try to avoid a two stent strategy.

I think that is best to keep it as simple as possible but also not to use this rule as a dogma. There is also a place for good selection and planning before intervention in some patients or anatomic subsets. There are situations that compel us to use different devices and more than one stent and thus, good judgement is essential.

Very difficult problem indeed. We put a lot of effort into trying to identify patients with low gradients that will benefit from AVR or TAVI. Often the crucial investigation is a dobutamine stress echo that documents contractile reserve and a low aortic valve area with stress.

There are several ways to assess “low flow” aortic stenosis (AS). This evaluation should rely on complementary techniques to assess valve area and transvalvular gradients and left ventricular function. Probably one way is to use stress- Echo with Dobutamine or exercise. It is also possible to use different evaluations in the cathlab including aortic valve resistance that can be useful to distinguish moderate or severe AS with low flow.

Patient selection is of the utmost importance. If the patient is expected to live with a good quality of life following successful TAVI, then we would offer this treatment also in this patient group.

Yes. Transcatheter valve replacement is the alternative for high risk, “end stage” patients considered not acceptable for surgical valve replacement. This technique has already proved to be effective and successful in these patients. We know that the surgical mortality is higher in patients with poor left ventricular function or co morbidities. In these patients,