Left atrial function index (LAFI) and outcome in patients undergoing transcatheter aortic valve replacement

Background

Clinical data regarding the association between the left atrial function index (LAFI) and outcome in patients undergoing transcatheter aortic valve replacement (TAVR) are limited.

Objectives

We aimed to investigate the association between the left atrial function index (LAFI) and outcome in patients undergoing TAVR.

Methods

In this retrospective multicenter study, we assessed baseline LAFI in 733 patients undergoing TAVR for severe aortic stenosis in two German high-volume centers between 2008 and 2019. Based on receiver operating characteristic curves, patients were stratified according to their baseline LAFI into two groups (LAFI ≤ 13.5 vs. LAFI > 13.5) and assessed for post-procedural outcome. The primary endpoint of our study was the 1-year all-cause mortality.

Results

Patients with a LAFI ≤ 13.5 had significantly more often atrial fibrillation (p < 0.001), lower LVEF (p < 0.001) and higher levels of NT-proBNP (p < 0.001). After TAVR, a significant improvement in the LAFI as compared to baseline was observed at 12 months after the procedure (28.4 vs. 32.9; p = 0.001). Compared to patients with a LAFI > 13.5, those with a LAFI ≤ 13.5 showed significantly higher rate of 1-year mortality (7.9% vs. 4.0%; p = 0.03). A lower LAFI has been identified as independent predictor of mortality in multivariate analysis (HR (95% CI) 2.0 (1.1–3.9); p = 0.03).

Conclusion

A reduced LAFI is associated with adverse outcome and an independent predictor of mortality in TAVR patients. TAVR improves LAFI within 12 months after the procedure.

Graphical abstract

Left Atrial Function Index (LAFI) in Patients undergoing Transcatheter Aortic Valve Implantation. A Kaplan–Meier survival analysis of 1-year all-cause mortality in patients with LAFI ≤ 13.5 compared with patients with LAFI > 13.5. Comparing rates of 1-year all-cause mortality between the different LAFI groups, we found a significant association between left atrial function and mortality. LAFI Left atrial function index. B Comparison of the mean LAFI before and after TAVR. After long-term follow-up the LAFI improved significantly. LAFI Left atrial function index; FU follow-up. C Assessment of the left atrial function index using the pre-procedural transthoracic echocardiography. A Measurement of the minimal left atrial volume (LAEDV). B Assessment of the maximal left atrial volume (LAESV).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-022-02010-5.

Assessment of LAA strain and thrombus mobility and its impact on thrombus resolution - value of a novel echocardiographic thrombus tracking method

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): FCT – Fundação para a Ciência e Tecnologia Portugal 2020 Partnership Agreement, through the European Regional Development Fund (FEDER)

Background

The left atrial appendage (LAA) is the major nidus for thrombus in patients with non-valvular atrial fibrillation. LAA thrombus mobility and changes hereof under anticoagulation may serve as a marker of both risk of embolism and efficacy of treatment. In this study, we hypothesized that LAA dynamics and thrombus mobility could serve as a baseline marker of thrombus dissolvability.

Methods

Transesophageal echocardiographic (TEE) images of in whom LAA thrombi were previously diagnosed were evaluated. Each image was tracked using a state-of-the-art tracking toolbox and functional information from the LAA and thrombi extracted. Global LAA motion was quantified through the longitudinal strain, while thrombus mobility was measured through a novel tracking scheme by directly capturing and measuring the thrombus motion isolated from the global cardiac motion. Baseline characteristics and echocardiographic parameters were compared between responders (thrombus resolution, i.e. no thrombus found at follow-up TEE) and non-responders (thrombus persistence or growth, i.e. thrombus found at follow up TEE) groups.

Results

35 patients (54.3% male and 45.7% female) with a mean age of 72.9 ± 14.1 years were included. Atrial fibrillation was present in all patients, showing a high risk for thromboembolism (CHA2DS2-VASc-Score 4.1 ± 1.5). Moderately reduced LVEF (41.7 ± 14.4%) and signs of diastolic dysfunction (E/E’ = 19.7 ± 8.5) was found in the cohort. While anticoagulation was initiated in all patients, resolution was achieved in 51.4% of patients. Significantly higher thrombus mobility (0.33 ± 0.13mm vs. 0.18 ± 0.08mm, p &lt; 0.01 – Figure 1A) and LAA peak strain (-3.0 ± 1.3 vs -1.6 ± 1.5%, p &lt; 0.01 – Figure 1B) were observed in responders against the non-responders group.

Conclusions

The quantification of the thrombus mobility through a tracking scheme is feasible. In our study population, higher thrombus mobility appeared to be associated with thrombus resolution. Further studies are required to evaluate the additional prognostic of the proposed technique.

Figure 1 – Quantification of the thrombus mobility (A) and peak LAA longitudinal strain (B) in both responder (blue) and non-responder group (green). *p &lt; 0.05, unpaired t-test between non-responder and responder groups. Abstract Figure 1

Haemodynamic differences between two generations of a balloon-expandable transcatheter heart valve

OBJECTIVES

This study aimed to investigate early haemodynamic and clinical performance of the SAPIEN 3 Ultra (S3 Ultra) transcatheter heart valve (THV) system in comparison to its precursor, the SAPIEN 3 (S3). Previous studies have indicated potential haemodynamic differences between the S3 Ultra and S3. Such differences may impact clinical outcome after transcatheter aortic valve implantation (TAVI).

METHODS

Postprocedural haemodynamic performance and 30-day clinical outcome were compared in patients who underwent TAVI receiving either the S3 or the new S3 Ultra prostheses. Multivariable analysis and propensity score matching (PSM) were used to identify factors associated with higher mean transvalvular gradients.

RESULTS

We included 697 patients (S3 Ultra: n=314, S3: n=383) from the multicentre RhineHeart TAVI Registry. Patients receiving the S3 Ultra prosthesis showed significantly higher postprocedural mean transvalvular gradients (14.2±4.8 vs 10.2±4.4 mm Hg; p<0.01). Multivariable logistic regression analyses and additional PSM revealed the use of the S3 Ultra to be associated with higher postprocedural mean transvalvular gradients (p<0.01). 30-day clinical outcomes, such as mortality, myocardial infarction, permanent pacemaker implantation and vascular complications were comparable between the groups.

CONCLUSIONS

The new S3 Ultra THV was associated with a higher postprocedural mean transvalvular gradient compared with the S3 system, while there was no difference in mortality or adverse clinical outcomes at 30 days. These echocardiographic differences will require long-term studies to assess the clinical relevance of this finding.

MicroRNA-mediated vascular intercellular communication is altered in chronic kidney disease

AIMS

Chronic kidney disease (CKD) is an independent risk factor for the development of coronary artery disease (CAD). For both, CKD and CAD, the intercellular transfer of microRNAs (miRs) through extracellular vesicles (EVs) is an important factor of disease development. Whether the combination of CAD and CKD affects endothelial function through cellular crosstalk of EV-incorporated miRs is still unknown.

METHODS AND RESULTS

Out of 172 screened CAD patients, 31 patients with CAD + CKD were identified and matched with 31 CAD patients without CKD. Additionally, 13 controls without CAD and CKD were included. Large EVs from CAD + CKD patients contained significantly lower levels of the vasculo-protective miR-130a-3p and miR-126-3p compared to CAD patients and controls. Flow cytometric analysis of plasma-derived EVs revealed significantly higher numbers of endothelial cell-derived EVs in CAD and CAD + CKD patients compared to controls. EVs from CAD + CKD patients impaired target human coronary artery endothelial cell (HCAEC) proliferation upon incubation in vitro. Consistent with the clinical data, treatment with the uraemia toxin indoxyl sulfate (IS)-reduced miR-130a-3p levels in HCAEC-derived EVs. EVs from IS-treated donor HCAECs-reduced proliferation and re-endothelialization in EV-recipient cells and induced an anti-angiogenic gene expression profile. In a mouse-experiment, intravenous treatment with EVs from IS-treated endothelial cells significantly impaired endothelial regeneration. On the molecular level, we found that IS leads to an up-regulation of the heterogenous nuclear ribonucleoprotein U (hnRNPU), which retains miR-130a-3p in the cell leading to reduced vesicular miR-130a-3p export and impaired EV-recipient cell proliferation.

CONCLUSION

Our findings suggest that EV-miR-mediated vascular intercellular communication is altered in patients with CAD and CKD, promoting CKD-induced endothelial dysfunction.

Assessment of LAA Strain and Thrombus Mobility and Its Impact on Thrombus Resolution-Added-Value of a Novel Echocardiographic Thrombus Tracking Method

PURPOSE

The mobility of left atrial appendage (LAA) thrombi and changes hereof under anticoagulation may serve as a marker of both risk of embolism and efficacy of treatment. In this study, we sought to evaluate thrombus mobility and hypothesized that LAA dynamics and thrombus mobility could serve as a baseline marker of thrombus dissolvability.

METHODS

Patients with two-dimensional transesophageal echocardiographic images of the LAA, and with evidence of LAA thrombus were included in this study. Using a speckle tracking algorithm, functional information from the LAA and thrombi of different patients was computed. While the LAA motion was quantified through the longitudinal strain, thrombus mobility was evaluated using a novel method by directly tracking the thrombus, isolated from the global cardiac motion. Baseline characteristics and echocardiographic parameters were compared between responders (thrombus resolution) and non-responders (thrombus persistence) to anticoagulation.

RESULTS

We included 35 patients with atrial fibrillation with evidence of LAA thrombi. Patients had a mean age of 72.9 ± 14.1 years, exhibited a high risk for thromboembolism (CHA2DS2-VASc-Score 4.1 ± 1.5) and had moderately reduced LVEF (41.7 ± 14.4%) and signs of diastolic dysfunction (E/E' = 19.7 ± 8.5). While anticoagulation was initiated in all patients, resolution was achieved in 51.4% of patients. Significantly higher LAA peak strain (- 3.0 ± 1.3 vs. - 1.6 ± 1.5%, p < 0.01) and thrombus mobility (0.33 ± 0.13 mm vs. 0.18 ± 0.08 mm, p < 0.01) were observed in patients in whom thrombi resolved (i.e. responders against non-responders). Receiver operating characteristic (ROC) analysis revealed a high discriminatory ability for thrombus mobility with regards to thrombus resolution (AUC 0.89).

CONCLUSION

Isolated tracking of thrombus mobility from echocardiographic images is feasible. In patients with LAA thrombus, higher thrombus mobility appeared to be associated with thrombus resolution. Future studies should be conducted to evaluate the role of the described technique to predict LAA thrombus resolution or persistence.

Incidence, persistence, and clinical relevance of iatrogenic atrial septal defects after percutaneous left atrial appendage occlusion

OBJECTIVE

To investigate the rate and clinical impact of a persisting iatrogenic atrial septal defect (iASD) after percutaneous left atrial appendage occlusion (LAAO).

BACKGROUND

Percutaneous LAAO is an alternative to oral anticoagulation (OAC) for the prevention of ischemic stroke and systemic embolism in patients with atrial fibrillation (AF). Data regarding incidence and persistence of iASD after LAAO procedures and its clinical relevance is scarce.

METHODS

We retrospectively analyzed 144 patients that underwent LAAO at our center between 2009 and 2020 who had at least one follow-up including transesophageal echocardiography (TEE). Baseline clinical, procedural data and echocardiographic characteristics in patients with and without evidence of an iASD were compared. We furthermore determined the rate of iASD persistence over time and evaluated outcomes of patients with and without spontaneous iASD closure.

RESULTS

After a median of 92 days (IQR 75-108 days) after LAAO, 50 patients (50/144, 34.7%) showed evidence of an iASD. Patients with iASD had higher CHADS-VASc-scores (4.9±1.5 vs 4.2±1.2, p = 0.03), larger left atrial volumes (80.5±30.5 ml vs 67.1±19.7 ml, p = 0.01) and were more likely to have relevant mitral regurgitation (≥° II) (46.0% vs 12.3%, p = 0.001). LAAO procedures took longer (50.1±24.3 vs 41.1±17.8 min, p = 0.06) in patients with a persisting iASD. Furthermore, larger device sizes were implanted (24.3±3.4 mm vs 22.1±2.8 mm, p = 0.03). The presence of an iASD had no impact on RV dysfunction, thromboembolism or mortality. Spontaneous closure of an iASD was documented in 52.0% (26/50). Hereby, similar risk factors were identified for the persistence of an iASD in follow-up.

Baseline PA/BSA ratio in patients undergoing transcatheter aortic valve replacement - A novel CT-based marker for the prediction of pulmonary hypertension and outcome

BACKGROUND

Pulmonary hypertension (pH) has a prognostic impact on patients undergoing transcatheter aortic valve replacement (TAVR). Pulmonary artery (PA) dilatation assessed by multidetector computed tomography (MDCT) has the potential to predict PH. The aim of the study was to evaluate the clinical parameters associated with PA dilatation and to investigate its prognostic relevance in patients undergoing TAVR.

METHODS

In 770 patients undergoing TAVR between February 2016 and July 2019, PA diameter was measured by MDCT before TAVR. Additionally, PA diameter divided by ascending aorta diameter or body surface area (BSA) was calculated.

RESULTS

Of all the CT-derived parameters compared with a receiver operating characteristic curve, the value for PA/BSA with a median of 1.68 (IQR 1.47, 1.91) cm/m2 showed the greatest area-under-the-curve (0.75) for predicting PH at baseline. Based on this median, patients were assigned to a small PA/BSA (n = 386) or a large PA/BSA (n = 384) group. Hereby, a large PA/BSA was independently associated with PH at baseline (OR:8.39 [5.36-13.14], p < 0.001) and after TAVR (OR:1.73 [1.18-2.53], p = 0.005). A large PA/BSA was associated with a significantly higher cumulative two-year all-cause mortality compared to small PA/BSA (30.0% vs. 13.7%, p < 0.001), which was supported in the multivariable model (HR:1.87; 95%CI, 1.12-3.04; p = 0.017).

CONCLUSION

Patients with a large PA/BSA on MDCT are more likely to have PH at baseline and after TAVR. Large PA/BSA is associated with an increased risk of mortality and could provide additional information for risk stratification in patients undergoing TAVR.

Spleen Size and Thrombocytopenia After Transcatheter Aortic Valve Implantation

The pathophysiology of thrombocytopenia after transcatheter aortic valve implantation (TAVI) thrombocytopenia is still poorly understood. We assessed the association of spleen size with acquired thrombocytopenia in patients undergoing TAVI. We included 732 patients who underwent TAVI with new generation transcatheter heart valves (THVs) at our center from February 2016 to July 2019. We measured splenic volume index in consecutive patients derived from multidetector row computed tomographic datasets. Patients were stratified according to post-TAVI thrombocytopenia, which was defined as a decline in platelet count (DPC) ≥50% at nadir, and evaluated regarding baseline characteristics and outcome parameters. After the procedure, platelet counts declined from 212.9 ± 67.4 × 10⁹/L at baseline to 138.8 ± 49.8 × 10⁹/L at nadir after a median of 2 days (interquartile range [IQR] 2 to 3). Of all patients, 10.1% showed a DPC ≥50%. Compared with patients with DPC <50%, patients with DPC ≥50% had significantly lower splenic volume index (95.5 ml/m² [IQR 78.0 to 123.7] vs 85.8 ml/m² [IQR 71.4 to 102.6], p = 0.008). A multivariable analysis revealed that the splenic volume index was negatively associated with a DPC ≥50% (OR 0.89, 95% CI 0.82 to 0.97, p = 0.005), independent of the type of THV (balloon-expandable THV: OR 2.06, 95% CI 1.13 to 3.76, p = 0.02), major bleeding (OR 13.40, 95% CI 3.58 to 50.40, p <0.001), blood transfusion (OR 3.63, 95% CI 1.54 to 8.56, p = 0.003), or postprocedural paravalvular leakage ≥moderate (OR 5.48, 95% CI 1.23 to 24.40, p = 0.03). Furthermore, DPC ≥50% was independently associated with 1-year mortality (HR 3.36, 95% CI 1.66 to 6.81, p <0.001). In conclusion, acquired thrombocytopenia remains prevalent in modern TAVI patients. Spleen size appears to be associated with the occurrence of thrombocytopenia after TAVI, which is independently correlated with 1-year mortality.

Frailty, malnutrition, and the endocrine system impact outcome in patients undergoing aortic valve replacement

BACKGROUND

Frailty is a multidimensional syndrome that affects mortality after aortic valve replacement (AVR). Malnutrition is often associated with the development of frailty. However, data regarding the association of frailty with nutritional status and underlying endocrinological dysregulation in patients with severe aortic valve stenosis are limited.

OBJECTIVES

We aimed to systematically screen for frailty and malnutrition, to evaluate for underlying endocrinological disorders and inflammation, and to assess the ability of these parameters to predict outcomes after AVR.

METHODS

Our study included 373 patients undergoing transcatheter and surgical AVR. Frailty was assessed using the Fried Frailty Phenotype (FFP), Essential Frailty Toolset, Lawton-Brody, and Katz Index. Malnutrition was measured using the Mini Nutritional Assessment (MNA-LF) and Controlling Nutritional Status. Outcomes of interest were 30-day and one-year mortality.

RESULTS

The prevalence of frailty ranged from 6.4% to 65.7% and malnutrition from 5.9% to 10.5%, depending on the evaluation tool. Both parameters were associated with higher levels of cortisol and parathormone as well as lower levels of IGF-1, testosterone, DHEAS, and c-reactive protein. Malnutrition was associated with increased 30-day mortality, and both frailty and malnutrition with increased one-year mortality. In a multivariate analysis, malnutrition measured by the MNA-LF (OR: 2.32 [95%CI: 1.19-4.53], p = 0.01) and frailty as assessed by the FFP (OR: 1.42 [95%CI: 1.02-1.96], p = 0.03) were independent predictors of one-year mortality.

CONCLUSION

The prevalence of frailty and malnutrition varies significantly depending on the assessment tool. Both syndromes share common endocrinological alterations. Frailty and malnutrition are independent risk factors for mortality after AVR.

Frailty in patients undergoing transcatheter aortic valve replacement: prognostic value of the Geriatric Nutritional Risk Index

BACKGROUND

Malnutrition is a hallmark of frailty, is common among elderly patients, and is a predictor of poor outcomes in patients with severe symptomatic aortic stenosis (AS). The Geriatric Nutritional Risk Index (GNRI) is a simple and well-established screening tool to predict the risk of morbidity and mortality in elderly patients. In this study, we evaluated whether GNRI may be used in the risk stratification and management of patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Patients with symptomatic severe AS (n = 953) who underwent transfemoral TAVR at the University Hospital Schleswig-Holstein Kiel, Germany, between 2010 and 2019 (development cohort) were divided into two groups: normal GNRI ≥ 98 (no nutrition-related risk; n = 618) versus low GNRI < 98 (at nutrition-related risk; n = 335). The results were validated in an independent (validation) cohort from another high-volume TAVR centre (n = 977).

RESULTS

The low-GNRI group had a higher proportion of female patients (59.1% vs. 52.1%), higher median age (82.9 vs. 81.8 years), prevalence of atrial fibrillation (50.4% vs. 40.0%), median logistic EuroSCORE (17.5% vs. 15.0%) and impaired left ventricular function (<35%: 10.7% vs. 6.8%), lower median estimated glomerular filtration rate (50 vs. 57 mL/min/1.73 m² ) and median albumin level (3.5 vs. 4.0 g/dL) compared with the normal-GNRI group. Among peri-procedural complications, Acute Kidney Injury Network (AKIN) Stage 3 was more common in the low-GNRI group (3.6% vs. 0.6%, p = 0.002). After a mean follow-up of 21.1 months, all-cause mortality was significantly increased in the low-GNRI group compared with the normal-GNRI group (p < 0.001). This was confirmed in the validation cohort (p < 0.001). Low GNRI < 98 was identified as an independent risk factor for all-cause mortality (hazard ratio 1.44, 95% CI 1.01-2.04, p = 0.043). Other independent risk factors included albumin level < median of 4.0 g/dL, high-sensitive troponin T in the highest quartile (> 45.0 pg/mL), N-terminal pro-B-type natriuretic peptide in the highest quartile (> 3595 pg/mL), grade III-IV tricuspid regurgitation, pulmonary arterial hypertension, life-threatening bleeding, AKIN Stage 3 and disabling stroke.

CONCLUSIONS

Low GNRI score was associated with an increased risk of all-cause mortality in patients undergoing TAVR, implying that this vulnerable group may benefit from improved preventive measures.

Device-Related Thrombus After Left Atrial Appendage Closure: Data on Thrombus Characteristics, Treatment Strategies, and Clinical Outcomes From the EUROC-DRT-Registry

[Figure: see text].

Levels of platelet derived extracellular vesicles in the left atrial appendage are higher in patients with permanent atrial fibrillation

Introduction

Atrial fibrillation (AF) is a frequent arrhythmic disease and one of the most important causes of thrombembolic disease due to intracardiac thrombus formation. The left atrial appendage has been identified as the structure, where thrombus formation typically takes place in AF patients. Previous studies have shown thrombus formation is more frequent in permanent, than in paroxysmal or persistent AF. Underlying causes for this finding, however, remain unclear. Recently, it has been shown, that large extracellular vesicles (Microvesicles, MVs) are mediators of platelet activation. The aim of this study is therefore to investigate if the AF subtype correlates with the regional abundance of platelet derived MVs in the left atrial appendage.

Methods and results

In order to address this question blood samples from 59 consecutive patients undergoing left and right atrial catheterization were collected from the right atrium (RA), the left atrium (LA) and the left atrial appendage (LAA). 49% of the patients had permanent AF, 34% had non-permanent AF and 17% had no history of AF. MVs were isolated from 150 μL citrate plasma by a four-step differential centrifugation protocol (20000g x 40 min as main pelleting step). The MVs were characterized by immunoblotting and nanoparticle tracking analysis. The size of the MVs ranged between 50 and 600 nm and the MVs were shown to carry typical markers such as Annexin V. For flowcytometric analysis and quantification, Calcein AM was used to identify vesicles and CD31-PE, CD41-APC, CD235a-PE-Cy7 were applied to differentiate between platelet-derived MVs (PMVs, CD41+ CD31+), endothelial cell-derived MVs (EMVs, CD41- CD31+) and Red blood cell-derived MVs (RMVs, CD235a+). Fluorescence minus one controls, a concentration row and detergent mediated degradation were used to confirm specific staining of MVs. Total MV numbers (Calcein + events) did not differ significantly between the three cardiac localizations. In the left atrial appendage, the proportion of PMV was significantly higher in permanent AF patients compared to non-permanent AF. EMV numbers only differed in the right atrium, where permanent AF patients exhibited significantly lower numbers of EMVs compared to no AF controls. No differences between the groups were detected for RMV.

Conclusion

In the present study, we found that PMV levels in the left atrial appendage correlate with the type of atrial fibrillation (permanent vs non-permanent). PMVs have been connected to platelet activation and thrombus formation. These results may help to better understand how different types of atrial fibrillation cause different rates of thrombus formation in the LAA.

PMV and EMV numbers by AF subtype

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical Faculty University Bonn

Risk modeling in transcatheter aortic valve replacement remains unsolved: an external validation study in 2946 German patients

Background

Surgical risk prediction models are routinely used to guide decision-making for transcatheter aortic valve replacement (TAVR). New and updated TAVR-specific models have been developed to improve risk stratification; however, the best option remains unknown.

Objective

To perform a comparative validation study of six risk models for the prediction of 30-day mortality in TAVR

Methods and results

A total of 2946 patients undergoing transfemoral (TF, n = 2625) or transapical (TA, n = 321) TAVR from 2008 to 2018 from the German Rhine Transregio Aortic Diseases cohort were included. Six surgical and TAVR-specific risk scoring models (LogES I, ES II, STS PROM, FRANCE-2, OBSERVANT, GAVS-II) were evaluated for the prediction of 30-day mortality. Observed 30-day mortality was 3.7% (TF 3.2%; TA 7.5%), mean 30-day mortality risk prediction varied from 5.8 ± 5.0% (OBSERVANT) to 23.4 ± 15.9% (LogES I). Discrimination performance (ROC analysis, c-indices) ranged from 0.60 (OBSERVANT) to 0.67 (STS PROM), without significant differences between models, between TF or TA approach or over time. STS PROM discriminated numerically best in TF TAVR (c-index 0.66; range of c-indices 0.60 to 0.66); performance was very similar in TA TAVR (LogES I, ES II, FRANCE-2 and GAVS-II all with c-index 0.67). Regarding calibration, all risk scoring models—especially LogES I—overestimated mortality risk, especially in high-risk patients.

Conclusions

Surgical as well as TAVR-specific risk scoring models showed mediocre performance in prediction of 30-day mortality risk for TAVR in the German Rhine Transregio Aortic Diseases cohort. Development of new or updated risk models is necessary to improve risk stratification.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s00392-020-01731-9) contains supplementary material, which is available to authorized users.

Prognostic impact of cancer history in patients undergoing transcatheter aortic valve implantation

BACKGROUND

The benefit of TAVI in cancer patients is currently unclear.

OBJECTIVES

The purpose of this study is to investigate prognostic impact of cancer status (active cancer or previous cancer) in severe aortic stenosis (AS) patients undergoing transcatheter aortic valve implantation (TAVI).

METHODS

Consecutive TAVI patients in the Heart Center Bonn were enrolled and we stratified the patients into three groups: current cancer (active cancer), non-current cancer (previous cancer), or no cancer. The primary outcome was all-cause death within a 5-year follow-up. We evaluated mean aortic pressure gradient (mPG) values following TAVI (baseline mPG) and at the final follow-up (follow-up mPG).

RESULTS

In total, 1568 TAVI patients were eligible and 298 patients (19.0%) had active or previous cancer. At the 5-year follow-up, cancer patients had a significantly worse prognosis than non-cancer patients (log rank, P < 0.001). In a multivariable analysis, previous cancer was a significant predictor for 5-year mortality (hazard ratio [HR], 1.56; P < 0.001). Estimated mortality rates at 5-year follow-up rates among active cancer, previous cancer, and non-cancer were 84.0%, 65.8%, and 50.2% (long-rank P < 0.001), respectively. The hazard ratios of active cancer and previous cancer for 5-year mortality were 2.79 (P < 0.001) and 1.38 (P = 0.019) compared to non-cancer patients. We found significantly higher mPG during follow-up than at baseline in cancer patients (follow-up 8.10 vs baseline 7.40 mmHg; Wilcoxon P = 0.012).

CONCLUSIONS

Active, and also previous, cancer status are associated with less beneficial long-term prognosis in TAVI patients.

P918Tricuspid regurgitation in patients undergoing transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) has become the treatment of choice in elderly patients with severe aortic stenosis and increased surgical risk. A significant number of these elderly patients have concomitant tricuspid valve regurgitation. The impact on outcome, however, is still matter of debate.

Objectives

In this prospective observational study, we investigated the impact of concomitant tricuspid regurgitation (TR) on outcome in patients undergoing transcatheter aortic valve implantation.

Methods

Between February 2008 and May 2018, 1411 patients with severe symptomatic aortic stenosis and increased operative risk underwent TAVI at the Heart Center Bonn and participated in this study, after written informed consent was obtained.

Before TAVI procedure, all patients underwent a careful cardiac evaluation and interdisciplinary discussion within the local, institutional Heart Team.

The pre-interventional 3D echocardiography was used to determine the degree of tricuspid valve regurgitation. According to the severity of TR, patients were divided into two groups; patients with TR < II and patients with moderate to severe TR ≥ II andcompared regarding rates of mortality after 1 year of follow-up between the two groups.

Results

Out of 1411 TAVI patients, 802 (56.8%) had tricuspid regurgitation < II, 610 (43.2%) patients suffered from tricuspid regurgitation ≥ II.

The mean age of our study population was 81.1 (±6.5). The baseline characteristics did not differ significantly between the two groups, such as extracardiac arteriopathy (TR < II: 44% vs TR ≥ II: 41.6%; p=0.37), diabetes (TR < II: 27.5% vs TR ≥ II: 27.7%; p=0.92) or arterial hypertension (TR < II: 91% vs TR ≥ II: 93.2%; p=0.64). However, patients with concomitant TR ≥ II had significantly more often NYHA class IV (TR < II: 5.0% vs TR ≥ II: 15.4%; p<0.001) and a higher logistic EuroSCORE (TR < II: 12.9 (8.8/21.2) vs TR ≥ II: 20.6 (13.1/33.4); p<0.001). Additionally, patients with a TR ≥ II had significantly more often a concomitant mitral regurgitation ≥ II (TR < II: 43.3% vs TR ≥ II: 60.4%; p<0.001). Comparing rates of mortality, we found a significant association between the degree of tricuspid regurgitation and 1-year mortality in patients undergoing TAVI (TR < II: 85 (10.6%) vs. TR ≥ II: 136 (22.3%); p<0.001), as presented in Figure 1.

Figure 1

Conclusion

Moderate to severe tricuspid valve regurgitation is associated with higher rates of mortality in patients undergoing transcatheter aortic valve implantation. Our results are hypothesis-generating and it has to be elucidated whether the severity of TR is only a surrogate for more advanced stage of aortic stenosis or whether it is causative so that mortality could be reduced by its treatment.

Acknowledgement/Funding

None

P1002Echocardiographic assessment of optimal device position after percutaneous left atrial appendage occlusion - introduction of a novel classification and its impact on outcome

Background

Left atrial appendage occlusion (LAAo) is an established therapy in patients with atrial fibrillation. However, criteria regarding optimal device position are not well defined making comparability of procedural results virtually impossible. We therefore sought to a) introduce a classification describing optimal vs. suboptimal device-position by assessing predefined parameters in transoesophageal echocardiography (TEE) and to b) analyze the impact of device-position on outcome in patients treated with different LAAo devices.

Methods and results

We retrospectively analyzed 120 patients who were treated by LAAo and had undergone follow-up TEEs after 3 or 6 months. Patients were at mean age: 76±8 years; female 40% and presented an increased CHADS-VASC- (4.6±1.4) and HAS-BLED-score (3.7±1). TEE-guidance was performed in all cases.

In 62.5% (75/120) pacifier occluders (PO) (ACP/Amulet, Lambre, Ultraseal) were used, whereas 37.5% (45/120) were treated with non-pacifier occluders (NPO) (Watchman, Wavecrest, Occlutech). To assess device position, TEE images in a commissural view (60–90°) were analyzed and characterised by 1) implantation depth in the left atrial appendage, 2) peridevice flow (PF) and 3) the angle between occluder disc and pulmonal ridge (LUPV). For the purpose of this study, optimal device position was defined as a) ostial (LUPV length <10mm) or slightly subostial position (LUPV length ≤15mm, angle ≥100°) with b) the absence of major PF (>3mm).

Overall, occluders were implanted at a depth of 12±7.8 mm with ostial positioning being achieved in 47.5% (57/120). Major PF was seen in 7.5% (9/120). NPOs were implanted deeper than POs (depth: 15.6±7.1 vs. 9.8±7.4 mm, p<0.01; ostial position: 31.1% vs. 57.3%, p<0.01) and were associated with a higher incidence of major PF (15.6% vs. 2.7%, p=0.01). Also, the depth/angle ratio was higher (i.e. “worse”) in NPOs (18.3±9 vs. 14.6±8, p<0.04). As a result, optimal device position was achieved in 48.3% (58/120) of all patients, with lower rates in NPOs than in POs (26.7% vs. 61.3%, p<0.01). Procedural aspects revealed slight differences in occluder size (optimal: 23.7±3.2 vs. suboptimal: 24.5±3.7 mm, p=0.3), need for repositioning (10.3% vs. 17.7%, p=0.25) and procedural duration (48±36 vs. 52±34 min, p=0.3).

Of interest, device related thrombi (DRT) occurred less frequently in optimally implanted devices (3.4% vs. 12.9%, p=0.06). Hereby, implantation depth and depth/angle ratio were found to be predictors for DRT in ROC-analysis, respectively (AUC: 0.7, 95% Confidence interval [CI]: 0.56–0.84, p=0.05 and AUC: 0.72, 95% CI: 0.58–0.86, p=0.03).

Optimal vs. suboptimal position

Conclusion

Echocardiographic classification of device-position is warranted to provide comparability and appears to be feasible. Based on the novel classification provided, optimal device-position is achieved in 50% and is found more often with the use of POs. DRT appeared to occur more often in suboptimal device-position.

P3723Impact of frailty status on 30-day mortality in patients with valvular heart disease undergoing percutaneous transcatheter valve interventions

Background

Transcatheter strategies to treat valvular heart disease (VHD) are an established therapeutic option in elderly patients, not suitable for open heart surgery. The current ESC guidelines recommend the STS score and EuroSCORE II as tools for risk stratification. However, these surgical risk score do not consider important risk factors such as frailty, cognitive and nutritional status of the patients.

Aims

The aim of this study was to assess the frailty status in patients with severe VHD evaluated for transcatheter treatment strategies and to investigate the impact on mortality of these patients.

Methods and results

Our study cohort consisted of 456 consecutive patients (mean age 79±7.9 years, median STS-score 3.15 and EuroSCORE II 3.65) who were evaluated for percutaneous treatment of severe aortic valve stenosis (n=311), mitral valve regurgitation (n=100), and tricuspid valve regurgitation (n=45) in 2018. The frailty status in these patients was assessed using the Katz Index of Independence in Activities of Daily Living, the Lawton Instrumental Activities of Daily Living Scale, the five times chair rise, and the Score for assessment of frailty phenotype. The Mini Nutritional Assessment (MNA) and the Controlling Nutritional Status score were used for the assessment of the nutritional status of the cohort.

Assessment by the score for frailty phenotype showed that 220 (48.2%) cases were considered frail, 200 (37.3%) cases as prefrail, and only 36 (6.7%) patients considered robust. Regarding the MNA, 212 (46.5%) patients were at normal nutritional status, whereas 207 (45.4%) patients were at risk for malnutrition, and 37 (8.1%) patients were already malnourished.

The overall 30-day mortality rate was 3.1% (n=14). Multivariate analysis showed a significant association of 30-day mortality with baseline serum creatinine (1.2 mg/dl [IQR: 0.9–1.5 mg/dl] for survivors vs 1.6 mg/dl [IQR: 1.4–2.2 mg/dl] for non-survivors, p=0.14), high-sensitive cardiac troponin T (24.3 ng/l [IQR: 16.0–42.6 ng/l] for survivors vs 55.6 ng/l [IQR: 40.4–84.7 ng/l] for non-survivors, p=0.002), and the five chair rise test (p=0.005). Interestingly, there was no significant correlation of nutrition scores and frailty tests with 30-day mortality except for the five chair rise test. Linear regression analysis showed serum creatinine (p=0.04; OR: 1.4, CI: 1.0–1.8) and the five chair rise test (p=0.03; OR: 0.7, CI: 0.5–1) as independent predictors of the mortality.

Frailty Kaplan Meier Analysis

Conclusion

A comprehensive assessment of the clinical patient condition including frailty status is thought to be crucial for risk stratification and the decision-making process which treatment option a specific patient should undergo. However, in our study only the five chair rise test was found to be an independent predictor of 30-day mortality in patients with VHD undergoing percutaneous therapeutic options and seems to be an easy-to-assess test to assess the mortality risk of a specific patient.