Utility of 30-Day Continuous Ambulatory Monitoring to Identify Patients With Delayed Occurrence of Atrioventricular Block After Transcatheter Aortic Valve Replacement

Background:

Mechanical injury in the conduction system requiring permanent pacemaker (PPM) associated with transcatheter aortic valve replacement (TAVR) procedure is a common complication. The objective of this study was to use ambulatory monitor BodyGuardian to assess late occurrence of atrioventricular block (AVB) after TAVR.

Methods:

This prospective study evaluated 365 patients who underwent TAVR at Mayo Clinic, Rochester, Minnesota between June 2016 and August 2017. Patients who received PPM for bradycardia after TAVR before discharge were considered as the PPM group. Those not requiring PPM received a BodyGuardian system (BodyGuardian group) for 30 days of continuous monitoring. Primary end point was Mobitz II or third-degree atrioventricular block (II/III AVB) at 30-day follow-up.

Results:

Of 365 patients, 74 who had a PPM or an implantable cardioverter-defibrillator before TAVR and 94 who were enrolled in other studies were excluded. Of 197 patients enrolled in the study, 70 (35.5%) received PPM and 127 had BodyGuardian before the hospital dismissal. Eleven of 127 (8.6%) BodyGuardian group required PPM within 30 days after TAVR for late occurrence of symptomatic bradycardia. In total, 33 of 197 (16.7%) patients developed II/III AVB (24 before and 9 after discharge). Thirty-four patients had preexisting right bundle branch block. Of them, 16 (47%) developed II/III AVB. Of 53 patients who developed new left bundle branch block after TAVR, 14% progressed to II/III AVB within 30 days.

Conclusions:

In patients without a standard post-TAVR pacing indication, yet a potential risk to develop AVB, a strategy of 30-day monitoring identifies additional patients who require permanent pacing.

Predictive value of left ventricular diastolic chamber stiffness in patients with severe aortic stenosis undergoing aortic valve replacement

Aims

Despite improvements in cardiac haemodynamics and symptoms, long-term mortality remains increased in some patients after aortic valve replacement (AVR). Limited data exist on the prognostic role of left ventricular (LV) chamber stiffening in these patients.

Methods and results

We performed a retrospective analysis in 1893 patients with severe aortic stenosis (AS) referred for AVR. LV end-diastolic pressure–volume relations (EDPVR, P = αV^β) were reconstructed from echocardiographic measurements of end-diastolic volumes and estimates of end-diastolic pressure (EDP). The impact of EDPVR-derived LV chamber stiffness (CS30, at 30 mmHg EDP) on all-cause mortality after AVR was evaluated. Mean age was 76 ± 10 years, 39% were females, and ejection fraction (EF) was 61 ± 12%. The mean LV chamber stiffness (CS30) was 2.2 ± 1.3 mmHg/mL. A total of 877 (46%) patients had high LV stiffness (CS30 >2 mmHg/mL). In these patients, the EDPVR curves were steeper and shifted leftwards, indicating higher stiffness at all pressure levels. These patients were slightly older, more often female, and had more prevalent comorbidities compared to patients with low stiffness. At follow-up [median 4.2 (interquartile range 2.8–6.3) years; 675 deaths], a higher CS30 was associated with lower survival (hazard ratio: 2.7 for severe vs. mild LV stiffening; P < 0.0001), both in patients with normal or reduced EF. At multivariate analysis, CS30 remained an independent predictor, even after adjusting for age, sex, comorbidities, EF, LV remodelling, and diastolic dysfunction.

Conclusion

Higher preoperative LV chamber stiffening in patients with severe AS is associated with poorer outcome despite successful AVR.

The MIDA Mortality Risk Score: development and external validation of a prognostic model for early and late death in degenerative mitral regurgitation

Aims

In degenerative mitral regurgitation (DMR), lack of mortality scores predicting death favours misperception of individual patients' risk and inappropriate decision-making.

Methods and results

The Mitral Regurgitation International Database (MIDA) registries include 3666 patients (age 66 ± 14 years; 70% males; follow-up 7.8 ± 5.0 years) with pure, isolated, DMR consecutively diagnosed by echocardiography at tertiary (European/North/South-American) centres. The MIDA Score was derived from the MIDA-Flail-Registry (2472 patients with DMR and flail leaflet-Derivation Cohort) by weighting all guideline-provided prognostic markers, and externally validated in the MIDA-BNP-Registry (1194 patients with DMR and flail leaflet/prolapse-Validation Cohort). The MIDA Score ranged from 0 to 12 depending on accumulating risk factors. In predicting total mortality post-diagnosis, the MIDA Score showed excellent concordance both in Derivation Cohort (c = 0.78) and Validation Cohort (c = 0.81). In the whole MIDA population (n = 3666 patients), 1-year mortality with Scores 0, 7-8, and 11-12 was 0.4, 17, and 48% under medical management and 1, 7, and 14% after surgery, respectively (P < 0.001). Five-year survival with Scores 0, 7-8, and 11-12 was 98 ± 1, 57 ± 4, and 21 ± 10% under medical management and 99 ± 1, 82 ± 2, and 57 ± 9% after surgery (P < 0.001). In models including all guideline-provided prognostic markers and the EuroScoreII, the MIDA Score provided incremental prognostic information (P ≤ 0.002).

Conclusion

The MIDA Score may represent an innovative tool for DMR management, being able to position a given patient within a continuous spectrum of short- and long-term mortality risk, either under medical or surgical management. This innovative prognostic indicator may provide a specific framework for future clinical trials aiming to compare new technologies for DMR treatment in homogeneous risk categories of patients.

Hemodynamics and Prognostic Impact of Concomitant Mitral Stenosis in Patients Undergoing Surgical or Transcatheter Aortic Valve Replacement for Aortic Stenosis

BACKGROUND

Mitral stenosis frequently coexists in patients with severe aortic stenosis. Mitral stenosis severity evaluation is challenging in the setting of combined aortic stenosis and mitral stenosis because of hemodynamic interactions between the 2 valve lesions. The impact of aortic valve replacement (AVR) for severe aortic stenosis on mitral stenosis is unknown. This study aimed to assess the effect of AVR on mitral stenosis hemodynamics and the clinical outcomes of patients with severe aortic stenosis with and without mitral stenosis.

METHODS

We retrospectively investigated patients who underwent surgical AVR or transcatheter AVR for severe aortic stenosis from 2008 to 2015. Mean transmitral gradient by Doppler echocardiography ≥4 mm Hg was identified as mitral stenosis; patients were then stratified according to mitral valve area (MVA, by continuity equation) as >2.0 cm² or ≤2.0 cm². MVA before and after AVR in patients with mitral stenosis were evaluated. Clinical outcomes of patients with and without mitral stenosis were compared using 1:2 matching for age, sex, left ventricular ejection fraction, method of AVR (surgical AVR versus transcatheter AVR) and year of AVR.

RESULTS

Of 190 patients with severe aortic stenosis and mitral stenosis (age 76±9 years, 42% men), 184 were matched with 362 with severe aortic stenosis without mitral stenosis. Among all mitral stenosis patients, the mean MVA increased after AVR by 0.26±0.59 cm² (from 2.00±0.50 to 2.26±0.62 cm², P<0.01). MVA increased in 105 (55%) and remained unchanged in 34 (18%). Indexed stroke volume ≤45 mL/m² (odds ratio [OR] 2.40; 95% CI, 1.15-5.01; P=0.020) and transcatheter AVR (OR, 2.36; 95% CI, 1.17-4.77; P=0.017) were independently associated with increase in MVA. Of 107 with significant mitral stenosis (MVA ≤2.0 cm²), MVA increased to >2.0 cm² after AVR in 52 (49%, pseudo mitral stenosis) and remained ≤2.0 cm² in 55 (51%, true mitral stenosis). During follow-up of median 2.9 (0.7-4.9) years, true mitral stenosis was an independent predictor of all-cause mortality (adjusted hazard ratio, 1.88; 95% CI, 1.20-2.94; P<0.01).

CONCLUSIONS

MVA improved after AVR in nearly half of patients with severe aortic stenosis and mitral stenosis. MVA remained ≤2.0 cm² (true mitral stenosis) in nearly half of patients with severe aortic stenosis and significant mitral stenosis; this was associated with worse survival among patients undergoing AVR for severe aortic stenosis.

P2601Trans-catheter or surgical mitral valve procedure versus conservative treatment in heart failure patients with preserved ejection fraction

Background

Secondary mitral regurgitation (SMR) impacts outcomes in heart failure with reduced ejection fraction (HFrEF) but whether it is a specific therapeutic target in heart failure patients with preserved ejection fraction (HFpEF) is less clear.

Purpose

The aims of this study were to investigate whether surgical or trans-catheter intervention reduces SMR and improves outcomes compared to optimal medical therapy in HFpEF patients.

Methods

We retrospectively identified 120 HFpEF patients with moderate-to-severe or greater SMR from January 1, 2007, until December 31, 2017. Moderate-to-severe SMR was defined as an effective regurgitant orifice area of >0.3cm2, and/or a regurgitation volume of >45ml per beat. Those with primary mitral regurgitation, endocarditis, HFrEF, hypertrophic cardiomyopathy, congenital heart disease, and history of valve intervention were excluded. All-cause mortality was analyzed and correlated to clinical and echocardiographic characteristics. Amongst the 120 patients, 36 received surgical or trans-catheter procedure in addition to medical therapy (procedure group) and 84 patients received optimal medical therapy only (conservative treatment group). The median follow-up period was 864 (15–3553) days.

Results

Patients in the procedure group were younger (75±8 vs 81±10, P=0.0002) and with fewer comorbidities (Charlson Comorbidity Index 7.0±2.4 vs 8.0±2.0, P=0.022) compared to the conservative treatment group. In addition, the procedure group had larger left ventricular end-diastolic diameters and higher SMR volume at baseline. During follow-up, SMR decreased by ≥2 grades in 75% of patients (27/36) in the procedure group compared to 20% of patients (12/60) in the conservative treatment group. After adjusting for age and comorbidities, the procedure group showed better overall survival compared to the conservative treatment group (HR 0.37; 95% CI 0.17–0.80; P=0.011). On multivariate analysis for the different groups (procedure group vs. conservative treatment group) (HR 0.40; 95% CI 0.17–0.91; P=0.019), increasing Charlson Comorbidity Index (HR 1.16; 95% CI 1.02–1.32; P=0.028) and average mitral E/e' ratio (HR 1.06; 95% CI 1.01–1.11; P=0.031) were independent predictors of increased all-cause mortality.

Kaplan-Meier Survival Curve

Conclusion

Among heart failure patients with preserved ejection fraction and moderate-to-severe or severe SMR, surgical or trans-catheter mitral-valve repair or replacement resulted in lower all-cause mortality compared to conservative treatment after 9 years of follow-up.

Prognostic Importance and Predictors of Survival in Isolated Tricuspid Regurgitation: A Growing Problem

OBJECTIVE

To define mortality associated with isolated tricuspid regurgitation (TR) and identify risk factors associated with decreased survival.

PATIENTS AND METHODS

We conducted a retrospective cohort study of residents of southeastern Minnesota with moderate-severe or more severe isolated TR diagnosed between January 1, 2005, and April 15, 2015. Isolated TR was defined as TR in the absence of left-sided heart disease or pulmonary hypertension. Patients with an ejection fraction of less than 50%, right ventricular systolic pressure greater than 45 mm Hg, moderate or more severe left-sided valve disease, congenital cardiac anomalies, previous valve operation, tricuspid stenosis, flail leaflet, carcinoid, and rheumatic disease were excluded. Five-year survival was compared with age- and sex-matched Minnesota census bureau data. Multivariate regression was used to identify variables associated with mortality.

RESULTS

Over a 10-year period, 289 patients with isolated TR were identified. The mean ± SD age was 79.2±10.6 years, 70.6% (204) were women, atrial fibrillation was present in 74.0% (214), and 24.6% (71) had an intracardiac device. By 5 years after diagnosis, 51.5% had been hospitalized for heart failure. Observed 5-year mortality was 47.8% compared with 36.3% in the census data (P=.005). After adjusting for age and other comorbidities, multivariate regression identified a dilated inferior vena cava (≥2.1 cm) without respiratory variation on echocardiography (hazard ratio, 1.93; 95% CI, 1.13-3.31; P=.02) and creatinine level greater than 1.6 mg/dL (hazard ratio, 1.8; 95% CI, 1.16-2.8; P=.009) as associated with increased mortality.

CONCLUSION

Patients with isolated TR are frequently hospitalized for heart failure and experience excess mortality. Elevated right atrial pressure and renal dysfunction are associated with mortality. This poor outcome may have implications for timing of intervention.

Atrial fibrillation is not an independent predictor of outcome in patients with aortic stenosis

OBJECTIVES

To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS).

METHODS

1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm² and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed.

RESULTS

Age was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- and sex-adjusted HR=1.66 (1.40-1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42-1.69), p<0.0001), dyspnoea (HR=1.58 (1.33-1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22-2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52-2.33), p<0.0001), left atrial volume index (HR per 10 mL/m²=1.13 (1.07-1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38-0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84-1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62-0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS.

CONCLUSION

AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.

Characteristics and treatment strategies for severe tricuspid regurgitation

OBJECTIVE

This study aimed to identify characteristics, spectrum of tricuspid regurgitation (TR) severity and treatment patterns in patients considered for intervention of severe TR at a tertiary centre. The population being considered for TR intervention is currently not well defined and the role of transcatheter interventions is unclear.

METHODS

The study involved 87 patients with severe TR considered for intervention from 1 March 2016 to 12 November 2018 at Mayo Clinic. Patients receiving medications alone were compared with those receiving intervention to identify patterns in demographics, clinical/echocardiographic associations and survival.

RESULTS

Mean age was 80±9 (56% female), 93% had atrial fibrillation and 64% had chronic kidney disease ≥3 a. Follow-up was 331±276 days; 95% were symptomatic with 6 min walk distance of 270±110 m. Loop diuretics were used in 93%; aldosterone antagonists in 35%. Mean tricuspid annular plane systolic excursion was 15.6±3.8 mm, effective regurgitant orifice area (EROA) 82±32 mm² and stroke volume index 39±11 mL/m²; 48% had at least moderate right ventricular (RV) dysfunction, and 75% did not undergo intervention. Patients receiving intervention showed trends towards larger EROA (93±33 vs 75±31 mm²), better right ventricular function and more severe symptoms. Overall group 30-day and 1-year survival were 100% and 76%, respectively.

CONCLUSIONS

Patients with severe TR considered for intervention are commonly elderly with atrial fibrillation, advanced TR and RV dysfunction; 75% were treated with medications alone and not offered intervention. Patients with greater EROA, better RV function and more severe symptoms were more likely to receive intervention. These findings have implications for future trial design.

Left Ventricular Contractility and Wall Stress in Patients With Aortic Stenosis With Preserved or Reduced Ejection Fraction

OBJECTIVES

This study sought to determine the prevalence of reduced contractility and uncompensated wall stress in patients with aortic stenosis (AS) with preserved or reduced left ventricular ejection fraction (LVEF) and their impact on survival.

BACKGROUND

LVEF in AS is determined not only by contractility but also by loading conditions.

METHODS

Patients with first diagnosis (time 0) of severe AS (aortic valve area [AVA]≤1 cm²) with prior echo study (-3±1 years) were identified. Contractility was evaluated by plotting midwall fractional shortening (mFS) against circumferential end-systolic wall stress (cESS), stratified by LVEF of 60% at time 0. The temporal changes (from -3 years to time 0) and prognostic value of LVEF, contractility, and wall stress were assessed.

RESULTS

Of 445 patients, 290 (65%) had LVEF ≥60% (median: 66% [interquartile range {IQR}: 63% to 69%]) and 155 patients (35%) had LVEF <60% (median: 47% [IQR: 34% to 55%]). Median AVA was 1.27 cm² (IQR: 1.13 to 1.43 cm²) at -3 years and 0.90 cm² (IQR: 0.83 to 0.96 cm²) at time 0. Decreased contractility was already present at -3 years (49 [17%] vs. 59 [38%]; LVEF ≥60% vs. <60%; p < 0.001) and became more prevalent at time 0 (69 [24%] vs. 106 [68%]; p < 0.001). Overall, wall stress was well controlled in both groups at -3 years (1 [0%] vs. 12 [8%]; p < 0.001) but deteriorated over time in patients with LVEF <60% (time 0: 0 [0%] vs. 26 [17%]; p < 0.001). During a median follow-up of 3.4 years, LVEF <60%, decreased contractility and high wall stress were associated with worse survival (p < 0.01 for all). Decreased contractility remained incremental to LVEF in patients with LVEF ≥60% (p < 0.01), but less so when LVEF was <60% (p = 0.11).

CONCLUSIONS

In patients with severe AS, LVEF <60% is associated with a poor prognosis, being linked with decreased contractility and/or high wall stress. Decreased contractility is also present in a subset of patients with LVEF ≥60% and provides incremental prognostic value. These abnormalities already exist before AVA reaches 1.0 cm².

Infective endocarditis following transcatheter aortic valve replacement: Diagnostic yield of echocardiography and associated echo-Doppler findings

BACKGROUND

Studies have suggested the diagnostic yield of echocardiography to be lower in prosthetic valve endocarditis (PVE) after transcatheter aortic valve replacement (TAVR) than reported in surgically-implanted valves but data are limited.

METHODS

We reviewed transthoracic (TTE) and transesophageal (TEE) echo-Doppler findings in 17 patients with PVE (13 definite and 4 possible cases according to modified Duke criteria) after TAVR at Mayo Clinic, Rochester, MN between 2007 and 2016.

RESULTS

Median age was 81 years [56; 91] and 5 patients (29%) were female. Median Society of Thoracic Surgery predicted risk of mortality was 8.8%. PVE occurred 197 days [27; 923] after TAVR. Enterococcus faecalis was the most commonly encountered organism (29%). All patients had TEE performed at the time of PVE; TTE was performed in 11 patients. TEE was diagnostic for PVE in 47% of cases and TTE in 18%. TEE was diagnostic in 62% of patients if only definite PVE cases are included. Two patients showed prosthetic obstruction at the time of PVE; obstruction improved with antibiotic therapy in the surviving patient.

CONCLUSION

Standard echocardiography techniques had limited diagnostic performance in patients with TAVR-related PVE. PVE can present as features of TAVR obstruction, thus PVE should also be considered in patients presenting with worsening prosthetic obstruction.

Left ventricular remodeling and function after transapical versus transfemoral transcatheter aortic valve replacement

BACKGROUND

The effect of utilizing transapical (TA) access for transcatheter aortic valve replacement (TAVR) on cardiac function has not been well studied.

AIMS

The aim of this retrospective study is to determine the direct effects of TA access for TAVR on myocardial function parameters and their correlation with 4-year survival.

METHODS

Three hundred and thirty propensity matched patients, who underwent TAVR using Sapien valve (Edwards Lifesciences Corp, Irvine, CA) between February 15, 2012 and June 17, 2016 (115 TA and 115 transfemoral [TF] routes) were studied. The pre- and 1 month post-TAVR echocardiographic features of both groups were compared. The 4-year survival in both groups was analyzed.

RESULTS

Baseline clinical characteristics, diastolic function parameters, left ventricular (LV) chamber size, and ejection fraction were similar between matched TA and TF groups. At 1 month following TAVR, there was a significant increase in stroke volume index (SVI) in both TA (mean increase 7 cm³ /m² ; P = 0.03) and TF groups (mean increase 7 cm³ /m² ; P < 0.001). Left ventricular ejection fraction (LVEF) significantly increased post TF TAVR (mean increase 2%; P = 0.008), but no significant increase was observed post TA TAVR (mean increase 1%; P = 0.27). Both groups had significant improvement in aortic valve (AV) hemodynamics post-TAVR (P < 0.001). Overall, there were no significant differences in the mean change of SVI, LVEF, or left ventricular end diastolic dimensions (LVEDDs) post TA versus TF TAVR. There was no significant difference in 4-year survival in the TF compared to TA group (49% vs 50%, P = 0.43).

CONCLUSION

Both TA and TF TAVR were equally associated with favorable changes in LV SVI and AV hemodynamics in 30 days. TA TAVR patients had similar 4 year survival to propensity matched TF TAVR; therefore, TA TAVR remains an acceptable alternative access route in patients not amenable to TF TAVR.

Comparative survival and role of STS score in aortic paravalvular leak after SAVR or TAVR: a retrospective study from the USA

OBJECTIVE

The presence of aortic paravalvular leak (PVL) is associated with lower survival, but a direct comparison of its impact after transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) has not been performed. This study sought to determine the differential influence of PVL on survival following TAVR versus SAVR and in patients with varying levels of risk as defined by the Society of Thoracic Surgeons (STS) risk score.

METHODS

Patients with and without postprocedural PVL were identified from 2290 patients undergoing TAVR or SAVR at Mayo Clinic between 2008 and 2014. The primary endpoint was overall survival.

RESULTS

There were 588 patients with PVL (374 TAVR, 214 SAVR): age 78±11 years, 63% male and mean follow-up of 3±2 years. PVL was trivial/mild in 442 (75%) patients. In propensity-matched analyses (n=86 per group), the overall survival at 1 and 4 years was 93% and 56% vs 89% and 61% in patients with PVL after TAVR versus SAVR, respectively (p=0.43). The presence or degree of PVL severity had no influence on survival of patients with high STS score (≥8%), while the presence of greater than mild PVL predicted worse survival in those with STS score <8%. During the first year after PVL diagnosis, while either improvement or stable PVL grade was seen in the majority of patients, worsening of PVL grade was more common in the TAVR group (19%) versus the SAVR group (4%) (p<0.0001).

CONCLUSIONS

At mid-term follow-up, the presence of PVL was associated with equally unfavourable outcomes following SAVR or TAVR. In patients with high STS risk score, the presence of PVL was not independently associated with increased mortality.

Relationship between procedural characteristics and cerebrovascular events after transcatheter aortic valve replacement

Objectives

The objective was to assess the impact of procedural characteristics on risk of stroke or transient ischaemic attack (TIA) after transcatheter aortic valve replacement (TAVR).

Methods

We included 370 consecutive patients who underwent balloon-expandable TAVR from 1 November 2008 to 30 June 2014. Procedural characteristics that may be associated with stroke/TIA were assessed. The primary outcome was stroke/TIA at 30 days. A propensity score was constructed using a logistic regression model with 29 parameters. Cox proportional hazards models were used with a propensity score covariate.

Results

Mean age was 80.9±7.9 years and mean Society of Thoracic Surgeons score was 8.3±5.0. The total number of balloon dilations ranged from 2 to 7. Out of 370 patients, 13 patients (3.5%) suffered stroke/TIA in the first 30 days after TAVR. In univariate analysis, postdeployment balloon dilation (PD) (HR 3.8, 95% CI 1.24 to 11.61; p=0.02) and emergent cardiopulmonary bypass (CPB) (HR 9.66, 95% CI 2.66 to 35.15; p<0.001) were significantly associated with 30-day stroke/TIA. In the multivariable Cox-proportional hazards model, PD (HR 4.95, 95% CI 1.02 to 24.03; p=0.04) and emergent CPB (HR 7.15, 95% CI 1.39 to 36.89; p=0.02) were independently associated with increased risk of 30-day stroke/TIA after adjusting for propensity score, total number of balloon dilations and periprosthetic regurgitation.

Conclusion

Postdilation as compared with total number of dilations, and emergent CPB were independently associated with increased risk of clinical neurological events in the first 30 days after TAVR. Reduction in balloon postdilation with appropriate valve sizing may reduce the risk of stroke or TIA after TAVR.

Prognostic Implication of Electrocardiographic Left Ventricular Strain in Patients Who Underwent Transcatheter Aortic Valve Implantation

Electrocardiographic (ECG) strain has been linked to excess cardiovascular morbidity and mortality in asymptomatic patients with aortic stenosis. We aim to determine the differential impact of baseline ECG-strain on long-term mortality after transcatheter aortic valve implantation (TAVI). Patients who underwent TAVI from January 2012 to March 2016 at Mayo Clinic were included. Left ventricular (LV) strain was defined as the presence of ≥1mm convex ST-segment depression with asymmetrical T-wave inversion in leads V5 to V6 on baseline ECG. Primary end point was all-cause long-term mortality. Of the 520 patients screened, 130 were excluded due to left bundle branch block or paced rhythm. Median follow-up was 1.5 years, IQR (0.9 to 2.7). In the 390 included patients, 47 (12%) had strain pattern on pre-TAVI ECG. Patients in the strain group had higher prevalence of peripheral vascular disease (83% vs 68%, p = 0.04), and atrial fibrillation/flutter (51% vs 37%, p = 0.06). They also had lower mean LV-ejection fraction (51 ± 16% vs 58±12%, p = 0.003, larger LV-internal diameter in systole (3.71 ± 1.04cm vs 3.26 ± 0.75 cm), higher LV-mass-index (136 ± 44 vs 121 ± 29 g/m²; p = 0.044), and higher estimated pulmonary artery systolic pressure (50 ± 13 vs 43 ± 15mm Hg; p = 0.02). Kaplan-Meier survival analysis showed a cumulative probability of survival at 3 years of 35.4% ± 8% in patients with LV-strain compared with 67% ± 3.4% in patients without LV-strain (log-rank p <0.001). In a multivariate logistic regression analysis, ECG-strain was an independent predictor of long-term mortality (Hazard ratio 2.67, 95% CI [1.72 to 4.05]; p <0.001). In conclusion, ECG strain is an independent predictor of long-term mortality post TAVI. Systematic strain measurements might aid in risk-stratifying patients who underwent TAVI.

Incidence and Management of Hemopericardium: Impact of Changing Trends in Invasive Cardiology

OBJECTIVE

As invasive cardiovascular care has become increasingly complex, cardiac perforation leading to hemopericardium is a progressively prevalent complication. We sought to assess the frequency, etiology, and outcomes of hemorrhagic pericardial effusions managed through a nonsurgical echo-guided percutaneous strategy.

PATIENTS AND METHODS

Over a 10-year period (January 1, 2007, to December 31, 2016), 1097 unique patients required pericardiocentesis for clinically important pericardial effusions. Of these 411 had drainage of hemorrhagic effusions (defined as a pericardial hemoglobin level >50% of serum hemoglobin or frank blood in the setting of cardiac perforation). Clinical characteristics, echocardiographic data, details of the procedure, and outcomes were determined.

RESULTS

Median patient age was 67 years (interquartile range, 56-76 years), and 60% were men. The procedure was emergent in 83% and elective in 17%. The site of pericardiocentesis was determined by echo-guidance in all: 68% from the left para-apical region, 18% from the left or right parasternal areas, and 14% were subxyphoid. Half (n=215 [52%]) occurred after cardiac perforation with percutaneous interventional procedure (ablation, n=94; device lead implantation, n=65; percutaneous coronary intervention, n=22; other, n=34), whereas 30% followed cardiac or thoracic surgery. Pericardial fluid volume drained was 546±440 mL. In 94% of cases, echo-guided pericardiocentesis was the only treatment of the effusion needed, whereas definitive surgery was required in 25 (6%) cases for persistent bleeding or acute management of the underlying etiology. There was no procedural mortality. Late mortality was better for hemorrhagic effusions compared with a contemporary cohort with nonhemorrhagic effusions.

CONCLUSION

Echocardiographic guidance allows rapid successful pericardiocentesis in the setting of hemopericardium related to microperforation with interventional procedures, malignancy, or pericarditis, with most not requiring surgical intervention. Surgery should remain the first-line approach for aortic dissection or myocardial rupture.

Fragmentation of QRS complex during ventricular pacing is associated with ventricular arrhythmic events in patients with left ventricular dysfunction

BACKGROUND

QRS fragmentation (fQRS) during baseline ventricular conduction, a myocardial fibrosis marker, is associated with increased risk of ventricular tachyarrhythmias but may not manifest unless ventricular activation change is provoked. We examined the association of fQRS during right ventricular (RV) pacing with death and ventricular tachyarrhythmia in patients with left ventricular (LV) dysfunction undergoing electrophysiology study (EPS).

METHODS AND RESULTS

Study participants had LV dysfunction (ejection fraction < 50%) undergoing EPS from January 2002 to May 2014 at Mayo Clinic in Rochester, Minnesota. fQRS during RV stimulation involved >2 notches on R/S waves identified in ≥2 contiguous standard electrocardiographic leads representing anterior, inferior, or lateral ventricular segments. Primary outcomes were ventricular tachyarrhythmias that were symptomatic or required intervention and total and cardiac deaths. In all, 528 patients participated (mean age, 65 years; male sex, 80%). Of them, 312 (59%) had ischemic cardiomyopathy and mean (SD) left ventricular ejection fraction (LVEF) of 33.2% (9.5%); 457 (87%) had implantable cardiac devices (implanted defibrillator, n  =  380). Mean (SD) follow-up was 3.2 (3.0) years. fQRS during RV pacing was observed in 292 patients (60%) in any ventricular segment. Patients with fQRS during RV pacing had 2.5 higher rate of ventricular tachyarrhythmia events than patients with no fQRS (hazard ratio [95% CI], 2.45 [1.5-4.2]; P < 0.01), after correcting for baseline ventricular conduction defect and QRS duration, LVEF, inducible sustained ventricular tachycardia, diabetes mellitus, chronic kidney disease, and ischemic cardiomyopathy.

CONCLUSIONS

RV stimulation can unmask fQRS, and it is associated with increased risk of ventricular tachyarrhythmia in LV dysfunction.