Association of Paravalvular Regurgitation With 1-Year Outcomes After Transcatheter Aortic Valve Replacement With the SAPIEN 3 Valve

Impact of burden and distribution of aortic valve calcification on the hemodynamic performance and procedural outcomes of a self-expanding, intra-annular transcatheter aortic valve system

Aortic valve calcification (AVC) has been explored as a powerful predictor of procedural complications in patients undergoing transcatheter aortic valve implantation (TAVI). However, little evidence exists on its impact on intra-annular devices' performance. We aimed to investigate the impact of AVC burden and distribution pattern on the occurrence of paravalvular leak (PVL), conduction disturbances requiring permanent pacemaker implantation (PPI) and 30-day clinical outcomes in patients undergoing TAVI with a self-expanding, intra-annular device. According to AVC, 103 patients enrolled in a single medical centre from November 2019 to December 2022 were divided into tertiles. Valve Academic Research Consortium (VARC)-3 definitions were used to classify procedural complications and outcomes. Patients in the highest AVC tertile showed an increased occurrence of mild or more PVL and conduction disorders (p < 0.001 and p = 0.006). AVC tertiles (highest tertile) emerged as an independent predictor of PVL (OR 7.32, 95%CI 3.10-17.28, p < 0.001) and post-TAVI conduction disturbances (OR 3.73, 95%CI 1.31-10.60, p = 0.013) but not of PPI (OR 1.44, 95%CI 0.39-5.35, p = 0.579). Considering calcium distribution, ROC analyses revealed that annular AVC but not left ventricle outflow tract (LVOT) calcium burden significantly indicated the development of PVL (AUC 0.863, 0.77-0.93, p < 0.001) and conduction disorders/PPI (AUC 0.797, 0.70-0.89, p < 0.001 and 0.723, 0.58-0.86, p = 0.018, respectively). After adjustment for age and sex, the highest tertile remained an independent predictor of the 30-day composite outcome (death, myocardial infarction, stroke, major vascular complications, type 3/4 bleedings, acute kidney injury, PPI and ≥ moderate PVL) (OR 3.26; 95%CI 1.26-8.40, p = 0.014). A higher AVC is associated with an increased risk of PVL and conduction disturbances after TAVI with a self-expanding, intra-annular device. However, our findings suggest a minor role for LVOT calcification compared with annular AVC in the performance of this specific prosthesis.

Next-Day Discharge After Transcatheter Aortic Valve Implantation With the ACURATE neo/neo2 Self-Expanding Aortic Bioprosthesis

Previous studies have shown the safety of early discharge pathways in selected patients and using selected transcatheter heart valves. Hence, we sought to evaluate the safety of next-day discharge (NDD) in patients who underwent transfemoral transcatheter aortic valve implantation (TF-TAVI) with the ACURATE neo/neo2 (Boston Scientific, Marlborough, Massachusetts) self-expanding aortic bioprosthesis. Patients who underwent TF-TAVI between January 2018 and April 2023 were prospectively included. Patients were stratified into 3 groups according to discharge times within 24 hours (NDD), between 24 and 48 hours, and those discharged >48 hours after TAVI. The primary outcome was the first unplanned readmission at 30 days after TAVI. Log-rank test was used to assess the differences in the outcome of interest between the groups. A total of 368 all-comers were included in this study. According to discharge times, 204 patients followed NDD, 69 patients 24 to 48 hours discharge, and 95 patients >48 hours discharge after TAVI. The mean age was 84 ± 6.3 years and 61% were women, without differences between the groups. The mean Society of Thoracic Surgeons score was lower in those with NDD versus 24 to 48 hours and >48 hours (2.9 ± 1.0, 3.2 ± 1.2, and 3.4 ± 1.4, respectively, p = 0.014). There were no differences between the groups in terms of preprocedural right bundle branch block or pacemaker. The need for new permanent pacemaker implantation was the leading postprocedural complication; it occurred more frequently in the >48 hours group than the 24 to 48 hours, and <24 hours groups (24% vs 8.6% and 2.2%, p <0.001). There were 5 strokes (1.4%) and all of them occurred in the >48 hours group (p = 0.005). At 30 days after discharge, there were no deaths and no differences in all-cause readmissions (9.3% in <24 hours, 8.6% in 24 to 48 hours, and 19% in >48 hours, log-rank p = 0.087). The readmission rates for new permanent pacemaker implantation requirement were 3.3% (n = 6) in NDD, 0% in 24 to 48 hours, and 1.6% (n = 5) in the >48 hours groups (p = 0.27). In conclusion, in unselected patients who underwent TF-TAVI with the ACURATE neo/neo2 self-expanding bioprosthesis, the NDD pathway is feasible and appears to be safe, without an increased risk of death or all-cause rehospitalization through 30 days after hospital discharge.

Asymmetrical Expansion of Balloon-Expandable Transcatheter Aortic Valve Prostheses: Implications for Valve Hemodynamic and Clinical Outcomes

BACKGROUND

Asymmetrical expansion of transcatheter heart valves (THVs), manifesting as stent frame deformation, is an occasional fluoroscopic finding in transcatheter aortic valve replacement (TAVR).

OBJECTIVES

The aim of this study was to investigate the impact of asymmetrical expansion of balloon-expandable THVs on hemodynamic valve performance and clinical outcomes.

METHODS

In a prospective registry, TAVR asymmetry index was measured using freeze-frame fluoroscopic images and was defined as the ratio of THV heights: [(longer height/shorter height) - 1] × 100. THV hemodynamic performance was measured using echocardiography before hospital discharge. Impaired hemodynamic valve performance was defined as a mean residual THV gradient ≥20 mm Hg and/or moderate or greater paravalvular regurgitation.

RESULTS

Among 1,216 patients undergoing transfemoral TAVR for native severe aortic valve stenosis with contemporary balloon-expandable THVs between February 2014 and June 2022, asymmetry index was an excellent predictor of impaired hemodynamic valve performance (area under the receiver-operating characteristic curve: 0.88; 95% CI: 0.84-0.92; P < 0.001). The optimal asymmetry index threshold for predicting impaired THV performance was >5.5% (sensitivity 77%, specificity 86%) and occurred in 17% of patients. Higher asymmetry index, as a continuous variable, was associated with impaired hemodynamic valve performance independent of total aortic valve calcium, bicuspid anatomy, balloon-expandable valve prosthesis type or size, and Society of Thoracic Surgeons Predicted Risk of Mortality score (OR: 1.37; 95% CI: 1.29-1.46; P < 0.001). High TAVR asymmetry index was not associated with all-cause mortality during a median of 376 days of follow-up (HR: 1.00; 95% CI: 0.71-1.41; P = 0.989).

CONCLUSIONS

Asymmetrical expansion of balloon-expandable THVs was associated with impaired hemodynamic valve performance but not with clinical outcomes.

Comparative Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Moderate-Risk Patients With Aortic Stenosis: A Systematic Review of Clinical Trials

Aortic stenosis (AS) is a prevalent condition among the elderly, characterized by the narrowing of the aortic valve, which, if untreated, can lead to heart failure and decreased quality of life in terms of reduced activity and high mortality in one to two years. Surgical aortic valve replacement (SAVR) has long been the standard treatment for AS. However, it poses significant risks, particularly in older patients with comorbidities. In recent years, transcatheter aortic valve replacement (TAVR) has emerged as a less invasive alternative and is increasingly used in low- and moderate-risk patients. This review seeks to assess the comparative outcomes of TAVR and SAVR in patients with moderate-risk AS. A systematic review was conducted in accordance with PRISMA guidelines, focusing on randomized controlled trials (RCTs) that compared TAVR and SAVR in this patient population. Also, the review included three major RCTs: PARTNER 2, UK TAVI, and DEDICATE. We analyzed the key outcomes of TAVR and SAVR, such as mortality, reintervention rates, complications (such as myocardial infarction, prosthetic valve endocarditis, and pacemaker implantation), and reintervention rates, to evaluate the relative efficacy and safety of TAVR and SAVR. The analysis included data from 4,359 patients across the three trials. TAVR demonstrated a lower all-cause mortality in two of the three trials, with an overall trend favoring TAVR in terms of survival. However, TAVR was associated with a higher incidence of prosthetic valve endocarditis, a greater need for pacemaker implantation, and more frequent reinterventions compared to SAVR. In conclusion, the findings suggest that TAVR may be a better option for moderate-risk AS patients, offering higher survival rates and a less invasive recovery process. While TAVR carries increased risks of endocarditis and pacemaker dependency, its overall benefits, particularly in terms of lower mortality and improved patient outcomes, make it a preferable option over SAVR for many patients. However, acknowledging potential limitations such as variations in trial design and differences in patient populations would indeed provide a more comprehensive perspective. Further research and long-term follow-up are essential to confirm these findings and refine patient selection criteria.

Outcomes and treatment strategy of transcatheter aortic valve replacement with balloon-expandable valve in borderline-size annulus

BACKGROUND

Candidates for transcatheter aortic valve replacement (TAVR) occasionally have a "borderline-size" aortic annulus between 2 transcatheter heart valve sizes, based on the manufacturer's sizing chart. Data on TAVR outcomes in such patients are limited.

METHODS

We retrospectively reviewed 1816 patients who underwent transfemoral-TAVR with balloon-expandable valve (BEV) at our institution between 2016 and 2020. We divided patients into borderline and non-borderline groups based on computed tomography-derived annular measurements and compared outcomes. Furthermore, we analyzed procedural characteristics and compared outcomes between the smaller- and larger-valve strategies in patients with borderline-size annulus.

RESULTS

During a median follow-up of 23.3 months, there was no significant difference between the borderline (n = 310, 17.0 %) and non-borderline (n = 1506) groups in mortality (17.3 % vs. 19.5 %; hazard ratio [HR] = 0.86 [95% CI = 0.62-1.20], p = 0.39), major adverse cardiac/cerebrovascular events (MACCE: death/myocardial infarction/stroke, 21.2 % vs. 21.5 %; HR = 0.97 [0.71-1.32], p = 0.85), paravalvular leak (PVL: mild 21.8 % vs. 20.6 %, p = 0.81; moderate 0 % vs. 1.2 %; p = 0.37), or mean gradient (12.9 ± 5.8 vs. 12.6 ± 5.2 mmHg, p = 0.69) at 1 year. There was no significant difference between the larger-(n = 113) and smaller-valve(n = 197) subgroups in mortality (23.7 % vs. 15.2 %; HR = 1.57 [0.89-2.77], p = 0.12), MACCE (28.1 % vs. 18.4 %; HR = 1.52 [0.91-2.54], p = 0.11), mild PVL (13.3 % vs. 25.9 %; p = 0.12), or mean gradient (12.3 ± 4.5 vs. 13.6 ± 5.3 mmHg, p = 0.16); however, the rate of permanent pacemaker implantation (PPI) was higher in the larger-valve subgroup (15.9 % vs. 2.6 %, p < 0.001).

CONCLUSION

Borderline-size annulus is not associated with higher risk of adverse outcomes after BEV-TAVR. However, the larger-valve strategy for borderline-size annulus is associated with higher PPI risk, suggesting a greater risk of injury to the conduction system.

Size of Self-Expandable Transcatheter Heart Valve and Mid-Term Adverse Events After Transcatheter Aortic Valve Replacement

The hemodynamic performance of self-expandable valves (SEVs) is a preferable choice for small aortic annuli in transcatheter aortic valve replacement (TAVR). However, no data are, so far, available regarding the relation between the size of SEVs and clinical outcomes. This study aimed to evaluate the impact of prosthesis size on adverse events after TAVR using SEVs. We retrospectively analyzed 1,400 patients (23-mm SEV: 13.6%) who underwent TAVR using SEVs at 12 centers. The impact of SEV size on all-cause death and heart failure (HF) after TAVR was evaluated by multivariate Cox regression and propensity score (PS) matching analysis. During the follow-up period (median 511 days), 201 all-cause deaths and 87 HF rehospitalizations were observed. The incidence of all-cause death was comparable between small- (23-mm SEV) and larger-sized (26- or 29-mm SEV) (16.8% vs 13.9%, log-rank p = 0.29). The size of SEV was not associated with a higher incidence of all-cause death (hazard ratio [HR] 1.21, 95% confidence interval [CI] 0.79 to 1.86 in Cox regression; HR 1.31, 95% CI 0.77 to 2.23 in PS matching) and HF after TAVR (subdistribution HR 0.79, 95% CI 0.37 to 1.72 in Cox regression; subdistribution HR 1.00, 95% CI 0.44 to 2.30 in PS matching). The multivariate model including postprocedural prosthesis-patient mismatch showed consistent results. In conclusion, small SEVs had comparable midterm clinical outcomes to larger-sized SEVs, even if the prosthesis-patient mismatch was observed after TAVR.

Cardiac computed tomography post-transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is performed to treat aortic stenosis and is increasingly being utilised in the low-to-intermediate-risk population. Currently, attention has shifted towards long-term outcomes, complications and lifelong maintenance of the bioprosthesis. Some patients with TAVR in-situ may develop significant coronary artery disease over time requiring invasive coronary angiography, which may be problematic with the TAVR bioprosthesis in close proximity to the coronary ostia. In addition, younger patients may require a second transcatheter heart valve (THV) to 'replace' their in-situ THV because of gradual structural valve degeneration. Implantation of a second THV carries a risk of coronary obstruction, thereby requiring comprehensive pre-procedural planning. Unlike in the pre-TAVR period, cardiac CT angiography in the post-TAVR period is not well established. However, post-TAVR cardiac CT is being increasingly utilised to evaluate mechanisms for structural valve degeneration and complications, including leaflet thrombosis. Post-TAVR CT is also expected to have a significant role in risk-stratifying and planning future invasive procedures including coronary angiography and valve-in-valve interventions. Overall, there is emerging evidence for post-TAVR CT to be eventually incorporated into long-term TAVR monitoring and lifelong planning.

Echocardiography Core Laboratory Methodology for TAVR: A Transatlantic Consensus

Inter-echocardiography core laboratory (ECL) harmonization is pivotal to consider data from different ECLs interchangeable. On the basis of the experience of the first trans-Atlantic harmonization of 2 established ECLs in the field of transcatheter aortic valve replacement (TAVR) trials, this review describes the harmonized ECL methodology in analyzing and adjudicating the post-TAVR echocardiographic endpoints according to Valve Academic Research Consortium 3 definitions. This review presents the feasibility and intra- and inter-ECL reproducibility, explains the root cause of potential important inter-ECL variability, and formulates ECL recommendations for optimal post-TAVR echocardiographic image acquisition. The implementation of inter-ECL harmonization may further define the best practice of ECLs and have logistic and regulatory implications for the realization of future TAVR trials.

Paravalvular regurgitation after transcatheter aortic valve replacement: incidence, quantification, and prognostic impact

Transcatheter aortic valve replacement (TAVR) is the standard of care in aortic stenosis with results comparable to surgical aortic valve replacement. However, paravalvular regurgitation (PVR) is more common after TAVR. With the alteration of devices and implantation techniques, the incidence of moderate or more PVR has declined. Mild PVR is still common in around 30% of TAVR patients in low-risk trials. Progression of AS causes myocardial hypertrophy and varying degrees of diastolic dysfunction which may cause heart failure even in combination with small volumes of PVR. Any degree of PVR is associated with an increased risk of overall and cardiovascular mortality. Predictors of PVR are annular eccentricity, severe calcification of the aortic valve, bicuspid aortic valves, and type of prosthesis where balloon-expandable devices are associated with less PVR. PVR is diagnosed using echocardiography, aortic angiogram with or without videodensitometry, haemodynamic parameters, or cardiac magnetic resonance. PVR can be treated using post-dilation, interventional treatment using a vascular plug, or implantation of a second device. Successful post-dilation depends on balloon size which should at least be equal to or >95% of the mean annulus diameter. Implantation of a second device to reduce PVR is successful in ∼90% of cases, either through lengthening of the sealing skirt in case of inadequate position or through further expansion of the index device. Implantation of a vascular plug can successfully reduce PVR and reduce mortality.

Complete transcatheter versus surgical approach to aortic stenosis with coronary artery disease: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to evaluate outcomes of transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) versus surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG).

METHODS

The MEDLINE, EMBASE, and Cochrane Library databases were searched through November 2021 to identify studies comparing TAVR + PCI and SAVR + CABG for severe aortic stenosis with concurrent coronary artery disease. Outcomes of interest were all-cause mortality, repeat coronary intervention, rehospitalization, myocardial infarction, and stroke during follow-up, and 30-day periprocedural outcomes.

RESULTS

Two randomized controlled trials and 6 observational studies including a total of 104,220 patients (TAVR + PCI, n = 5004; SAVR + CABG, n = 99,216) were included. The weighted mean follow-up period was 30.2 months. TAVR + PCI was associated with greater all-cause mortality and coronary reintervention during follow-up period (hazard ratio, 1.35; 95% confidence interval [CI], 1.11-1.65; P = .003, hazard ratio, 4.14; 95% CI, 1.74-9.86; P = .001, respectively), 30-day permanent pacemaker implantation rate (odds ratio [OR], 3.79; 95% CI, 1.61-8.95; P = .002), and periprocedural vascular complications (OR, 6.97; 95% CI, 1.85-26.30; P = .004). In contrast, TAVR + PCI was associated with a lower rate of 30-day acute kidney injury (OR, 0.32; 95% CI, 0.20-0.50; P = .0001). Rehospitalization, myocardial infarction, stroke during follow-up, and other periprocedural outcomes including 30-day mortality were similar in both groups.

CONCLUSIONS

In patients with severe aortic stenosis and coronary artery disease, TAVR + PCI was associated with greater all-cause mortality at follow-up compared with SAVR + CABG. Heart Team approach to assess TAVR candidacy remains imperative.

Minimally invasive, surgical, and transcatheter aortic valve replacement: A network meta-analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has evolved as an alternative to surgical aortic valve replacement (SAVR). In addition to full-sternotomy (FS), recent reports have shown successful minimally-invasive SAVR approaches, including mini-sternotomy (MS) and mini-thoracotomy (MT). This network-meta-analysis (NMA) seeks to provide an outcomes comparison based on these different modalities (MS, MT, TAVR) compared with FS as a reference arm for the management of aortic valve disease.

METHODS

A comprehensive literature search was performed to identify studies that compared minimally-invasive SAVR (MS/MT) to conventional FS-SAVR, and/or TAVR. Bayesian NMA was performed using the random effects model. Outcomes were pooled as risk ratios (RR) with their 95 % confidence intervals (CIs). Our primary outcomes included 30-day mortality, stroke, acute kidney injury (AKI), major bleeding, new permanent pacemaker (PPM), and paravalvular leak (PVL). We also assessed long-term mortality at the latest follow-up.

RESULTS

A total of 27,117 patients (56 studies) were included; 10,397 patients had FS SAVR, 9523 had MS, 5487 had MT, and 1710 had TAVR. Compared to FS, MS was associated with statistically-significantly lower rates of 30-day mortality (RR, 0.76, 95%CI 0.59-0.98), stroke (RR, 0.84, 95%CI 0.72-0.97), AKI (RR, 0.76, 95%CI 0.61-0.94), and long-term mortality (RR 0.84, 95%CI 0.72-0.97) at a weighted mean follow-up duration of 10.4 years, while MT showed statistically-significantly higher rates of 30-day PVL (RR, 3.76, 95%CI 1.31-10.85) and major bleeding (RR 1.45; 95%CI 1.08-1.94). TAVR had statistically significant lower rates of 30-day AKI (RR 0.49, 95%CI 0.31-0.77), but showed statistically-significantly higher PPM (RR 2.50; 95%CI 1.60-3.91) and 30-day PVL (RR 12.85, 95%CI 5.05-32.68) compared to FS.

CONCLUSIONS

MS was protective against 30-day mortality, stroke, AKI, and long-term mortality compared to FS; TAVR showed higher rates of 30-day PVL and PPM but was protective against AKI. Conversely, MT showed higher rates of 30-day PVL and major bleeding. With the emergence of TAVR, the appropriate benchmarks for SAVR comparison in future trials should be the minimally-invasive SAVR approaches to provide clinical equipoise.

Preoperative computed tomography-imaging with patient-specific computer simulation in transcatheter aortic valve implantation: Design and rationale of the GUIDE-TAVI trial

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is an established treatment option for patients with severe aortic valve stenosis, but is still associated with relatively high rates of pacemaker implantation and paravalvular regurgitation. Routine preoperative computed tomography (CT) combined with patient-specific computer modelling can predict the interaction between the TAVI device and the patient's unique anatomy, allowing physicians to assess the risk for paravalvular regurgitation and conduction disorders in advance to the procedure. The aim of this trial is to assess potential improvement in the procedural outcome of TAVI by applying CT-based patient-specific computer simulations in patients with suitable anatomy for TAVI.

METHODS

The GUIDE-TAVI trial is an international multicenter randomized controlled trial including patients accepted for TAVI by the Heart Team. Patients enrolled in the study will be randomized into 2 arms of each 227 patients. In patients randomized to the use of FEops HEARTGuide (FHG), patient-specific computer simulation with FHG is performed in addition to routine preoperative CT imaging and results of the FHG are available to the operator(s) prior to the scheduled intervention. In patients randomized to no use of FHG, only routine preoperative CT imaging is performed. The primary objective is to evaluate whether the use of FHG will reduce the incidence of mild to severe PVR, according to the Valve Academic Research Consortium 3. Secondary endpoints include the incidence of new conduction disorders requiring permanent pacemaker implantation, the difference between preoperative and final selected valve size, the difference between target and final implantation depth, change of preoperative decision, failure to implant valve, early safety composite endpoint and quality of life.

CONCLUSIONS

The GUIDE-TAVI trial is the first multicenter randomized controlled trial to evaluate the value of 3-dimensional computer simulations in addition to standard preprocedural planning in TAVI procedures.

Third-Generation Transcatheter Aortic Heart Valve with Reverse Parachute Sealing Cuff in Patients with Aortic Valve Disease

BACKGROUND

The Navitor (Abbott Inc, IL, USA) transcatheter heart valve is a novel third-generation self-expanding bioprosthesis with specific features to mitigate paravalvular regurgitation (PVR). Owing to its novelty, there is a paucity of data on its application in clinical practice.

METHODS

Consecutive cohort analysis of the use of the Navitor system in an as-treated clinical setting at a quaternary heart hospital.

RESULTS

Sixty consecutive non-clinical trial patients treated with Navitor were identified. All patients underwent a successful procedure. The mean age was 79.3 years (±SD 7.82), 56.67% (n=34) were female, and the mean STS score was 4.87 (±SD 5.70). At 30 days post-procedure, all patients were alive with no readmissions for heart failure. One patient had a major vascular complication (1.7%). Four patients (7.14% of patients without a pre-existing pacemaker) received a new permanent pacemaker. Two patients (3.4%) had a non-disabling stroke. PVR at 30 days was trivial or none in 75% of patients, and no patient had worse than mild PVR.

CONCLUSIONS

The Navitor system in this as-treated cohort was associated with favourable clinical, haemodynamic, and safety outcomes.

Impact of balloon post-dilation on valve durability and long-term clinical outcomes after self-expanding transcatheter aortic valve implantation

BACKGROUND

Balloon post-dilation (BPD) is a widely adopted strategy to optimize acute results of TAVI, with a positive impact on both paravalvular leak and mean gradients. On the other hand, the inflation of the balloon inside prosthetic leaflets may damage them increasing the risk of structural valve deterioration (SVD). Furthermore, the impact of BPD on long-term clinical outcomes and valve hemodynamics is yet unknown.

AIMS

To evaluate the impact of BPD on valve durability and long-term clinical outcomes in patients undergoing self-expanding transcatheter valve implantation (TAVI).

METHODS

Echocardiographic and clinical data from the ClinicalService (a nation-based data repository and medical care project) were analyzed. Patients were divided into two groups, those who underwent BPD after TAVI and those who did not. Coprimary endpoints were all-cause death and SVD. Cumulative incidence functions for SVD were estimated.

RESULTS

Among 1835 patients included in the study, 417 (22.7%) underwent BPD and 1418 (77.3%) did not undergo BPD. No statistically significant differences at 6-year follow-up were found between groups in terms of all-cause mortality (HR: 1.05, 95% CI: 0.9-1.22; p = 0.557) and SVD (2.1% vs. 1.4%, p = 0.381). In addition, BPD did not predispose to higher risk of cardiovascular death, myocardial infarction, valve thrombosis, and endocarditis at 6-year follow-up.

CONCLUSIONS

BPD following TAVI with a self-expanding prosthesis does not seem to be associated with an increased risk of adverse clinical outcomes or SVD at 6-year follow-up.

One-year clinical outcomes of transcatheter aortic valve implantation with the latest iteration of self-expanding or balloonexpandable devices: insights from the OPERA-TAVI registry

BACKGROUND

Midterm comparative analyses of the latest iterations of the most used Evolut and SAPIEN platforms for transcatheter aortic valve implantation (TAVI) are lacking.

AIMS

We aimed to compare 1-year clinical outcomes of TAVI patients receiving Evolut PRO/PRO+ (PRO) or SAPIEN 3 Ultra (ULTRA) devices in current real-world practice.

METHODS

Among patients enrolled in the OPERA-TAVI registry, patients with complete 1-year follow-up were considered for the purpose of this analysis. One-to-one propensity score matching was used to compare TAVI patients receiving PRO or ULTRA devices. The primary endpoint was a composite of 1-year all-cause death, disabling stroke and rehospitalisation for heart failure. Five prespecified subgroups of patients were considered according to leaflet and left ventricular outflow tract calcifications, annulus dimensions and angulation, and leaflet morphology.

RESULTS

Among a total of 1,897 patients, 587 matched pairs of patients with similar clinical and anatomical characteristics were compared. The primary composite endpoint did not differ between patients receiving PRO or ULTRA devices (Kaplan-Meier [KM] estimates 14.0% vs 11.9%; log-rank p=0.27). Patients receiving PRO devices had higher rates of 1-year disabling stroke (KM estimates 2.6% vs 0.4%; log-rank p=0.001), predominantly occurring within 30 days after TAVI (1.4% vs 0.0%; p=0.004). Outcomes were consistent across all the prespecified subsets of anatomical scenarios (all pinteraction>0.10).

CONCLUSIONS

One-year clinical outcomes of patients undergoing transfemoral TAVI and receiving PRO or ULTRA devices in the current clinical practice were similar, but PRO patients had higher rates of disabling stroke. Outcomes did not differ across the different anatomical subsets of the aortic root.

Transcatheter Aortic-Valve Replacement in Low-Risk Patients at Five Years

BACKGROUND

A previous analysis in this trial showed that among patients with severe, symptomatic aortic stenosis who were at low surgical risk, the rate of the composite end point of death, stroke, or rehospitalization at 1 year was significantly lower with transcatheter aortic-valve replacement (TAVR) than with surgical aortic-valve replacement. Longer-term outcomes are unknown.

METHODS

We randomly assigned patients with severe, symptomatic aortic stenosis and low surgical risk to undergo either TAVR or surgery. The first primary end point was a composite of death, stroke, or rehospitalization related to the valve, the procedure, or heart failure. The second primary end point was a hierarchical composite that included death, disabling stroke, nondisabling stroke, and the number of rehospitalization days, analyzed with the use of a win ratio analysis. Clinical, echocardiographic, and health-status outcomes were assessed through 5 years.

RESULTS

A total of 1000 patients underwent randomization: 503 patients were assigned to undergo TAVR, and 497 to undergo surgery. A component of the first primary end point occurred in 111 of 496 patients in the TAVR group and in 117 of 454 patients in the surgery group (Kaplan-Meier estimates, 22.8% in the TAVR group and 27.2% in the surgery group; difference, -4.3 percentage points; 95% confidence interval [CI], -9.9 to 1.3; P = 0.07). The win ratio for the second primary end point was 1.17 (95% CI, 0.90 to 1.51; P = 0.25). The Kaplan-Meier estimates for the components of the first primary end point were as follows: death, 10.0% in the TAVR group and 8.2% in the surgery group; stroke, 5.8% and 6.4%, respectively; and rehospitalization, 13.7% and 17.4%. The hemodynamic performance of the valve, assessed according to the mean (±SD) valve gradient, was 12.8±6.5 mm Hg in the TAVR group and 11.7±5.6 mm Hg in the surgery group. Bioprosthetic-valve failure occurred in 3.3% of the patients in the TAVR group and in 3.8% of those in the surgery group.

CONCLUSIONS

Among low-risk patients with severe, symptomatic aortic stenosis who underwent TAVR or surgery, there was no significant between-group difference in the two primary composite outcomes. (Funded by Edwards Lifesciences; PARTNER 3 ClinicalTrials.gov number, NCT02675114.).

Early offering transcatheter aortic valve replacement to patients with moderate aortic stenosis: quantifying costs and benefits - a Markov model-based simulation study

OBJECTIVE

Aortic stenosis (AS) is one of the most common acquired cardiac valvular diseases. The success of transcatheter aortic valve implantation (TAVI) for severe AS has led to increasing interest in its use to earlier disease-moderate AS (MAS).

DESIGN

Model-based study using a Markov microsimulation technique to evaluate the long-term costs and benefits associated with 'early' TAVI. Key data inputs were sourced from the international literature and costs were obtained from Australian sources.

SETTING

Australian health care system perspective.

PARTICIPANTS

10 000 hypothetical MAS patients with or without left ventricular diastolic dysfunction or impaired left ventricular ejection fraction.

INTERVENTION

Comparing early TAVI to medical management over a life time horizon for MAS patients aged >65 years. We evaluated the cost-effectiveness of offering early TAVI in five scenarios (10%, 25%, 50%, 75% and 90% take-up rates).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure is quality-adjusted life years (QALY) gained and the incremental cost-utility ratio (ICUR). Secondary outcomes are life-years gained and the number of heart failure case avoided.

RESULTS

Offering early TAVI for MAS patients resulted in both higher healthcare costs and greater benefits (an increase of 3.02 QALYs or 3.99 life-years) per person treated. The ICUR was around $A10 867 and $A11 926 per QALY gained for all five scenarios, with the total cost of early TAVI to the healthcare system being anticipated to be up to $A3.66 billion. Sensitivity analyses indicated a 100% probability of being cost-effective with a willingness to pay threshold of $A50 000/QALY. The benefits remained, even with assumptions of high levels of repeat valve replacement after TAVI.

CONCLUSION

While ongoing randomised controlled trials will define the benefit of TAVI to MAS patients, these results suggest that this intervention is likely to be cost-effective.

A systematic review of contrast-enhanced computed tomography calcium scoring methodologies and impact of aortic valve calcium burden on TAVI clinical outcomes

Different methodologies have been used to assess the role of AV calcification (AVC) on TAVI outcomes. This systematic review aims to describe the burden of AVC, synthesize the different methods of calcium score quantification, and evaluate the impact of AVC on outcomes after TAVI. We included studies of TAVI patients who had reported AV calcium scoring by contrast-enhanced multidetector CT and the Agatston method. The impact of calcification on TAVI outcomes without restrictions on follow-up time or outcome type was evaluated. Results were reported descriptively, and a meta-analysis was conducted when feasible. Sixty-eight articles were included, with sample sizes ranging from 23 to 1425 patients. Contrast-enhanced calcium scoring was reported in 30 studies, calcium volume score in 28 studies, and unique scoring methods in two. All studies with calcium volume scores had variable protocols, but most utilized a modified Agatston method with variable attenuation threshold values of 300-850 HU. Eight studies used the Agatston method, with the overall mean AV calcium score in studies published from 2010 to 2012 of 3342.9 AU [95%CI: 3150.4; 3535.4, I2 ​= ​0%]. The overall mean score was lower and heterogenous in studies published from 2014 to 2020 (2658.9 AU [95% CI: 2517.3; 2800.5, I2 ​= ​79%]. Most studies reported a positive association between calcium burden and increased risk of adverse outcomes, including implantation of permanent pacemaker (7/8 studies), paravalvular leak (13/13 studies), and risk of aortic rupture (2/2 studies). AVC quantification methodology with contrast-enhanced CT is still variable. AVC negatively impacts TAVI outcomes independently of the quantification method.

Cardiac Death After Transcatheter Aortic Valve Replacement With Contemporary Devices

BACKGROUND

The burden of cardiac death after transcatheter aortic valve replacement (TAVR), particularly from advanced heart failure (HF) and sudden cardiac death (SCD), remains largely unknown.

OBJECTIVES

This study sought to evaluate the incidence and predictors of SCD and HF-related death in TAVR recipients treated with newer-generation devices.

METHODS

This study included a total of 5,421 consecutive patients who underwent TAVR with newer-generation devices using balloon (75.7%) or self-expandable (24.3%) valves.

RESULTS

After a median follow-up of 2 (IQR: 1-3) years, 976 (18.0%) patients had died, 50.8% from cardiovascular causes. Advanced HF and SCD accounted for 11.6% and 7.5% of deaths, respectively. Independent predictors of HF-related death were atrial fibrillation (HR: 2.17; 95% CI: 1.47-3.22; P < 0.001), prior pacemaker (HR: 1.79; 95% CI: 1.10-2.92; P = 0.01), reduced left ventricular ejection fraction (HR: 1.08 per 5% decrease; 95% CI: 1.01-1.14; P = 0.02), transthoracic approach (HR: 2.50; 95% CI: 1.37-4.55; P = 0.003), and new-onset persistent left bundle branch block (HR: 1.85; 95% CI: 1.14-3.02; P = 0.01). Two baseline characteristics (diabetes, HR: 1.81; 95% CI: 1.13-2.89; P = 0.01; and chronic kidney disease, HR: 1.72; 95% CI: 1.02-2.90; P = 0.04) and 3 procedural findings (valve in valve, HR: 2.17; 95% CI: 1.01-4.64; P = 0.04; transarterial nontransfemoral approach, HR: 2.23; 95% CI: 1.23-4.48; P = 0.01; and periprocedural ventricular arrhythmia, HR: 7.19; 95% CI: 2.61-19.76; P < 0.001) were associated with an increased risk of SCD after TAVR.

CONCLUSIONS

Advanced HF and SCD accounted for a fifth of deaths after TAVR in contemporary practice. Potentially treatable factors leading to increased risk of HF deaths and SCD were identified, such as arrhythmia/dyssynchrony factors for HF and valve-in-valve TAVR or periprocedural ventricular arrhythmias for SCD.

Heart Failure after Aortic Valve Replacement: Incidence, Risk Factors, and Implications

Severe aortic stenosis (AS) carries a poor prognosis with the onset of heart failure (HF) symptoms, and surgical or transcatheter aortic valve replacement (AVR) is its only definitive treatment. The management of AS has seen a paradigm shift with the adoption of transcatheter aortic valve replacement (TAVR), allowing for the treatment of AS in patients who would not otherwise be candidates for surgical AVR. Despite improving long-term survival after TAVR in recent years, residual HF symptoms and HF hospitalization are common and are associated with an increased mortality and a poor health status. This review article summarizes the incidence and risk factors for HF after AVR. Strategies for preventing and better managing HF after AVR are necessary to improve outcomes in this patient population. Extensive research is underway to assess whether earlier timing for AVR, prior to the development of severe symptomatic AS and associated extra-valvular cardiac damage, can improve post-AVR patient outcomes.

The Evolving Role of Surgical Aortic Valve Replacement in the Era of Transcatheter Valvular Procedures

Surgical aortic valve replacement (SAVR) has long been the standard treatment for severe symptomatic aortic stenosis (AS). However, transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative; it was initially intended for high-risk patients and has now expanded its use to patients of all risk groups. While TAVR has demonstrated promising outcomes in diverse patient populations, uncertainties persist regarding its long-term durability and potential complications, raising the issue of the ideal lifetime management strategy for patients with AS. Therefore, SAVR continues to play an important role in clinical practice, particularly in younger patients with longer life expectancies, those with complex aortic anatomy who are unsuitable for TAVR, and those requiring concomitant surgical procedures. The choice between TAVR and SAVR warrants personalized decision-making, considering patient characteristics, comorbidities, anatomical considerations, and overall life expectancy. A multidisciplinary approach involving an experienced heart team is crucial in the preoperative evaluation process. In this review, we aimed to explore the current role of surgical management in addressing aortic valve stenosis amidst the expanding utilization of less invasive transcatheter procedures.

Percutaneous paravalvular leak closure after transcatheter aortic valve implantation: the international PLUGinTAVI Registry

BACKGROUND

Data regarding the safety and long-term effectiveness of percutaneous closure of paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) are scarce.

AIMS

This study aims to present a large multicentre international experience of percutaneous post-TAVI PVL closure.

METHODS

All patients who underwent percutaneous post-TAVI PVL closure in 14 hospitals across Europe and North America between January 2018 and October 2022 were included.

RESULTS

Overall, 45 patients (64% male) were enrolled. The median age was 80 years (75-84). Among them, 67% and 33% had self-expanding and balloon-expandable valve implantations, respectively. Baseline post-TAVI PVL was severe in 67% of cases and moderate in the rest. The time from index TAVI to PVL closure procedure was 16.1 (8.7-34.8) months. Most patients were in NYHA Class III and IV (73%) before the procedure, and 40% had referred hospitalisations for heart failure between TAVI and the PVL closure procedure. Successful PVL closure was achieved in 94%, reducing regurgitation to ≤mild in 91% and moderate in the rest. The Amplatzer Valvular Plug III was the most frequently used device (27 cases), followed by the Amplatzer Valvular Plug 4. The incidence of severe adverse events was 11%. None of the patients died during the index hospitalisation. During long-term follow-up (21.7±16.2 months), the all-cause mortality rate was 14%, and patients presented improvement in functional status and a significant reduction in the rate of hospitalisation for heart failure (from 40% to 6%).

CONCLUSIONS

Percutaneous PVL closure is a feasible and safe option for treating post-TAVI leaks. Successful PVL reduction to mild or less could be associated with acute and long-lasting improvements in clinical outcomes.

Aortic Valve Disease, Transcatheter Aortic Valve Replacement, and the Heart Failure Patient: A State-of-the-Art Review

Concomitant aortic stenosis (AS) in heart failure (HF) is associated with high rates of mortality and morbidity. Current guidelines recommend aortic valve replacement in patients with severe symptomatic AS and asymptomatic AS with left ventricular ejection fraction <50% and during other cardiac surgeries. Transcatheter aortic valve replacement (TAVR) has now allowed for the treatment of severe AS in previously inoperable or high-surgical-risk patients. Leveraging multimodality imaging techniques is increasingly recognized for reinforcing the rationale for intervening early, thus mitigating the risk of ongoing progression to advanced HF. There are increasing data in favor of TAVR in diverse clinical scenarios, particularly asymptomatic AS and moderate AS. Limited information is, however, available regarding the advantages of HF medical therapy before and after intervention. This review aims to comprehensively examine the phenotypes of AS in the context of HF progression, while exploring the evolving role of TAVR in specific populations.

Balloon Aortic Valvuloplasty in the Modern Era: A Review of Outcomes, Indications, and Technical Advances

Balloon aortic valvuloplasty (BAV) improves the hemodynamics and symptoms of patients with severe aortic stenosis in the short term with low rates of complications, but has not been shown to be an effective destination therapy. Our pooled analysis of >14,300 patients from studies published between January 1, 1991, and April 31, 2022, reported intraprocedural mortality and in-hospital mortality rates as 1.94% (95% CI, 1.39%-2.59%) and 6.02% (95% CI, 4.83%-7.32%), respectively. Hence, BAV is primarily indicated as a bridge to aortic valve replacement/decision with secondary uses as bridge to noncardiac surgery and palliative therapy. Recent advancements in alternative access sites, balloon catheters, and lithotripsy for BAV have opened opportunities for expanded use and further improvements in complication rates. As the utilization of BAV has continually increased since the advent of transcatheter aortic valve replacement, reexamining the role and outcomes of BAV in the era of transcatheter aortic valve replacement has become increasingly important. This review focuses on the outcomes, indications, advances, and technical considerations for BAV.

Post-procedural structural heart CT imaging: TAVR, TMVR, and other interventions

Transcatheter valve replacement has experienced substantial growth in the past decade and this technique can now be used for any of the four heart valves. Transcatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement. Transcatheter mitral valve replacement (TMVR) is often performed in pre-existing valves or after prior valve repair, although numerous devices are undergoing trials for replacement of native valves. Transcatheter tricuspid valve replacement (TTVR) is similarly under active development. Lastly, transcatheter pulmonic valve replacement (TPVR) is most often used for revision treatment of congenital heart disease. Given the growth of these techniques, radiologists are increasingly called upon to interpret post-procedural imaging for these patients, particularly with CT. These cases will often arise unexpectedly and require detailed knowledge of potential post-procedural appearances. We review both normal and abnormal post-procedural findings on CT. Certain complications-device migration or embolization, paravalvular leak, or leaflet thrombosis-can occur after replacement of any valve. Other complications are specific to each type of valve, including coronary artery occlusion after TAVR, coronary artery compression after TPVR, or left ventricular outflow tract obstruction after TMVR. Finally, we review access-related complications, which are of particular concern due to the requirement of large-bore catheters for these procedures.

Quantity and location of aortic valve calcification predicts paravalvular leakage after transcatheter aortic valve replacement: a systematic review and meta-analysis

Introduction

Transcatheter aortic valve replacement (TAVR) is the first-line treatment for patients with moderate-to-high surgical risk of severe aortic stenosis. Paravalvular leakage (PVL) is a serious complication of TAVR, and aortic valve calcification contributes to the occurrence of PVL. This study aimed to investigate the effect of location and quantity of calcification in the aortic valve complex (AVC) and left ventricular outflow tract (LVOT) on PVL after TAVR.

Method

We performed a systematic review and meta-analysis to evaluate the effect of quantity and location of aortic valve calcification on PVL after TAVR using observational studies from PubMed and EMBASE databases from inception to February 16, 2022.

Results

Twenty-four observational studies with 6,846 patients were included in the analysis. A high quantity of calcium was observed in 29.6% of the patients; they showed a higher risk of significant PVL. There was heterogeneity between studies (I2 = 15%). In the subgroup analysis, PVL after TAVR was associated with the quantity of aortic valve calcification, especially those located in the LVOT, valve leaflets, and the device landing zone. A high quantity of calcium was associated with PVL, regardless of expandable types or MDCT thresholds used. However, for valves with sealing skirt, the amount of calcium has no significant effect on the incidence of PVL.

Conclusion

Our study elucidated the effect of aortic valve calcification on PVL and showed that the quantity and location of aortic valve calcification can help predict PVL. Furthermore, our results provide a reference for the selection of MDCT thresholds before TAVR. We also showed that balloon-expandable valves may not be effective in patients with high calcification, and valves with sealing skirts instead of those without sealing skirts should be applied more to prevent PVL from happening.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=354630, identifier: CRD42022354630.

A review of numerical simulation in transcatheter aortic valve replacement decision optimization

BACKGROUND

Recent trials indicated a further expansion of clinical indication of transcatheter aortic valve replacement to younger and low-risk patients. Factors related to longer-term complications are becoming more important for use in these patients. Accumulating evidence indicates that numerical simulation plays a significant role in improving the outcome of transcatheter aortic valve replacement. Understanding mechanical features' magnitude, pattern, and duration is a topic of ongoing relevance.

METHODS

We searched the PubMed database using keywords such as "transcatheter aortic valve replacement" and "numerical simulation" and reviewed and summarized relevant literature.

FINDINGS

This review integrated recently published evidence into three subtopics: 1) prediction of transcatheter aortic valve replacement outcomes through numerical simulation, 2) implications for surgeons, and 3) trends in transcatheter aortic valve replacement numerical simulation.

INTERPRETATIONS

Our study offers a comprehensive overview of the utilization of numerical simulation in the context of transcatheter aortic valve replacement, and highlights the advantages, potential challenges from a clinical standpoint. The convergence of medicine and engineering plays a pivotal role in enhancing the outcomes of transcatheter aortic valve replacement. Numerical simulation has provided evidence of potential utility for tailored treatments.

Transcatheter Mitral Valve Replacement in Failed Bioprosthetic Valve, Ring, and Mitral Annular Calcification Associated Mitral Valve Disease Using Balloon Expandable Transcatheter Heart Valve

Transcatheter mitral valve replacement (TMVR) using the SAPIEN platform has been performed in failed bioprosthetic valves (valve-in-valve), surgical annuloplasty rings (valve-in-ring), and native valves with mitral annular calcification (MAC) (valve-in-MAC). Experience over the past decade has identified important challenges and solutions to improve clinical outcomes. In this review, we discuss the indication, trend in utilization, unique challenges, procedural planning, and clinical outcomes of valve-in-valve, valve-in-ring, and valve-in-MAC TMVR.

Gender Disparities after Transcatheter Aortic Valve Replacement with Newer Generation Transcatheter Heart Valves: A Systematic Review and Meta-Analysis

Previous studies have demonstrated gender disparities in mortality and vascular complications after transcatheter aortic valve replacement (TAVR) with early generation transcatheter heart valves (THVs). It is unclear, however, whether gender-related differences persist with the newer generation THVs. We aim to assess gender disparities after TAVR with newer generation THVs. The MEDLINE and Embase databases were thoroughly searched from inception to April 2023 to identify studies that reported gender-specific outcomes after TAVR with newer generation THVs (Sapien 3, Corevalve Evolut R, and Evolut Pro). The outcomes of interest included 30-day mortality, 1-year mortality, and vascular complications. In total, 5 studies (4 databases) with a total of 47,933 patients (21,073 females and 26,860 males) were included. Ninety-six percent received TAVR via the transfemoral approach. The females had higher 30-day mortality rates (odds ratio (OR) = 1.53, 95% confidence interval (CI) 1.31-1.79, p-value (p) < 0.001) and vascular complications (OR = 1.43, 95% CI 1.23-1.65, p < 0.001). However, one-year mortality was similar between the two groups (OR = 0.78, 95% CI 0.61-1.00, p = 0.28). The female gender continues to be associated with higher 30-day mortality rates and vascular complications after TAVR with newer generation transcatheter heart valves, while there was no difference in 1-year mortality between the genders. More data is needed to explore the causes and whether we can improve TAVR outcomes in females.

Acute advanced aortic stenosis

Acute decompensation often represents the onset of symptoms associated with severe degenerative aortic stenosis (AS) and usually complicates the clinical course of the disease with a dismal impact on survival and quality of life. Several factors may derange the faint balance between left ventricular preload and afterload and precipitate the occurrence of symptoms and signs of acute heart failure (HF). A standardized approach for the management of this condition is currently lacking. Medical therapy finds very limited application in this setting, as drugs usually indicated for the control of acute HF might worsen hemodynamics in the presence of AS. Urgent aortic valve replacement is usually performed by transcatheter than surgical approach whereas, over the last decades, percutaneous balloon valvuloplasty gained renewed space as bridge to definitive therapy. This review focuses on the pathophysiological aspects of acute advanced AS and summarizes current evidence on its management.

Impact of Mild Paravalvular Regurgitation on Long-Term Clinical Outcomes After Transcatheter Aortic Valve Implantation

The impact of mild paravalvular regurgitation (PVR) after transcatheter aortic valve implantation (TAVI) remains controversial. We evaluated the impact of mild PVR after TAVI on long-term clinical outcomes. We included patients who underwent TAVI for severe symptomatic aortic stenosis between December 2008 and June 2019 at 2 international centers and compared all-cause death between the group with mild PVR (group 1) and the group with none or trace PVR (group 2). PVR was categorized using a 3-class grading scheme, and patients with PVR ≧ moderate and those who were lost to follow-up were excluded. This retrospective analysis included 1,404 patients (mean age 81.7 ± 6.5 years, 58.0% women). Three hundred fifty eight patients (25.5%) were classified into group 1 and 1,046 patients (74.5%) into group 2. At baseline, group 1 was older and had a lower body mass index, worse co-morbidities, and more severe aortic stenosis. To account for these differences, propensity score matching was performed, resulting in 332 matched pairs. Within these matched groups, during a mean follow-up of 3.2 years, group 1 had a significantly lower survival rate at 5 years (group 1: 62.0% vs group 2: 68.0%, log-rank p = 0.029, hazard ratio: 1.41 [95% confidence interval: 1.04 to 1.91]). In the matched cohort, patients with mild PVR had a significant 1.4-fold increased risk of mortality at 5 years after TAVI compared with those with none or trace PVR. Further studies with more patients are needed to evaluate the impact of longer-term outcomes.

Valve-Related Complications in TAVI Leading to Emergent Cardiac Surgery

Transcatheter aortic valve implantation (TAVI) is now a standard procedure for the treatment of symptomatic aortic valve stenosis in many patients. In Germany, according to the annual reports from the German Institute for Quality Assurance and Transparency in Healthcare (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen), the rate of serious intraprocedural complications, such as valve malpositioning or embolization, coronary obstruction, aortic dissection, annular rupture, pericardial tamponade, or severe aortic regurgitation requiring emergency cardiac surgery has decreased markedly in recent years from more than 5.5% in 2012 to 2.0% in 2019. However, with increased use, the total number of adverse events remains about 500 per year, about 100 of which require conversion to sternotomy. These, sometimes, fatal events can occur at any time and are still challenging. Therefore, the interdisciplinary TAVI heart team should be prepared and aware of possible rescue strategies.

One-year clinical and echocardiographic outcomes of transcatheter aortic valve replacement with SAPIEN 3 Ultra versus SAPIEN 3

BACKGROUND

The newest-generation balloon-expandable valve, SAPIEN 3 Ultra (S3U), is expected to function well with the enhanced sealing skirt compared with SAPIEN 3 (S3). However, current literature on the comparison between these two valves is limited to short-term follow-ups. Therefore, we aimed to evaluate the 1-year outcomes and echocardiographic changes of S3U compared with S3.

METHODS

We retrospectively identified patients who underwent transfemoral-transcatheter aortic valve replacement with S3U or S3 (20/23/26 mm) at our institution in 2018-2020. Outcomes were 1-year clinical events and echocardiographic parameters, and were compared between S3U and S3 after adjustment with inverse probability of treatment weighting.

RESULTS

The S3U and S3 groups included 297 (25.7%) and 858 (74.3%) patients, respectively. There were no significant differences between the two groups in clinical events (death 5.8% vs. 5.5%, hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.81-1.90; death or heart failure hospitalization 10.3% vs. 10.1%, HR 1.04, 95% CI 0.67-1.62). The S3U group had a lower prevalence of mild paravalvular leakage (PVL) (13.7% vs. 22.3%, p = 0.044), with similar moderate PVL (0.7% vs. 1.2%, p > 0.99). No significant differences were observed in aortic valve mean gradient and Doppler velocity index at 1 year. However, the S3U group had a larger increase in mean gradient from implantation to 1 year (median +4.70 vs. +1.63 mmHg, p < 0.001).

CONCLUSIONS

S3U and S3 carried similarly favorable clinical event risks. Nonetheless, S3U was associated with less frequent mild PVL but a larger increase in transprosthetic gradient. Further studies are needed to determine the prognostic impact of these hemodynamic differences.

Cardiovascular Outcomes of Older versus Newer Generation Transcatheter Aortic Valve Replacement Recipients: A Systematic Review & Meta-analysis

Newer generation transcatheter heart valves (THV) are presumed to yield better clinical efficacy and postprocedural complication profile as compared to transcatheter aortic valve replacement (TAVR) using older generation THVs. The real impact of newer generation valves on TAVR outcomes is not well known. Studies comparing older and newer generation THVs were identified from online databases including PubMed, EMBASE, Cochrane, and ClinicalTrials.gov from inception until August 2020. The primary outcome of the study was to compare mortality. Secondary outcomes included cerebrovascular events, myocardial infarction, major vascular complications, major bleeding, acute kidney injury, paravalvular leak, and post-procedural pacemaker implantation. Statistical analysis was performed using the Mantel-Haenszel random effect model with an odds ratio (OR), 95% confidence interval (CI), and p-value significance ≤0.05. A total of 14 studies were included with a combined patient population of 5697 patients (older generation n=1996; newer generation n=3701). Newer generation valves showed statistically significant results favoring lower major vascular complications (OR=2.05; 95% CI, 1.33-3.18; P = 0.00), major bleeding (OR=1.99; 95% CI, 1.35-2.93; P = 0.00), acute kidney injury (OR=1.71; 95% CI, 1.13-2.59; P = 0.01), paravalvular leak (OR=2.41; 95% CI, 1.11-5.28; P = 0.03) and mortality (OR=1.50; 95% CI, 1.10-2.06; P = 0.01) as compared to older generation valves. Cerebrovascular events, myocardial infarction, and pacemaker placement rates were found to be similar between older and newer generation valves. TAVR outcomes using newer generation valves are superior to those of older generation valves in terms of major vascular complications, acute kidney injury, paravalvular leak, and mortality.

Leaving obstacles aside: Antegrade paravalvular leakage closure after transcatheter aortic valve replacement

Paravalvular leakage (PVL) is yet a potential and serious complication after transcatheter aortic valve replacement. Percutaneous PVL closure may be the treatment of choice upon failure of balloon postdilation in patients with excessive surgical risk. If the retrograde approach fails, an antegrade strategy might provide the solution.

Ongoing experience with patient-specific computer simulation of transcatheter aortic valve replacement in bicuspid aortic valve

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is increasingly being used to treat younger, lower-risk patients with bicuspid aortic valve (BAV). Patient-specific computer simulation may identify patients at risk for developing paravalvular regurgitation (PVR) and major conduction disturbance. Only limited prospective experience of this technology exist. We wished to describe our ongoing experience with patient-specific computer simulation.

METHODS

Patients who were referred for consideration of TAVR with a self-expanding transcatheter heart valve (THV) and had BAV identified on pre-procedural cardiac computed tomography imaging underwent patient-specific computer simulation. The computer simulations were reviewed by the Heart Team and used to guide surgical or transcatheter treatment approaches and to aid in THV sizing and positioning. Clinical outcomes were recorded.

RESULTS

Between May 2019 and May 2021, 16 patients with BAV were referred for consideration of TAVR with a self-expanding THV. Sievers Type 1 morphology was present in 15 patients and Type 0 in the remaining patient. Two patients were predicted to develop moderate-to-severe PVR with a TAVR procedure and these patients underwent successful surgical aortic valve replacement. In the remaining 14 patients, computer simulation was used to optimize THV sizing and positioning to minimise PVR and conduction disturbance. One patient with a low valve implantation depth developed moderate PVR and this complication was correctly predicted by the computer simulations. No patient required insertion of a new permanent pacemaker.

CONCLUSION

Patient-specific computer simulation may be used to guide the most appropriate treatment modality for patients with BAV. The usage of computer simulation to guide THV sizing and positioning was associated with favourable clinical outcomes.

Quantification of paravalvular leaks associated with TAVI implants using 4D MRI in an aortic root phantom made possible by the use of 3D printing

Introduction

Transcatheter aortic valve implantation (TAVI) has become an alternative to surgical replacement of the aortic valve elderly patients. However, TAVI patients may suffer from paravalvular leaks (PVL). Detecting and grading is usually done by echocardiography, but is limited by resolution, 2D visualization and operator dependency. 4D flow magnetic resonance imaging (MRI) is a promising alternative, which did not reach clinical application in TAVI patients. The aim of this study was applying 3D printing technologies in order to evaluate flow patterns and hemodynamics of PVLs following TAVI, exploiting 4D flow MRI and standard ultrasound.

Materials and methods

An MR-compatible, anatomically left ventricle, aortic root, and ascending aorta model was fabricated by combining 3D-printed parts and various soft silicone materials to match physiological characteristics. An Abbott Portico™ valve was used in continuous antegrade flow (12-22 l/min), retrograde flow with varying transvalvular pressures (60-110 mmHg), and physiological pulsatile hemodynamics (aortic pressure: 120/80 mmHg, cardiac output: 5 l/min) Time-resolved MR measurements were performed above and below the TAVI stent and compared with color Doppler ultrasound measurements in exactly the same setup.

Results

The continuous antegrade flow measurements from MRI largely agreed with the flowmeter measurements, and a maximum error of only 7% was observed. In the retrograde configuration, visualization of the paravalvular leaks was possible from the MR measurements, but flow was overestimated by up to 33%. The 4D MRI measurement in the pulsatile setup revealed a single main PVL, which was also confirmed by the color Doppler measurements, and velocities were similar (2.0 m/s vs. 1.7 m/s).

Discussion

4D MRI techniques were used to qualitatively assess flow in a patient-specific, MR-compatible and flexible model, which only became possible through the use of 3D printing techniques. Flow patterns in the ascending aorta, identification and quantification of PVLs was possible and the location and extent of PVLs were confirmed by ultrasound measurements. The 4D MRI flow technique allowed evaluation of flow patterns in the ascending aorta and the left ventricle below the TAVI stent with good results in identifying PVLs, demonstrating its capabilities over ultrasound by providing the ability to visualize the paravalvular jets in three dimensions at however, additional expenditure of time and money.

Effect of BMI on patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis

BACKGROUND

The relationship of body mass index (BMI) and an "obesity paradox" with cardiovascular risk prediction is controversial. This systematic review and meta-analysis aims to compare the associations of different BMI ranges on transcatheter aortic valve implantation (TAVI) outcomes.

METHODS

International databases, including PubMed, the Web of Science, and the Cochrane Library, were systematically searched for observational and randomized controlled trial studies investigating TAVI outcomes in any of the four BMI categories: underweight, normal weight, overweight, and obese with one of the predefined outcomes. Primary outcomes were in-hospital, 30-day, and long-term all-cause mortality. Random-effects meta-analysis was performed to calculate the odds ratio (OR) or standardized mean differences (SMD) with 95% confidence interval (CI) for each paired comparison between two of the BMI categories.

RESULTS

A total of 38 studies were included in our analysis, investigating 99,829 patients undergoing TAVI. There was a trend toward higher comorbidities such as hypertension, diabetes, and dyslipidemia in overweight patients and individuals with obesity. Compared with normal-weight, patients with obesity had a lower rate of 30-day mortality (OR 0.42, 95% CI 0.25-0.72, p < 0.01), paravalvular aortic regurgitation (OR 0.63, 95% CI 0.44-0.91, p = 0.01), 1-year mortality (OR 0.48, 95% CI 0.24-0.96, p = 0.04), and long-term mortality (OR 0.69, 95% CI 0.51-0.94, p = 0.02). However, acute kidney injury (OR 1.16, 95% CI 1.04-1.30, p = 0.01) and permanent pacemaker implantation (OR 1.25, 95% CI 1.05-1.50, p = 0.01) odds were higher in patients with obesity. Noteworthy, major vascular complications were significantly higher in underweight patients in comparison with normal weight cases (OR 1.62, 95% CI 1.07-2.46, p = 0.02). In terms of left ventricular ejection fraction (LVEF), patients with obesity had higher post-operative LVEF compared to normal-weight individuals (SMD 0.12, 95% CI 0.02-0.22, p = 0.02).

CONCLUSION

Our results suggest the presence of the "obesity paradox" in TAVI outcomes with higher BMI ranges being associated with lower short- and long-term mortality. BMI can be utilized for risk prediction of patients undergoing TAVI.

Real-World Comparison of Transcatheter Versus Surgical Aortic Valve Replacement in the Era of Current-Generation Devices

Few studies have reported comparisons of out-of-hospital clinical outcomes after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) in the era of current-generation valves that reflect the real-world situation. Data on patients with severe AS aged 65 years or older who underwent TAVR or SAVR between 2015 and 2018 were obtained from the National Health Insurance Service in Korea and clinical event rate was analyzed. The primary endpoint was all-cause death at 1 year. The cohort included a total of 4623 patients over 65 years of age, of whom 1269 (27.4%) were treated with TAVR. After 1:1 propensity score matching, 2120 patients were included in the study. TAVR was associated with reduced 1-year mortality (hazard ratio (HR): 0.55; 95% confidence interval (CI): 0.42−0.70; p < 0.001). There was no difference between the groups in the incidence of ischemic stroke (HR: 0.72, 95% CI: 0.43−1.20; p = 0.21) and intracranial hemorrhage (HR: 1.10; p = 0.74). Permanent pacemaker insertion was observed more frequently in the TAVR cohort (9.4% vs. 2.5%, HR: 3.95, 95% CI: 2.57−6.09; p < 0.001), whereas repeat procedures were rare in both treatments (0.5% vs. 0.3%, p = 0.499). In the nation-wide real-world data analysis, TAVR with current-generation devices showed significantly lower 1-year mortality compared to SAVR in severe AS patients.

Left ventricular stroke volume index following transcatheter aortic valve replacement is an early predictor of 1-year survival

BACKGROUND

Adverse cardiac events are common following transcatheter aortic valve replacement (TAVR). Our aim was to investigate the low left ventricular stroke volume index (LVSVI) 30 days after TAVR as an early echocardiographic marker of survival.

HYPOTHESIS

Steady-state (30-day) LVSVI after TAVR is associated with 1-year mortality.

METHODS

A single-center retrospective analysis of all patients undergoing TAVR from 2017 to 2019. Baseline and 30-day post-TAVR echocardiographic LVSVI were calculated. Patients were stratified by pre-TAVR transaortic gradient, surgical risk, and change in transvalvular flow following TAVR.

RESULTS

This analysis focuses on 238 patients treated with TAVR. The 1-year mortality rate was 9% and 124 (52%) patients had normal flow post-TAVR. Of those with pre-TAVR low flow, 67% of patients did not normalize LVSVI at 30 days. The 30-day normal flow was associated with lower 1-year mortality when compared to low flow (4% vs. 14%, p = .007). This association remained significant after adjusting for known predictors of risk (adjusted odds ratio [OR] of 3.45, 95% confidence interval: 1.02-11.63 [per 1 ml/m2 decrease], p = .046). Normalized transvalvular flow following TAVR was associated with reduced mortality (8%) when compared to those with persistent (15%) or new-onset low flow (12%) (p = .01).

CONCLUSIONS

LVSVI at 30 days following TAVR is an early echocardiographic predictor of 1-year mortality and identifies patients with worse intermediate outcomes. More work is needed to understand if this short-term imaging marker might represent a novel therapeutic target.

Management Challenges in Patients Younger Than 65 Years With Severe Aortic Valve Disease

Importance

The management of aortic valve disease, including aortic stenosis and aortic regurgitation (AR), in younger adult patients (age &amp;lt;65 years) is complex, and the optimal strategy is often unclear, contingent on multiple anatomic and holistic factors.

Observations

Traditional surgical approaches carry significant considerations, including compulsory lifelong anticoagulation for patients who receive a mechanical aortic valve replacement (AVR) and the risk of structural valvular deterioration and need for subsequent valve intervention in those who receive a bioprosthetic AVR. These factors are magnified in young adults who are considering pregnancy, for whom issues of anticoagulation and valve longevity are heightened. The Ross procedure has emerged as a promising alternative; however, its adoption is limited to highly specialized centers. Valve repair is an option for selected patients with AR. These treatment options offer varying degrees of durability and are associated with different risks and complications, especially for younger adult patients. Patient-centered care from a multidisciplinary valve team allows for discussion of the optimal timing of intervention and the advantages and disadvantages of the various treatment options.

Conclusions and Relevance

The management of severe aortic valve disease in adults younger than 65 years is complex, and there are numerous considerations with each management decision. While mechanical AVR and bioprosthetic AVR have historically been the standards of care, other options are emerging for selected patients but are not yet generalizable beyond specialized surgical centers. A detailed discussion by members of the multidisciplinary heart team and the patient is an integral part of the shared decision-making process.

Impact of moderate or severe left ventricular outflow tract calcification on clinical outcomes of patients with severe aortic stenosis undergoing transcatheter aortic valve implantation with self- and balloon-expandable valves: a post hoc analysis from the SOLVE-TAVI trial

BACKGROUND

Left ventricular outflow tract (LVOT) calcification has been associated with worse outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) and may influence the selection of prosthetic valve type.

AIMS

We aimed to evaluate the impact of LVOT calcification on outcomes after TAVI with a self-expanding valve (SEV) versus a balloon-expandable valve (BEV).

METHODS

Patients of the SOLVE-TAVI trial, randomised to Edwards SAPIEN 3 or Medtronic Evolut R, were divided according to LVOT calcification into no/mild (≤1 calcium nodule extending <5 mm and covering <10% of the LVOT perimeter) and moderate/severe LVOT calcification groups. The primary endpoint was a composite of death, stroke, moderate/severe paravalvular regurgitation, permanent pacemaker implantation and annulus rupture at 30 days. Additional endpoints included all-cause and cardiovascular mortality at 1 year.

RESULTS

Out of 416 eligible patients, moderate/severe LVOT calcification was present in 143 (34.4%). Moderate/severe LVOT calcification was associated with significantly longer fluoroscopy time and higher rates of pre- and post-dilation. Regardless of the LVOT calcification group, there was no significant difference in the primary endpoint associated with the valve type (no/mild LVOT calcification group: SEV 25.0% vs BEV 27.0%; hazard ratio [HR] 1.10, 95% confidence interval [95% CI]: 0.68-1.73; p=0.73 and moderate/severe LVOT calcification group: SEV 25.0% vs BEV 19.4%; HR 0.76, 95% CI: 0.38-1.61; p=0.49), no significant interaction between LVOT calcification and valve type (pint=0.29) and no differences between SEV vs BEV within LVOT calcification groups regarding 1-year all-cause and cardiovascular mortality.

CONCLUSIONS

Moderate/severe LVOT calcification was associated with longer fluoroscopy time and an increased need for pre- and post-dilation, but not with a higher incidence of early and mid-term adverse clinical outcomes, regardless of valve type. (ClinicalTrials.gov: NCT02737150).

Review of Prosthetic Paravalvular Leaks: Diagnosis and Management

PURPOSE OF REVIEW

Paravalvular leak (PVL) is a relatively uncommon complication associated with prosthetic valve implantation. PVL can occasionally lead to serious adverse consequences such as congestive heart failure, infective endocarditis, and hemolytic anemia. Surgical re-operation carries a high mortality risk.

RECENT FINDINGS

Transcatheter closure therapy provides a viable alternative for the treatment of this disorder with reasonable procedural and clinical success. The recent advent of hybrid imaging modalities has increased procedural success. This article summarizes the pathophysiology, clinical characteristics, and treatment modalities surroundings prosthetic paravalvular leak.

Incidence, Outcomes and Predictors of Aortic Regurgitation After Transcatheter Aortic Valve Replacement in Al Azhar University Hospitals and National Heart Institute, Egypt

Background: Aortic regurgitation (AR), which has ill-defined predictors and an unknown long-term influence on outcomes, is a significant transcatheter aortic valve replacement (TAVR) constraint. Objective: this research aimed to assess the prevalence, identify predictors, and evaluate the outcomes of aortic regurgitation following trans catheter aortic valve implantation (TAVI). 1. To calculate the prevalence of aortic regurgitation in elderly patients receiving trans catheter aortic valve implantation who have severe symptomatic aortic stenosis. 2. To determine aortic regurgitation risk factors after trans catheter aortic valve implantation. Methods: From November 2017 to November 2020, this prospective observational study was done in the National Heart Institute on severe aortic valve stenosis patients above 65 years who were candidates for aortic valve replacement from the outpatient department. Results: LVEF significantly improved. Compared to before TAVI (55.08 ± 9.71), LVEF elevated to 58.9 ± 8.8 (P<0.001). Twenty-five patients (83.3%) showed class III/IV, four patients (13.3%) showed class II, and one patient (3.3%) showed class I before TAVI. While after TAVI, three patients (10%) only showed NYHA class III/IV, six patients (20 %) in class II, and 21 patients (70%) improved to be in class I. The left ventricular mass index mean was 158 ±32.37 before TAVI and 133.50 ±21.96 after TAVI (p<0.001). Compared to before TAVI (0.75 ± 0.2), mean aortic valve area was improved to 2.0 ± 0.2 following TAVI (P<0.001). A significant reduction in the mean pressure gradient from 47 ± 11.08 mmHg across the native valve prior to TAVI to 10.28 ± 3.21 mmHg across the prosthetic valve following TAVI (P <0.001). Expert commentary: The clinical and results of TAVR devices were clearly outlined in literature study. The study showed a high incidence of pacemaker implantation with Core valve and aortic regurgitation. This information strongly supports the need for a randomized trial with sufficient power to compare the most recent self-expandable valve generation to balloon expandable valves. In the 2019 PARTNER 3 prospective randomized trial, it was discovered that, when compared to surgical management, low-risk patients (defined as STS 4%) had a lower risk of the composite outcome of stroke, death, and rehospitalization at 1 year. Additionally, it was shown that TAVR had a lower risk of stroke and required less time in the hospital (3 days as opposed to 7, P0.001) than surgery [1]. In addition, despite an elevated permanent pacemaker implantation rate, the 2019 Medtronic Evolut Transcatheter Aortic Valve Replacement revealed no inferiority for composite all-cause stroke and death, as well as a statistically significant decrease in the rates of life-threatening bleeding, acute kidney injury and atrial fibrillation, compared with SAVR at 30 days following the procedure [2]. Conclusion: According to the study in high-risk patients with severe symptomatic aortic stenosis, TAVI is alternative, viable, safe, and successful therapy compared to traditional open-heart surgery.