Predictors of Permanent Pacemaker Implantation in Patients With Severe Aortic Stenosis Undergoing TAVR

Reducing periprocedural complications in transcatheter aortic valve replacement: review of paravalvular leaks, stroke and vascular complications

Transcatheter aortic valve replacement has been established as the standard of care for inoperable patients and a valid alternative for high-risk individuals with severe symptomatic native aortic stenosis. Over the last decade, substantial improvement has been made in the transcatheter technology. Nevertheless, this less-invasive procedure is still associated with complications like paravalvular leaks, strokes and vascular complications. This review article discusses these worrisome complications associated with transcatheter aortic valve replacement and proposes methods to prevent these hurdles.

Optimizing clinical outcomes of transcatheter aortic valve implantation patients with comorbidities

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of high-risk or inoperable patients presenting with symptomatic severe aortic stenosis (AS). There are several factors to consider to optimize patient outcomes from TAVI. Before TAVI, patient selection is key and an understanding the effects of common comorbidities on outcomes after TAVI is critical. Some comorbidities share common risk factors with AS (e.g. coronary artery disease), others are directly or indirectly caused or exacerbated by severe AS (e.g. atrial fibrillation, pulmonary hypertension, mitral regurgitation, tricuspid regurgitation and right ventricular dysfunction), whereas others are not directly related to severe AS (e.g. chronic kidney disease and chronic lung disease). Choice of transcatheter heart valve prosthesis, vascular access route and mode of anesthesia are important considerations during TAVI. New onset conduction disturbances and arrhythmias remain a vexing issue after TAVI. The aim of the present review is to provide an overview of these issues.

Predictors of Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement

OBJECTIVE

Determine predictors of permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR).

DESIGN

A retrospective chart review of patients undergoing TAVR at the authors' institution. Extracted data included patient demographics, electrocardiogram, procedural, and echocardiographic data. Multivariate regression was performed to identify associations with PPM implantation.

SETTING

Single-center academic hospital.

PARTICIPANTS

Patients undergoing TAVR.

INTERVENTIONS

This study was retrospective. No interventions were performed on patients.

MEASUREMENTS AND MAIN RESULTS

Baseline electrocardiogram, Society of Thoracic Surgeons score, age, and echocardiographic parameters were not predictors of PPM implantation. However, multiple deployments was a risk factor, and degree of paravalvular leak trended toward significance. Ten patients required placement of a 2nd valve, or valve-in-valve (VIV). Of the 10 patients with VIV, 5 (50%) required a PPM, compared with 8 (14%) of 56 patients with a single valve (OR 6.0, p = 0.02). PPM implantation occurred in 5 (42%) patients with no leak, 8 (19%) patients with trace leak, and no patients with mild or moderate leak (p = 0.085). In patients with no or trace leak, VIV increased the likelihood of PPM from 17.4% to 62.5% (OR 7.9, p = 0.006). For the 42 patients with trace leak, VIV increased the likelihood of PPM from 11.4% to 57.1% (OR 10.33, p = 0.005).

CONCLUSIONS

The authors found VIV placement, and likely degree of paravalvular leak, to be predictors of PPM placement. VIV and the degree of leak may be useful markers for postoperative prophylactic pacemaker placement.

[From FRANCE 2 to FRANCE TAVI: are indications, technique and results of transcatheter aortic valve replacement the same?]

Transcatheter aortic valve implantation (TAVI) is indicated in patients with severe symptomatic aortic stenosis who are not suitable for surgery or should be considered when there is a high surgical risk as assessed by a heart team. There is a decrease in mean logistic EuroSCORE since January 2010, which translates a gradual evolution in patients' selection. Expertise of geriatricians to further assess frailty is a key step in the risk stratification process of this elderly population (mean age: 83.4±7.3 years). Femoral access is used in 80% of cases with a procedural success rate higher than 95%. In-hospital mortality rate is 5.9%. The main complications of the procedure are aortic annulus rupture (0.9% in FRANCE TAVI), tamponade (2.3%), stroke (2.2%), severe paravalvular leak (1.3%) and permanent pacemaker implantation (15%). The awaited results of PARTNER II and SURTAVI may lead to expand the indications to lower-risk patients if it is shown that TAVI is non-inferior to surgery in this population which has been suggested by the recent randomized NOTION Trial while the CoreValve Pivotal Trial even points in the direction of a possible superiority of the percutaneous technique over surgery.

Early discharge after transfemoral transcatheter aortic valve implantation

BACKGROUND

The aim of this study was to assess the feasibility and the safety of early discharge (within 72 h) after transfemoral transcatheter aortic valve implantation (TAVI) and to identify baseline features and/or peri-procedural variables, which may affect post-TAVI length-of-stay (LoS) duration.

METHODS AND RESULTS

Patients discharged within 72 h of TAVI (early discharge group) were compared with consecutive patients discharged after 3 days (late discharge group). Propensity-matched cohorts of patients with a 2:1 ratio were created to better control confounding bias. Among 465 patients, 107 (23.0%) were discharged within 3 days of the procedure. Multivariable regression analysis of unmatched patients demonstrated that baseline New York Heart Association (NYHA) class IV (OR: 0.22, 95% CI 0.05 to 0.96; p=0.045) and any bleeding (OR: 0.31, 95% CI 0.74 to 0.92; p=0.031) were less likely to be associated with early discharge after TAVI. Conversely, the year of procedure (OR: 1.66, 95% CI 1.25 to 2.20; p<0.001) and the presence of a permanent pacemaker (PPM) before TAVI (OR: 2.80, 95% CI 1.36 to 5.75; p=0.005) were associated with a higher probability of early discharge. In matched populations, patients in the early discharge group reported lower incidence of in-hospital bleeding (7.9% vs 19.4%, p=0.014), major vascular complications (2.3% vs 9.1%, p=0.038) and PPM implantation (7.9% vs18.5%, p=0.021), whereas after discharge, at 30-day, no significant differences were reported between groups in terms of death (2.2% vs 1.7%, p=0.540), bleeding (0.0% vs 1.1%, p=0.444), PPM implantation (1.1% vs 0.0%, p=0.333) and re-hospitalisation (1.1% vs 1.1%, p=1.000).

CONCLUSIONS

Early discharge (within 72 h) after transfemoral TAVI is feasible and does not seem to jeopardise the early safety of the procedure, when performed in a subset of patients selected by clinical judgement. Patients undergoing TAVI in unstable haemodynamic compensation and patients experiencing bleeding after the procedure demonstrated to be poorly suitable to this approach, whereas increasing experience in post-TAVI management was associated with a reduction of LoS.

Transfemoral aortic valve implantation with the repositionable Lotus valve compared with the balloon-expandable Edwards Sapien 3 valve

BACKGROUND

The rate of paravalvular aortic insufficiency (AI) with transcatheter aortic valve implantation (TAVI) with first generation devices was higher compared with surgical replacement. Residual AI after TAVI has been linked to an increased mortality rate. We compared two second generation TAVI devices - the repositionable Lotus valve with the balloon-expandable Edwards Sapien 3 valve - regarding procedural and 30 day outcome.

METHODS AND RESULTS

In 78 patients with severe aortic stenosis undergoing transfemoral TAVI we evaluated post-procedural paravalvular AI, device success and early safety according to VARC criteria. Valve size was based on a 256-multislice computed tomography. Patients were followed for 30 days. The Lotus valve (N = 26) and the Edwards Sapien 3 valve (N = 52) were implanted under fluoroscopic guidance. Baseline characteristics were similar between groups. Perimeter derived annulus diameter did not differ with 25.7 ± 1.6mm for Lotus and 25.2 ± 2.1mm for Edwards Sapien 3 patients. After TAVI aortography and transthoracic echocardiography revealed no moderate or severe AI. The rate of mild AI was 12% for Lotus and 15% for Edwards Sapien 3 (p = 0.62). There were no deaths, stroke, annulus rupture or coronary obstruction. Device success was 96% and 98% (p = 0.61), early safety according to VARC 11.5% in both groups (p = 1.0) and the need for pacemaker implantation 27% and 4% (p < 0.003), respectively.

CONCLUSIONS

TAVI with second-generation devices was associated with no moderate or severe AI and a low rate of mild AI. Device success was high for Lotus and Edwards Sapien 3 while the need for permanent pacemaker was significantly higher with the Lotus valve.

Valvular heart disease and postoperative considerations

Despite increasing trends in catheter-based cardiac surgical procedures, more than 278 000 Americans had traditional cardiac surgery in 2013. Of those surgical procedures, approximately 133 000 involved valvular repair or replacement. Aortic valve replacement was by far the most common valvular operation, followed by mitral valve repair or replacement. This review article will discuss characteristics of valvular pathologies and postoperative concerns for each the 4 cardiac valves.

Transcatheter aortic valve implantation--update and evidence

Transcatheter aortic valve implantation (T-AVI) has become the standard of care for high-risk patients suffering from severe aortic valve stenosis. More than 60,000 implants have been performed to date. While the first-generation T-AVI devices had some specific issues, the advancements in these first-generation devices and the development of second-generation devices significantly reduced the incidence of peri-procedural complications. The two major access routes are the transfemoral (TF) and the transapical (TA) approach. Both approaches have their advantages and should be considered equal alternatives for finding the best treatment option for the individual patient. Currently there are discussions about extending the indication to patients with lower risk profiles. However, there is no real evidence to justify an expansion, as results of surgical aortic valve replacement in low and intermediate risk patients are excellent.

Influence of QRS infarct score and QRS duration prior to transcatheter aortic valve replacement on follow-up left ventricular end systolic volume in patients with new persistent left bundle branch block

BACKGROUND

New-onset left bundle branch block (LBBB) is a known complication during Transcatheter Aortic Valve Replacement (TAVR). This study evaluated the influence of pre-TAVR cardiac conditions on left ventricular functions in patients with new persistent LBBB post-TAVR.

METHODS

Only 11 patients qualified for this study because of the strict inclusion criteria. Pre-TAVR electrocardiograms were evaluated for Selvester QRS infarct score and QRS duration, and left ventricular end-systolic volume (LVESV) was used as outcome variable.

RESULTS

There was a trend towards a positive correlation between QRS score and LVESV of r=0.59 (p=0.058), while there was no relationship between QRS duration and LVESV (r=-0.18 [p=0.59]).

CONCLUSION

This study showed that patients with new LBBB and higher pre-TAVR QRS infarct score may have worse post-TAVR left ventricular function, however, pre-TAVR QRS duration has no such predictive value. Because of the small sample size these results should be interpreted with caution and assessed in a larger study population.

Avoiding Coronary Occlusion and Root Rupture in TAVI - The Role of Pre-procedural Imaging and Prosthesis Selection

Coronary occlusion and rupture of the aortic root or annulus remain two major concerns of transcatheter aortic valve implantation technique. Despite their relatively low frequency they raised the interest of the scientific community as they carry an extremely poor prognosis. Prosthesis type and size selection is part of the patient selection process that allows the operator to prevent these complications. In this article, the techniques used either during pre-TAVI screening or during the procedure itself to avoid coronary occlusion and aortic rupture will be discussed.

Editor-in-chief's picks from 2014: part two

As I spent countless hours pouring over hundreds of manuscripts to select those that rose to the top over the past year, I became incredibly excited about being part of a Journal that produces such wonderfully rich and diverse content each year. I have personally selected the papers (both original investigations and review articles) from 13 distinct specialties for your review. There are approximately 150 articles selected across this 2-part series, which represents less than 3% of the papers submitted to JACC in 2014. In order to present the full breadth of this important research in a consumable fashion, we will present these manuscripts over the course of 2 issues of JACC. Part One includes the sections: Congenital Heart Disease, Coronary Disease & Interventions, Genetics, Omics, & Tissue Regeneration, CV Prevention & Health Promotion, Cardiac Failure, and Cardiomyopathies. Part Two includes the sections: Hypertension, Imaging, Metabolic Disorders & Lipids, Neurovascular & Neurodegenerative Disorders, Rhythm Disorders, Valvular Heart Disease, and Vascular Medicine (1-86).

Risk Assessment in Patient Selection for Transcatheter Aortic Valve Replacement

Risk assessment models for transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement in high-risk patients and TAVR versus palliation in inoperable patients are based on surgical data and have limited discrimination and calibration in the setting of TAVR. Several novel risk models specifically designed for TAVR have improved discrimination over existing models but require further validation. Several clinical and echocardiographic variables, such as chronic lung disease, mitral regurgitation, and stroke volume index, influence outcomes. This article reviews current and novel risk models and important predictors of TAVR outcomes and proposes a framework to integrate them into clinical decision-making for patients with severe, symptomatic aortic stenosis.

Permanent Pacemaker Implantation after TAVR - Predictors and Impact on Outcomes

The number of patients undergoing transcatheter aortic valve replacement (TAVR) worldwide is increasing steadily. Atrioventricular conduction disturbances, with or without the need for permanent pacemaker (PPM) implantation, are one of the most common adverse events after TAVR. Among transcatheter heart valves (THV), rates of conduction abnormalities vary from less than 10 % to more than 50 %. Depending on the reported data referred to, historical data showed that up to one-third of the patients required implantation of a PPM following TAVR. Although generally considered as a minor complication, PPM may have a profound impact on prognosis and quality of life after TAVR. Current data support the hypothesis that conduction abnormalities leading to pacemaker dependency result from mechanical compression of the conduction system by the prosthesis stent frame and individual predisposing conduction defects such as right bundle-branch block (RBBB). With several large randomised trials and registry studies having been published recently and second generation THV having been introduced, the debate about predictors for pacemaker implantation and their impact on outcome after TAVR is still ongoing.