Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond

Minimally Invasive vs Conventional Aortic Valve Replacement With Rapid-Deployment Bioprostheses

BACKGROUND

The aim of this multicenter retrospective study was to compare early and midterm clinical and hemodynamic results of aortic valve replacement with rapid-deployment bioprostheses performed through conventional full-sternotomy vs mini-sternotomy.

METHODS

Data from the Italian multicenter registry of aortic valve replacement with rapid-deployment bioprostheses (INTU-ITA registry) were analyzed. Patients were divided into 2 groups: full sternotomy (FS) and ministernotomy (MS). Primary endpoint was the comparison of early and midterm mortality. Secondary endpoints were: comparison of intraoperative variables, complications, and hemodynamic performance. A propensity score weighting approach was used for data analysis.

RESULTS

A total of 1057 patients were analyzed: 435 (41.2%) and 622 (58.8%) in group FS and MS, respectively. Thirty-day mortality was 1.6% and 0.6% in FS and MS groups, respectively (P = .074). cardiopulmonary bypass time was 78.5 minutes and 83 minutes in FS and MS groups, respectively (P = .414). In the overall cohort, the incidence of intraoperative complications and of device success was 3.8% (40 patients) and 95.9% (1014 patients), respectively, with no significant differences between groups. Survival at 1, 3, and 5 years was 94.1%, 98.1%, 88.5% and 91.8%, 85.2%, and 84.8% in FS and MS groups, respectively (P = .412). The 2 groups showed similar postoperative gradients (median mean gradient, FS: 10.0 mm Hg, MS: 11.0 mm Hg; P = .170) and also similar incidence of patient-prosthesis mismatch (FS: 7%, MS: 6.4%, P = .647).

CONCLUSIONS

According to our data, rapid-deployment bioprostheses allow the performance of minimally invasive aortic valve replacement with similar surgical times and similar clinical and hemodynamic outcomes to conventional surgery and should be considered the first choice in these procedures.

Outcomes of transfemoral transcatheter aortic valve implantation (TAVI) and predictors of thirty-day major adverse cardiovascular events (MACE) and one-year mortality

OBJECTIVE

TAVI is more frequently used to treat aortic stenosis with the mandate to have a low as possible rate of adverse events. We present our 30-day outcomes and one-year mortality and examine the factors associated with them.

METHODS

A prospective evaluation was performed of all patients who underwent transfemoral TAVI in Nicosia General Hospital from January 2015 until March 2020. MACE were defined as cardiac death, disabling stroke, and/or major vascular complications (VC). Multiple logistic and Cox regression analyses were used to identify the factors associated with 30-day MACE and one-year mortality, respectively.

RESULTS

A total of 235 TAVI procedures were performed (178 balloon-expandable, 57 self-expandable). Thirty-day outcomes were MACE: 4.3%, cardiovascular death: 2.1%, disabling stroke: 1.3%, major VC: 1.7%, and contrast induced nephropathy (CIN): 4.3%. There was a rate of 6.2% new pacemaker implantations and 0.9% of more than mild aortic valve regurgitation (AR) at 30 days. Mortality at one year was 15.1%. The balloon-expandable valves appear to have less new pacemakers, less mild AR, lower contrast volume used, and less days of hospitalization, while the self-expandable valves have lower post-procedural gradients. Low hemoglobulin, history of atrial fibrillation (AF), and lower BMI were predictors of 30-day MACE. Serum creatinine >2 mg/dL, history of AF, RVSP >60 mmHg and major VC are predictors of one-year mortality.

CONCLUSION

We have shown excellent 30-day results with low incidence of adverse events for both the balloon-expandable and self-expandable valves. Clinical factors are the main predictors of both 30-day MACE and one-year mortality; major VC is a strong predictor of one-year mortality.

Comparison of outcome of transcatheter aortic valve implantation in patients with advanced age: A systematic review and meta-analysis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is an effective treatment to aortic stenosis in patients with advanced age. However, age is recognized as one of the most important risk factors. The aim of our study is to compare the outcome of TAVI between octogenarian patients and young patients.

METHODS

Randomized controlled trials, cohort studies and propensity score matching studies will be included in our systematic review and meta-analysis to evaluate clinical outcome in octogenarian patients who undergo TAVI. PubMed, EMBASE, MEDLINE, Cochrane Library and Web of Science will be searched using a comprehensive strategy. The related conference proceedings and reference lists of the included studies will also be checked to identify additional studies. Retrieved records, extract information and assess the risk of bias will be screened by two reviewers independently. STATA software will be used to conduct data synthesis. There is no requirement of ethical approval and informed consent.

RESULTS

This study will eventually be published in a peer reviewed journal in the form of a scientific paper.

CONCLUSION

This study will provide a comprehensive review of the available evidence for the treatment of aortic stenosis in octogenarian patients underwent TAVI. We hope it will provide a relatively comprehensive reference for clinical practice and future relevant clinical trials.

PROSPERO REGISTRATION NUMBER

CRD42020155189.

STUDY PROTOCOL REGISTRY

The protocol has been registered in PROSPERO, which is an International Prospective Register of Systematic Reviews. The registration number is CRD42020155189.

ETHICS AND DISSEMINATION

Ethics approval and patient consent are not required as this study is a systematic review and meta-analysis.

Prevalence and Predictors of Atherosclerotic Peripheral Arterial Obstructive Disease in Severe Heart Valve Diseases

Despite witnessing an upsurge in heart valve diseases (HVDs), the correlation between HVDs and atherosclerotic peripheral arterial obstructive disease (PAOD) remains unclear. This study aims to investigate the prevalence and predictors of PAOD in HVDs.In this study, a total of 245 consecutive patients were examined: 153 with severe aortic valve stenosis (AS), 66 with severe primary mitral valve regurgitation (MR), and 26 with severe pure native aortic valve regurgitation (AR). All patients underwent ultrasound scan of the carotid artery to ascertain the presence of internal carotid artery stenosis (ICAS). ICAS was defined as a peak systolic velocity ≥ 125 cm/second and/or ≥ 50% reduction in diameter. In addition, we measured the ankle-brachial index in each leg using a volume plethysmograph. A result of ≤ 0.9 was considered lower extremity artery disease (LEAD).The presence of ICAS was statistically more frequent in patients with severe AS than in patients with severe MR and AR (11.1% versus 1.5% versus 3.8%; P = 0.038). LEAD was present in patients with severe AS (17.6%) and MR (10.6%) but not in patients with severe AR (P = 0.037). The multivariate analysis revealed that the presence of severe AS (OR, 5.6 [1.3-24.9]; P = 0.023) was an independent predictor for ICAS, while history of coronary artery disease (OR, 4.8 [2.2-10.5]; P < 0.001) was an independent predictor for LEAD.The prevalence of PAOD varies depending on each valvular disease. Individual screening should be considered on the basis of atherosclerotic risk factors, especially for patients with severe AS.

How low is "low-flow" in aortic stenosis? A retrospective analysis of patients with true low-flow/low-gradient aortic stenosis undergoing TAVI

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a valuable treatment option for patients with reduced left ventricular ejection fraction (LVEF) and low-flow/low-gradient (LF/LG) aortic stenosis (AS). According to current literature, the presence of severe AS is unlikely in case of severely reduced LVEF and mean pressure gradient (meanPG) below 30 mmHg. However, a considerable number of patients presenting with typical clinical symptoms of severe AS, show gradients below 30 mmHg. We hypothesized, that these patients undergoing TAVI do have a measurable clinical benefit and an improved LVEF.

METHODS

In this single center retrospective cohort study, data from 1199 patients undergoing TAVI between 2013 and 2017 was analyzed. A 6-month follow-up was performed to assess changes in NT-proBNP, NYHA-class, and LVEF.

RESULTS

Thirty patients presented with LVEF<35%, an aortic valve area (AVA<1 cm²), and a meanPG below 30 mmHg. Mean logistic EuroSCORE II was 24.05±10.9. Most patients (56%) showed improved NYHA-class upon follow-up. NT-proBNP-levels decreased from 3.901 pg/mL IQR 10.880 to 1.491 pg/mL IQR 2.245 (P<0.001). LVEF increased from 30% IQR 6.25 to 40% IQR 15 (P<0.001).

CONCLUSIONS

Based on our findings TAVI represents a valuable treatment option even in patients with LF/LG AS and PGmean below 30mmHg.

The impact of subclinical congestion on the outcome of patients undergoing transcatheter aortic valve implantation

BACKGROUND

We investigated the impact of an elevated plasma volume status (PVS) in patients undergoing TAVI on early clinical safety and mortality and assessed the prognostic utility of PVS for outcome prediction.

MATERIALS AND METHODS

We retrospectively calculated the PVS in 652 patients undergoing TAVI between 2009 and 2018 at two centres. They were then categorized into two groups depending on their preoperative PVS (PVS ≤-4; n = 257 vs PVS>-4; n = 379). Relative PVS was derived by subtracting calculated ideal (iPVS = c × weight) from actual plasma volume (aPVS = (1 - haematocrit) × (a + (b × weight in kg)).

RESULTS

The need for renal replacement therapy (1 (0.4%) vs 17 (4.5%); P = .001), re-operation for noncardiac reasons (9 (3.5%) vs 32 (8.4%); P = .003), re-operation for bleeding (9 (3.5%) vs 27 (7.1%); P = .037) and major bleeding (14 (5.4%) vs 37 (9.8%); P = .033) were significantly higher in patients with a PVS>-4. The composite 30-day early safety endpoint (234 (91.1%) vs 314 (82.8%); P = .002) confirms that an increased preoperative PVS is associated with a worse overall outcome after TAVI.

CONCLUSIONS

An elevated PVS (>-4) as a marker for congestion is associated with significantly worse outcome after TAVI and therefore should be incorporated in preprocedural risk stratification.

Predictors of survival in patients undergoing cardiac rehabilitation after transcatheter aortic valve implantation

AIMS

Cardiac rehabilitation may improve physical and functional recovery after transcatheter aortic valve implantation (TAVI), but outcome predictors in TAVI patients are usually based on assessments made before or at the time of TAVI without regard to cardiac rehabilitation referral. We aimed to assess exercise-based cardiac rehabilitation-derived parameters that may predict 3-year outcome in TAVI patients undergoing residential cardiac rehabilitation.

METHODS AND RESULTS

In 95 consecutive TAVI patients (82.7 ± 4.9 years, 65% women) who underwent a 3-week cardiac rehabilitation program, at 3-year follow-up 35 deaths occurred. Compared with survivors, nonsurvivors had longer stay in cardiac rehabilitation (29.5 ± 12.3 vs. 21.6 ± 7.5 days, P = 0.0001), worse serum creatinine at admission/discharge (1.59 ± 0.86 vs. 1.26 ± 0.43 mg/dl, P = 0.0164; 1.52 ± 0.61 vs. 1.23 ± 0.44 mg/dl, P = 0.011), higher Cumulative Illness Rated State Comorbidity Index (5.4 ± 1.5 vs. 4.6 ± 1.8, P = 0.036) and Barthel Index at admission/discharge (51.8 ± 24.5 vs. 68.1 ± 23.2, P = 0.0016; 73.5 ± 27.2 vs. 88.6 ± 15.3, P = 0.0007), higher Morse Fall Risk score (35.6 ± 24 vs. 24.3 ± 14.1, P = 0.0056), and were less likely to train above the median exercise workload (fit) (11 vs. 35%, P = 0.008) or perform the 6-min walk test (6MWT) at admission/discharge (NO-6MWT: 34 vs. 12%, P = 0.008) and walked less distance on admission (6MWT: 129.6 ± 88.3 vs. 193.3 ± 69.8 m, P = 0.008). Univariate predictors of 3-year survival were cardiac rehabilitation duration, serum creatinine, Cumulative Illness Rated State Comorbidity Index, Barthel Index and NO-6MWT at admission/discharge, 6MWT at admission, Morse Fall Risk score at discharge and fit. Multivariate analysis confirmed exercise tolerance, Barthel Index and sCr at discharge as predictors.

CONCLUSION

In TAVI patients who undergo cardiac rehabilitation, lower exercise tolerance, higher Barthel Index and sCr at discharge may predict 3-year mortality.

Role of Frailty on Risk Stratification in Cardiac Surgery and Procedures

The number of older people candidates for interventional cardiology, such as PCI but especially for transcatheter aortic valve implantation (TAVI) , would increase in the future. Generically, the surgical risk, the amount of complications in the perioperative period, mortality and severe disability remain significantly higher in the elderly than in younger. For this reason it's important to determine the indication for surgical intervention, using tools able to predict not only the classics outcome (length of stay, mortality), but also those more specifically geriatrics, correlate to frailty: delirium, cognitive deterioration, risk of institutionalization and decline in functional status. The majority of the most used surgical risks scores are often specialist-oriented and many variables are not considered. The need of a multidimensional diagnostic process, focused on detect frailty, in order to program a coordinated and integrated plan for treatment and long term follow up, led to the development of a specific geriatric tool: the Comprehensive Geriatric Assessment (CGA). The CGA has the aim to improve the prognostic ability of the current risk scores to capture short long term mortality and disability, and helping to resolve a crucial issue providing solid clinical indications to help physician in the definition of on interventional approach as futile. This tool will likely optimize the selection of TAVI older candidates could have the maximal benefit from the procedure.

Living Donor Liver Transplantation Following Transcatheter Aortic Valve Implantation for Aortic Valvular Disease

Over the last few decades, outcomes with living donor liver transplantation (LDLT) have improved significantly. This has resulted in patients who were denied liver transplantation previously, due to various comorbidities and high risk, now being considered for LDLT. This includes patients with severe valvular heart disease such as aortic stenosis. These patients require aortic valve replacement to help cope with significant perioperative hemodynamic changes. High-risk cardiac procedures like aortic valve replacement are associated with serious perioperative morbidity and mortality in patients with end-stage liver disease. Since the advent of transcatheter aortic valve implantation (TAVI) in 2002, there have been a few case reports of its successful use prior to deceased donor liver transplantation, but there is no literature on this procedure before LDLT. In this article, we report our experience with 2 patients, the first patient with infective endocarditis-induced acute aortic regurgitation and the second patient with bicuspid aortic stenosis who underwent uneventful TAVI followed by successful LDLT. In conclusion, with the increasing expertise and experience in this procedure, an increasing number of potential recipients, previously considered as high-risk transplant candidates, can now be offered liver transplantation by performing pretransplant TAVI.

A meta-analysis of ≥5-year mortality after transcatheter versus surgical aortic valve replacement

INTRODUCTION

It remains unclear whether long-term survival is superior following transcatheter aortic valve implantation (TAVI) than following surgical aortic valve replacement (SAVR). We performed a meta-analysis of mortality with ≥5-year follow-up in randomized controlled trials (RCTs) and propensity-score matched (PSM) studies of TAVI versus SAVR.

EVIDENCE ACQUISITION

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through March 2019. Eligible studies were RCTs or PSM studies of TAVI versus SAVR enrolling patients with severe aortic stenosis and reporting all-cause mortality with ≥5-year follow-up as an outcome. A hazard ratio of mortality for TAVI versus SAVR was extracted from each individual study.

EVIDENCE SYNTHESIS

Our search identified 3 RCTs and 7 PSM studies enrolling 5498 patients. A pooled analysis of all 10 studies demonstrated a statistically significant 38% increase in mortality with TAVI relative to SAVR. A subgroup meta-analysis showed no statistically significant difference between TAVI and AVR in RCTs and a statistically significant 68% increase with TAVI relative to SAVR in PSM studies.

CONCLUSIONS

On the basis of a meta-analysis of 7 PSM studies, TAVI is associated with greater all-cause mortality with ≥5-year follow-up than SAVR. However, another meta-analysis of 3 RCTs suggests no difference in mortality between TAVI and SAVR.

Does additional coronary artery bypass grafting to aortic valve replacement in elderly patients affect the early and long-term outcome?

Early and long-term outcomes in elderly patients who underwent isolated aortic valve replacement (iAVR) are well defined. Conflicting data exist in elderly patients who underwent AVR plus coronary artery bypass grafting (CABG). We sought to evaluate the early and long-term outcomes of combined AVR + CABG in patients older than 75 years of age. From June 1999 to June 2018, 402 patients ≥ 75 years who underwent iAVR (n = 200; 49.7%) or combined AVR plus CABG (n = 202; 50.3%) were retrospectively analysed. AVR + CABG patients were older than iAVR patients (78.5 ± 2.5 vs 77.6 ± 2.8 years; p < 0.0001), with greater co-morbidities and more urgent/emergency surgery. 30-day mortality was 6.5% in the AVR + CABG and 4.5% in the iAVR group (p = 0.38). Multivariate analysis identified EuroSCORE II [odd ratio (OR) 1.13] postoperative stroke (OR 12.53), postoperative low cardiac output syndrome (OR 8.72) and postoperative mechanical ventilation > 48 h (OR 8.92) as independent predictors of 30-day mortality; preoperative cerebrovascular events (OR 3.43), creatinine (OR 7.27) and extracorporeal circulation time (OR 1.01) were independent predictors of in-hospital major adverse cardiovascular and cerebral events (MACCE). Treatment was not an independent predictor of 30-day mortality and in-hospital MACCE. Survival at 1, 5 and 10 years was 94.7 ± 1.6%, 72.6 ± 3.6% and 31.7 ± 4.8% for iAVR patients and 89.1 ± 2.3%, 73.9 ± 3.5% and 37.2 ± 4.8% for AVR + CABG subjects (p = 0.99). Using adjusted Cox regression model, creatinine [hazard ration (HR) 1.50; p = 0.018], COPD (HR 1.97; p = 0.003) and NYHA class (HR 1.39; p < 0.0001) were independent predictors of late mortality; the combined AVR + CABG was not associated with increased risk of late mortality (HR 0.83; p = 0.30). In patients aged ≥ 75 years, combined AVR + CABG was not associated with increased 30-day mortality, in-hospital MACCE and long-term mortality. Surgical revascularization can be safely undertaken at the time of AVR in elderly patients.

Five-Year Outcomes of Transfemoral Transcatheter Aortic Valve Replacement or Surgical Aortic Valve Replacement in a Real World Population

Background:

The OBSERVANT study (Observational Study of Effectiveness of SAVR–TAVI Procedures for Severe Aortic Stenosis Treatment) showed that mortality at 1 year is similar after transfemoral transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) for real-world propensity-matched patients with aortic stenosis at low and intermediate risk. We report the 5-year outcomes of the Italian OBSERVANT study.

Methods and Results:

The unadjusted enrolled population (N=7618) between December 2010 and June 2012 included 5707 patients on SAVR and 1911 patients on TAVR. The propensity score method was applied to select 2 groups with similar baseline characteristics. All outcomes were adjudicated through a linkage with administrative databases. The primary end points of this analysis were death from any cause and major adverse cardiac and cerebrovascular events at 5 years. The matched population had a total of 1300 patients (650 per group). The propensity score method generated a low and intermediate-risk population (mean logistic EuroSCORE 2: 5.1±6.2% versus 4.9±5.1%, SAVR versus transfemoral TAVR; P =0.485). At 5 years, the rate of 5 death from any cause was 35.8% in the surgical group and 48.3% in the transcatheter group (hazard ratio, 1.38; 95% CI, 1.12–1.69; P =0.002). Similarly, TAVR was associated with an increased risk of major adverse cardiac and cerebrovascular events as compared with SAVR (42.5% versus 54.0%; hazard ratio, 1.35; 95% CI, 1.11–1.63; P =0.003). The cumulative incidence of cerebrovascular events, myocardial infarction, and coronary revascularization were similar in the study groups at 5 years.

Conclusions:

The present results suggest that at 5 years, in a real-world population with severe aortic stenosis and at low and intermediate risk, suggest that SAVR is associated in with lower mortality and major adverse cardiac and cerebrovascular events rates than transfemoral TAVR performed using first-generation devices. These data need to be confirmed in randomized trials using new-generation TAVR devices.

Ten-year experience with transcatheter and surgical aortic valve replacement in Finland

Aim: We investigated the outcomes of transcatheter (TAVR) and surgical aortic valve replacement (SAVR) in Finland during the last decade. Methods: The nationwide FinnValve registry included data from 6463 patients who underwent TAVR or SAVR with a bioprosthesis for aortic stenosis from 2008 to 2017. Results: The annual number of treated patients increased three-fold during the study period. Thirty-day mortality declined from 4.8% to 1.2% for TAVR (p = .011) and from 4.1% to 1.8% for SAVR (p = .048). Two-year survival improved from 71.4% to 83.9% for TAVR (p < .001) and from 87.2% to 91.6% for SAVR (p = .006). During the study period, a significant reduction in moderate-to-severe paravalvular regurgitation was observed among TAVR patients and a reduction of the rate of acute kidney injury was observed among both SAVR and TAVR patients. Similarly, the rate of red blood cell transfusion and severe bleeding decreased significantly among SAVR and TAVR patients. Hospital stay declined from 10.4 ± 8.4 to 3.7 ± 3.4 days after TAVR (p < .001) and from 9.0 ± 5.9 to 7.8 ± 5.1 days after SAVR (p < .001). Conclusions: In Finland, the introduction of TAVR has led to an increase in the invasive treatment of severe aortic stenosis, which was accompanied by improved early outcomes after both SAVR and TAVR. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03385915 Key Messages This study demonstrated that the introduction of transcatheter aortic valve replacement has led to its widespread use as an invasive treatment for severe aortic stenosis. Early and 2-year survival after transcatheter and surgical aortic valve replacement has improved during past decade. Transcatheter aortic valve replacement has fulfilled its previously unmet clinical needs and has surpassed surgical aortic valve replacement as the most common invasive treatment for aortic stenosis.

Impact of age on long term survival following transcatheter aortic valve implantation

Objective

To compare the long-term survival following transcatheter aortic valve implantation (TAVI) in an octogenarian population with that in a younger population.

Methods

This retrospective study included 274 patients that underwent TAVI for severe symptomatic aortic stenosis. The study group was divided into two age groups, as those with an age ≥ 80 years (octogenarians, n = 132), and age < 80 (younger patients, n = 142). The two groups were compared in terms of clinical outcomes and survival. In addition, significant predictors of survival were estimated.

Results

Non-cardiac mortality (during follow-up) (21.9% vs. 10.5%, P = 0.01) and in-hospital stroke (8.3% vs. 2.8%, P = 0.01) were more common among octogenarians. The two groups did not differ in terms of mean survival (41.0 ± 2.1 vs. 38.2 ± 2.2 months, respectively, P = 0.18). Multivariate analysis identified left ventricular ejection fraction < 35% (OR: 2.17, 95% CI: 1.17–4.03; P = 0.01), preoperative of moderate to severe mitral insufficiency (OR: 1.88, 95% CI: 1.15–3.06; P = 0.01), postoperative major and life-threating bleeding (OR: 2.49, 95% CI: 1.05–5.89; P = 0.03), and in-hospital stroke (OR: 2.29, 95% CI: 1.04–5.04; P = 0.03) as potential predictors of poor survival.

Conclusions

In this study, similarly favorable survival outcomes were achieved in the elderly population as in younger patients, despite the presence of comorbid conditions. A consideration should be given to non-surgical management of severe aortic stenosis with the TAVI procedure in elderly patients, in the absence of co-existent conditions associated with shortened life expectancy.

Cardiac rehabilitation to improve health-related quality of life following trans-catheter aortic valve implantation: a randomised controlled feasibility study: RECOVER-TAVI Pilot, ORCA 4, For the Optimal Restoration of Cardiac Activity Group

Objectives

Transcatheter aortic valve implantation (TAVI) is often undertaken in the oldest frailest cohort of patients undergoing cardiac interventions. We plan to investigate the potential benefit of cardiac rehabilitation (CR) in this vulnerable population.

Design

We undertook a pilot randomised trial of CR following TAVI to inform the feasibility and design of a future randomised clinical trial (RCT).

Participants

We screened patients undergoing TAVI at a single institution between June 2016 and February 2017.

Interventions

Participants were randomised post-TAVI to standard of care (control group) or standard of care plus exercise-based CR (intervention group).

Outcomes

We assessed recruitment and attrition rates, uptake of CR, and explored changes in 6-min walk test, Nottingham Activities of Daily Living, Fried and Edmonton Frailty scores and Hospital Anxiety and Depression Score, from baseline (30 days post TAVI) to 3 and 6 months post randomisation. We also undertook a parallel study to assess the use of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the post-TAVI population.

Results

Of 82 patients screened, 52 met the inclusion criteria and 27 were recruited (3 patients/month). In the intervention group, 10/13 (77%) completed the prescribed course of 6 sessions of CR (mean number of sessions attended 7.5, SD 4.25) over 6 weeks. At 6 months, all participants were retained for follow-up. There was apparent improvement in outcome scores at 3 and 6 months in control and CR groups. There were no recorded adverse events associated with the intervention of CR. The KCCQ was well accepted in 38 post-TAVI patients: mean summary score 72.6 (SD 22.6).

Conclusions

We have demonstrated the feasibility of recruiting post-TAVI patients into a randomised trial of CR. We will use the findings of this pilot trial to design a fully powered multicentre RCT to inform the provision of CR and support guideline development to optimise health-related quality of life outcomes in this vulnerable population. Retrospectively registered 3rd October 2016 clinicaltrials.gov NCT02921880.

Trial registration

Clinicaltrials.Gov identifier NCT02921880.

The prognostic value of fragmented QRS in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Although transcatheter aortic valve implantation (TAVI) can successfully correct aortic narrowing, pre-existing pathophysiological alterations in the left ventricle are still a concern in terms of long-term mortality. This study aimed to examine the predictive role of fQRS morphology on long-term prognosis in patients undergoing TAVI due to severe aortic stenosis.

METHODS

A total of 117 patients undergoing TAVI due to severe aortic stenosis were included in this retrospective cohort study. Patients were assigned into two groups based on the presence (n = 36) or absence (n = 81) of fQRS. Predictors of long-term survival were estimated.

RESULTS

In-hospital mortality was higher in fQRS group (5.5% vs. 1.2%, p = 0.0224). In the long-term, fQRS (OR: 3.06, 95% CI 1.29-7.27, p: 0.01), LVEF <50% (OR: 2.54, 95% CI 1.07-6.02, p: 0.03) and presence of atrial fibrillation (OR: 2.42, 95% CI 1.05-5.60, p: 0.03) emerged as significant independent predictors of short survival.

CONCLUSION

Presence of fQRS on ECG, an indirect indicator of myocardial fibrosis, seems to have the potential to be used as a prognostic marker after TAVI procedure. Large prospective studies are warranted.

Effect of preoperative low serum albumin on postoperative complications and early mortality in patients undergoing transcatheter aortic valve replacement

Background

Patients undergoing transcatheter aortic valve replacement (TAVR) are mostly elderly patients with substantial comorbidities. Established risk scores are not validated for TAVR and collectives with elderly patients making periprocedural risk stratification difficult. Serum albumin is known to be an indicator for malnutrition and frailty and is simple to measure, independent of physician's bias. Using serum albumin as a preoperative marker for postoperative complications might help estimating morbidity and mortality of these patients.

Methods

A total of 457 patients with severe symptomatic aortic stenosis undergoing TAVR at our institution in a period from January 2014 to December 2015 were included in this retrospective study. Baseline characteristics as well as preoperative laboratory parameters were registered. Postoperative morbidity and 30-day mortality were analyzed as primary end points. Enrolled patients with preoperative low serum albumin (<3.5 g/dL) were compared with those revealing normal serum albumin (≥3.5 g/dL).

Results

Among 457 patients, 51 (11%) presented pre-procedural low serum albumin and 406 (89%) had normal serum albumin. Patients' mean age was 81±6 years and 50% of them were male. Postoperative complications such as requirement of blood transfusions (63% versus 33%, P<0.001), infection (53% versus 24%, P<0.001), acute kidney injury (41% versus 19%, P=0.001) and 30-day mortality (10% versus 3%, P=0.045) showed significant differences between preoperative low and normal albumin groups.

Conclusions

Preoperative low serum albumin might be an indicator for higher morbidity and mortality in patients undergoing TAVR.

TAVI-thick on technology but thin on evidence

Transcatheter aortic valve implantation (TAVI) has emerged as one of the most popularly deployed interventional innovations of recent times. After addressing the inoperable and high-risk patients, it is application is being extended to intermediate and low-risk category. There is some disquiet about the strength of evidence on which the clinical application is based. Durability and pacemaker requirement are also areas of concern. This review highlights the areas of concern on these aspects. There is also a need to address these deficiencies in future trials and also bring updated database reports in the public domain.

Transcatheter aortic valve implantation in patients younger than 75 years: Guidelines-based patients selection and clinical outcome

BACKGROUND

Patients treated by transcatheter aortic valve implantation (TAVI) in all major recent trials are still mostly octogenarians. Aim of this study is to analyze the risk profile and outcome of TAVI patients <75 years.

METHODS AND RESULTS

We retrospectively analyzed 172 patients <75 years with symptomatic severe native AS or degeneration of surgical aortic bioprosthesis treated with TAVI. The level of surgical risk was reassessed according to multiparametric ACC classification (prohibitive in 68 patients, high in 34, intermediate in 70). Mean age was 69.02 ± 6.18 years, mean STS score 5.56 ± 5.21. The majority of them presented one or more clinical or anatomical characteristics favoring TAVI according to ECS guidelines, despite the young age. Vascular access was transfemoral in 76%. According to the VARC-2 definitions, device success was high (90%) in all groups. The early safety was 89%, clinical recovery was slower in prohibitive risk patients. Bleeding events were more frequent in prohibitive and high surgical risk classes. Clinical efficacy at 1 year was overall 83%, and significantly better in intermediate risk patients (p = 0.004). The functional status remained stable over time as well as prostheses performance.

CONCLUSION

About 40% of patients <75 years were treated by TAVI due to the presence of a prohibitive risk, mainly related to technical impediments. The remaining was referred to TAVI due to an estimated high or intermediate surgical risk driven by STS score, frailty and/or major organ system compromise. Early and mid-term clinical and hemodynamic outcomes were good, in particular in intermediate risk patients.

Factors associated with early cardiac complications following transcatheter aortic valve implantation with transapical approach

Purpose

To estimate the incidence of postprocedural early cardiac complications among patients undergoing transcatheter aortic valve implantation, through transapical approach (TA-TAVI), and to identify factors independently associated with the occurrence of them.

Patients and methods

A retrospective cohort study of 90 patients, who had undergone TA-TAVI in a tertiary hospital of Liverpool, UK, during a 5-year period (September 2008–October 2013), was conducted. Data on patient demographics, periprocedural characteristics and cardiac complications presented within 30-day post TA-TAVI were collected, retrospectively, using the hospital’s electronic database.

Results

The overall 30-day incidence of cardiac complications was estimated at 18.9% (n=17/90). The rate of new onset of atrial fibrillation (AF), atrioventricular block requiring permanent pacemaker implantation, shockable cardiac arrest rhythm and cardiac tamponade was 11.1%, 3.3%, 2.2% and 2.2%, respectively. Bivariate analysis found that absence of preoperative AF (p=0.01), receiving of oral inotropes preprocedurally (p=0.01), intravenous inotropic support postprocedurally (p=0.01) and requirement for postprocedural tracheal intubation (p=0.001) were the main factors associated with increased probability for patient cardiac morbidity.

Conclusion

It seems that patients with absence of AF and oral inotropic support preprocedurally and those with post TA-TAVI mechanical ventilatory and intravenous inotropic support have greater probability to develop cardiac complications. This knowledge allows the early identification of high-risk patients and supports clinicians to apply both preventive and therapeutic interventions for the optimum patient management and care. In addition, administrators could allocate the health care system resources effectively.