Suicide left ventricle following transcatheter aortic valve implantation

Silent Threats of the Heart: A Case Series and Narrative Review on Suicide Left Ventricle Post-Aortic Valve Replacement in Patients with Dynamic LVOT Obstruction and Aortic Stenosis

Aortic stenosis (AS) is the most prevalent valvular heart disease in Europe and North America, with transcatheter aortic valve implantation (TAVI) revolutionizing its management. Hypertrophic left ventricle (HLV) frequently coexists with AS, complicating treatment due to the associated risk of left ventricular outflow tract (LVOT) obstruction, heart failure, and sudden death. A rare but severe post-aortic valve replacement (AVR) complication, termed "suicide left ventricle" (SLV), has emerged, necessitating further study. This report synthesizes current literature on SLV, its pathophysiology, and management strategies, alongside four patient case studies. The patients aged 79-87 years, underwent AVR for symptomatic AS with HLV. Post-AVR, all experienced severe complications, including dynamicLVOT gradients, systolic anterior motion (SAM) of the mitral valve, and severe hypotension, leading to death in two cases. One patient survived following surgical aortic valve replacement (SAVR) with surgical myectomy. One patient survived after TAVI. These cases highlight the critical importance of multidisciplinary Heart Team evaluations and personalized treatment plans in managing SLV. Despite advancements in AVR, SLV remains a complex, life-threatening condition, requiring an exhaustive and multifaceted approach for optimal patient outcomes. This report offers valuable insights into SLV occurrence and management from a clinical perspective.

Septal Ablation to Treat Subaortic Dynamic Obstruction Following Transcatheter Aortic Valve Implantation

Dynamic obstruction of the left ventricle is an unusual complication that can occur after aortic valve replacement. It is important to be aware of this pathology as it requires different management than normal complications and can rapidly lead to death. We present a case of successful resolution following transcatheter aortic valve implantation.

Acute Hemodynamic Compromise After Transcatheter Aortic Valve Replacement Due to Dynamic Left Ventricle Obstruction: A Systematic Review

Acute hemodynamic compromise after transcatheter aortic valve replacement (TAVR) because of dynamic left ventricle (LV) obstruction (LVO), also known as suicide LV, is an infrequent but severe complication of TAVR that is poorly defined in previous studies. Understanding this complication is essential for its prompt diagnosis and optimal treatment. We conducted a systematic literature review using PubMed, Embase, Web of Science, and Medline databases for studies describing acute hemodynamic compromise after TAVR because of dynamic LVO or suicide LV. Each study was reviewed by 2 authors individually for eligibility, and a third author resolved disagreements. From a total of 506 studies, 25 publications were considered for the final analysis. The majority of patients with this condition were women demonstrating a hypertrophic septum, a small ventricle, and hyperdynamic contractility on pre-TAVR echocardiographic assessment. An intraventricular gradient before TAVR was found in half of the cases. Acute hemodynamic compromise after TAVR because of dynamic LVO manifested mainly as significant hypotension and occurred most often immediately after valve deployment. The LV outflow tract was the most common site of obstruction. Advanced therapies were required in nearly 65% of the cases. In conclusion, acute hemodynamic compromise after TAVR because of dynamic LVO occurred almost invariably in women. Echocardiography before TAVR may offer essential information to anticipate this complication. LV outflow tract obstruction appears to carry the highest risk of developing this phenomenon. Advanced therapies should be promptly considered as a bailout strategy in patients with hemodynamic collapse refractory to medical therapy.

Impact of VA-ECMO on Dynamic LV Outflow Obstruction After Transcatheter Aortic Valve Replacement

Dynamic left ventricular outflow obstruction is a rare but severe complication of transcatheter aortic valve replacement. It presents as a paradoxical hemodynamic collapse after relieving the left ventricular afterload. Considering its unique pathophysiology, this entity dictates counterintuitive treatments. We describe a case of left ventricular outflow obstruction treated with venoarterial extracorporeal membrane oxygenation and discuss its management principles.

Acute decompensated heart failure after transcatheter aortic valve implantation: A case report

Transcatheter aortic valve implantation (TVAI) is a widely used treatment modality for severe aortic stenosis. The complication rates of the procedure have gradually decreased over time, owing to the improvements in procedural skills and development of TVAI devices. However, several rare but serious complications can still occur after TAVI. We recently encountered acute decompensated heart failure as a rare and fatal complication of TAVI and would like to share our experience.

Concomitant Septal Myectomy with Aortic Valve Replacement for Severe Aortic Stenosis with Left Ventricular Outflow Tract Obstruction

Objectives

Septal myectomy confers survival benefits on patients with hypertrophic cardiomyopathy. However, its role in the treatment of severe aortic stenosis (sAS) with left ventricular outflow tract obstruction (LVOTO) remains under investigation. Another challenging question in the era of transcatheter aortic valve replacement is who would benefit more from traditional surgical aortic valve replacement (SAVR) with myectomy. Therefore, this study aimed to investigate myectomy cases at our hospital in Japan.

Methods

A total of 740 patients who underwent SAVR for sAS between 2012 and 2019 were identified. The demographics and baseline echocardiographic findings were retrospectively compared between patients who underwent concomitant myectomy and those who did not. The myectomy group was further assessed for factors predisposing to LVOTO, operative details, echocardiographic changes, and prognosis. The resected septa were histopathologically analyzed.

Results

The myectomy group mostly comprised elderly females with a small hypercontractile heart. Myectomy with SAVR led to statistically significant improvements in concentric left ventricular hypertrophy and LVOTO parameters. Survival was comparable with that reported in previous reports, even in the elderly subset (≥ 75 years). The septa showed mild fibrosis.

Conclusions

Myectomy can be safely performed with SAVR for sAS with LVOTO, even in the elderly, and it effectively improves LVOTO. Special attention should be paid to elderly females with relatively more severe AS and a small yet extra-hypertrophic and extra-hypercontractile heart. Such patients warrant comprehensive assessment of LVOTO, and despite its invasiveness, SAVR may be potentially more beneficial by allowing direct observation of LVOTO and ancillary myectomy.

Suicide left ventricle following protamine: A case report

A patient with severe aortic stenosis and left ventricular hypertrophy underwent a transcatheter aortic valve replacement. The patient's blood pressure significantly dropped after protamine administration. A diagnosis of suicide left ventricle post-valve replacement was made. The diagnosis and management of the protamine reaction are detailed. This case highlights the need to slowly infuse protamine sulfate and monitor for adverse events.

Non-surgical management of an acute decompensated heart failure patient with severe aortic stenosis and concomitant left ventricular outflow tract obstruction

Acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) and concomitant left ventricular outflow tract (LVOT) obstruction is a serious condition. Treatment with medication alone is sometimes difficult, and the efficacy of further interventional strategies has not been fully elucidated. In patients with high surgical risks, combination therapy using transcatheter aortic valve replacement (TAVR) and percutaneous alcohol septal ablation (ASA) is used as a non-surgical intervention. However, this treatment cannot be performed under unstable hemodynamic conditions. This report highlights the utility and efficacy of emergent balloon aortic valvuloplasty (BAV) in controlling heart failure and its potential to serve as a bridge to curative therapy, even in older patients with ADHF due to severe AS with concomitant LVOT obstruction. Furthermore, combination therapy with TAVR and percutaneous ASA could be safely performed after controlling for ADHF using BAV. Non-surgical management is a more feasible treatment option in older patients with ADHF who are at higher risk of complications during surgical intervention.

<Learning objective: Management of acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) and concomitant left ventricular outflow tract (LVOT) obstruction can be difficult. Despite concomitant LVOT obstruction, emergent balloon aortic valvuloplasty is potentially useful and effective for controlling heart failure and could become a bridge to subsequent combination therapy using transcatheter aortic valve replacement and percutaneous alcohol septal ablation. This sequential non-surgical management is a novel strategy for older patients with high surgical risk and ADHF due to severe AS with concomitant LVOT obstruction.>

Unexpected suicide left ventricle post-surgical aortic valve replacement requiring veno-arterial extracorporeal membrane oxygenation support despite gold-standard therapy: a case report

Background

Suicide left ventricle is a well-documented phenomenon occurring after valve replacement, however, it is most commonly described in the mitral valve replacement (MVR) and transcatheter aortic valve replacement (TAVR) population. Cases within the surgical aortic valve replacement (SAVR) population usually resolve with optimal medical and interventional therapies. We describe a case of left ventricular suicide following SAVR presenting with persistent haemodynamic instability despite currently accepted medical and surgical therapies.

Case summary

A 62-year-old male with severe aortic stenosis presented for SAVR and a MAZE procedure. There were no significant signs of ventricular hypertrophy on preoperative transthoracic echocardiogram (TTE). Intraoperatively, there was mild chordal systolic anterior motion of the mitral valve (SAM) which only occurred when underfilled. During recovery in the intensive care unit, the patient’s pulmonary arterial pressures were noted to rise with worsening cardiac output. Subsequent TTE showed severe dynamic left ventricular outflow tract (LVOT) obstruction secondary to SAM. Due to refractory medical management, an alcohol septal ablation was performed. Despite resolution of obstruction, the patient exhibited biochemical signs of systemic hypoperfusion, and thus veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was initiated. Following 72 h of VA-ECMO support, the patient was weaned with complete resolution of biochemical insults. He was subsequently discharged from the hospital without complication.

Discussion

Compared to the TAVR population, suicide ventricle post-SAVR is comparatively rare. Patients who exhibit persistent impaired cardiac output postoperatively should be investigated rapidly with echocardiography. Furthermore, resolution of a LVOT obstruction state from procedural intervention may not immediately follow with improved cardiac output, and may require further supportive management.

Case Report: Minimally Invasive Therapy by Transcatheter Aortic Valve Replacement and Percutaneous Intramyocardial Septal Radiofrequency Ablation for a Patient With Aortic Stenosis Combined With Hypertrophic Obstructive Cardiomyopathy: Two-Year Follow-Up Results

With the development of minimally invasive technologies in the medical field, more and more technologies can replace surgical thoracotomy and relieve the pain of disease via minimally invasive methods. We reported a case of aortic valve stenosis combined with left ventricular outflow track obstruction treated by two minimally invasive techniques, transcatheter aortic valve replacement and transthoracic echocardiography–guided percutaneous intramyocardial septal radiofrequency ablation, and followed up for 2 years.

Mechanical Complications of Transcatheter Aortic Valve Replacement

Mechanical complications after transcatheter aortic valve replacement are fortunately rare with the current generation of devices. Unfortunately, life-threatening complications will occur and it is the responsibility of operators to be familiar with strategies to prevent and manage these challenging scenarios. Because these cases will not occur often, it is important for us to highlight and talk about those that do occur, to learn best practices in how to manage and prevent them going forward. We can learn much from each other's good crash landings.

Haemodynamic collapse immediately after transcatheter aortic valve implantation due to dynamic intraventricular gradient: a case report and review of the literature

Background

Dynamic intraventricular obstruction after transcatheter aortic valve implantation (TAVI) has been previously reported. There is a risk of haemodynamic collapse in the case of left ventricular outflow tract (LVOT) obstruction due to systolic anterior motion (SAM) of the mitral valve.

Case summary

An 83-year-old woman with aortic stenosis (AS) was referred to our hospital for TAVI. Transthoracic echocardiography revealed a severely calcified aortic valve with a peak velocity of 6.3 m/s across the valve. Acceleration of blood flow (peak velocity 2.6 m/s) at the LVOT due to a septal bulge was also seen. Transfemoral TAVI was performed, and a 29 mm Evolut PRO was implanted under general anaesthesia. After the implantation, a complete atrioventricular block with junctional rhythm developed, and refractory hypotension occurred immediately. Transoesophageal echocardiography revealed LVOT obstruction due to SAM of the mitral valve associated with severe mitral regurgitation (MR), which was not observed preoperatively. Fluid infusion and catecholamine administration were not effective. However, after performing temporary pacing from the right ventricular (RV) apex, the LVOT obstruction and severe MR improved. Her haemodynamics stabilized, and we could complete the procedure. A dual-chamber permanent pacemaker with beta-blocker administration as a longer-term treatment further improved the LVOT obstruction. The patient was finally discharged to a rehabilitation hospital.

Discussion

Alertness and recognition of potential LVOT obstruction after TAVI are important. Pacing from the RV apex, as well as dual-chamber pacing, comprise a less invasive and feasible therapeutic option in such cases.

Early Adverse Impact of Transfusion After Transcatheter Aortic Valve Replacement: A Propensity-Matched Comparison From the TRITAVI Registry

BACKGROUND

There is no consensus on the benefit of red blood cell (RBC) transfusion after transcatheter aortic valve replacement.

METHODS

The multicenter Transfusion Requirements in Transcatheter Aortic Valve Implantation (TRITAVI) registry retrospectively included patients after transfemoral transcatheter aortic valve replacement; propensity score-matching identified pairs of patients with and without RBC transfusion. The primary end point was 30-day mortality; nonfatal myocardial infarction, cerebrovascular accident, and stage 2 to 3 acute kidney injury at 30 days were secondary end points. We repeated propensity score-matching according to the hemoglobin nadir, hemoglobin drop, and in the subgroup of uncomplicated patients, without major vascular complications or major bleeding.

RESULTS

Among 2587 patients, RBC transfusion was administered in 421 cases (16%). The primary end point occurred in 104 (4.0%) patients, myocardial infarction in 9 (0.4%), cerebrovascular accident in 38 (1.5%), and acute kidney injury in 125 (4.8%) cases. In the 842 propensity-matched patients, RBC transfusion was associated with increased mortality (hazard ratio, 2.07 [95% CI, 1.06-4.05]; P=0.034) and acute kidney injury (hazard ratio, 4.35 [95% CI, 2.21-8.55]; P<0.001). Interaction testing between RBC transfusion and mortality was not statistically significant in the above-mentioned subgroups, and such association was not documented in the corresponding propensity score-matched cohorts. In the multivariable Cox proportional hazards regression model, major vascular complications (P=0.044), major bleeding (P=0.041), and RBC transfusion (P=0.048) were independent correlates of 30-day mortality.

CONCLUSIONS

RBC transfusion correlates with increased mortality and acute kidney injury early after transcatheter aortic valve replacement and is an independent predictor of 30-day mortality, irrespective of periprocedural major bleeding and vascular complications. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03740425.

The use of MitraClip to prevent posttranscatheter aortic valve replacement left ventricular "suicide"

Patients with concomitant severe aortic stenosis (AS) and left ventricular outflow tract (LVOT) obstruction undergoing transcatheter aortic valve replacement (TAVR) are at risk for hemodynamic collapse due to a sudden decrease in afterload causing worsening LVOT obstruction. We present a case of an 88-year-old female with symptomatic, severe AS, and LVOT obstruction with systolic anterior motion (SAM) of the mitral leaflet in whom alcohol septal ablation was contraindicated secondary to a chronic total occlusion of the right coronary artery that filled retrograde via septal collaterals. MitraClip at the time of TAVR was successfully performed to treat SAM with subsequent stabilization of LVOT gradients despite treatment of the patient's AS. This novel approach may represent a feasible option to prevent hemodynamic complications after TAVR in patients with significant LVOT obstruction secondary to SAM and AS.

Association of Hypertrophic Obstructive Cardiomyopathy With Outcomes Following Transcatheter Aortic Valve Replacement

This cohort study investigates the association of hypertrophic obstructive cardiomyopathy with outcomes following transcatheter aortic valve replacement.

The Determinants and Outcomes of Myocardial Injury After Transcatheter Aortic-Valve Implantation: SAPIEN 3 Study

BACKGROUND

The effect of myocardial injury (MI) post-transcatheter aortic valve implantation (TAVI) on clinical outcomes is controversial. This study aimed to evaluate the effect of MI severity on clinical outcome and left ventricle function 30 days post-TAVI and determine MI post-TAVI predictors.

METHODS

Overall, 138 consecutive patients who underwent successful transfemoral TAVI using SAPIEN3 and diagnosed using echocardiography and computed tomography were analyzed. High-sensitivity cardiac troponin T (TnT) was evaluated at baseline, immediately, and at 24, 48, and 72 h post-TAVI. Echocardiography findings and N-terminal pro-B-type natriuretic peptide (Nt-pro BNP) levels were evaluated 30 days post-TAVI.

RESULTS

Mean age and STS score were 84.4 ± 3.5 years and 6.4 ± 3.2%, respectively. All cases showed severe aortic valve stenosis. Peri-procedural MI was observed in 48 of 100 patients (48.0%). Patients were grouped into MI (n = 48) and non-MI (n = 52), without significant difference in characteristics. Pre-balloon aortic valvuloplasty rate and total pacing time were significantly higher in MI vs non-MI. Total rapid pacing time (TRPT) was an independent predictor for MI (OR 1.06; 95% CI 1.01-1.16; p = 0.04). Echocardiography and Nt-pro BNP changes 30 days post-TAVI were similar between groups.

CONCLUSION

Peri-procedural MI, assessed by TnT changes, was observed in 48% of patients. The MI was not associated with overt cardiac dysfunction, and the recovery of left ventricular function and Nt-pro BNP level occurred similarly by 30 day post-TAVI between both groups. In multivariate analysis, TRPT was associated with MI after SAPIEN3 implantation.

TRIAL REGISTRATION NUMBER

UMIN000036669.

Men are from mars, women are from venus: Factors responsible for gender differences in outcomes after surgical and trans-catheter aortic valve replacement

Females suffer higher operative (30-day) mortality than males after surgical aortic valve replacement (SAVR). In contrast, outcomes after trans-catheter aortic valve replacement (TAVR) seem to favor females, both in terms of procedural mortality, and more prominently, medium to long-term survival. With an ever-greater number of TAVR procedures being performed, an understanding of factors responsible for gender differences in outcomes after the two AVR modalities is critical for better patient selection. Current evidence suggests that this gender difference in outcomes after SAVR and TAVR stems from differences in baseline risk profiles, as well as inherent anatomic/physiological differences between genders. This review attempts to examine these clinical and physiological factors, with a goal of guiding better patient selection for each AVR modality, and to highlight areas that beg further investigation.

Undiagnosed hypertrophic obstructive cardiomyopathy during transcatheter aortic valve replacement: a case report

BACKGROUND

Transcatheter aortic valve replacement is indicated for severe symptomatic aortic stenosis in patients who have a very high or prohibitive surgical risk as assessed pre-procedurally by the Society of Thoracic Surgery Risk Score, EuroSCORE (II), frailty testing, and other predictors. When combined with another left ventricular outflow tract obstruction, careful consideration must be taken prior to proceeding with transcatheter aortic valve replacement because an additional masked left ventricular outflow tract pathology can lead to challenging hemodynamics in the peri-deployment phase, as reported in this case.

CASE PRESENTATION

A 56-year-old Caucasian man with multiple comorbidities and severe aortic stenosis underwent transcatheter aortic valve replacement under monitored anesthesia care. During the deployment phase, he developed dyspnea that progressed to pulmonary edema requiring emergent conversion to general anesthesia, orotracheal intubation, acute respiratory distress syndrome-type ventilation, and vasopressor medications. Intraoperative transesophageal echocardiography was performed and hypertrophic obstructive cardiomyopathy with systolic anterior motion of the mitral valve was discovered as an underlying pathology, undetected on preoperative imaging. After treatment with beta blockers, fluid resuscitation, and alpha-1 agonists, he stabilized and was eventually discharged from our hospital without any lasting sequelae.

CONCLUSIONS

Patients with aortic stenosis most often develop symmetric hypertrophy; however, a small subset has asymmetric septal hypertrophy leading to left ventricular outflow tract obstruction. In cases of severe aortic stenosis, however, evidence of left ventricular outflow tract obstruction via both symptoms and echocardiographic findings may be minimized due to extremely high afterload on the left ventricle. Diagnosing a left ventricular outflow tract obstruction as the cause of hemodynamic instability during transcatheter aortic valve replacement, in the absence of abnormal findings on echocardiogram preoperatively, requires a high index of clinical suspicion. The management of acute onset left ventricular outflow tract obstruction intraoperatively consists primarily of medical therapy, including rate control, adequate volume resuscitation, and avoidance of inotropes. With persistently elevated gradients, interventional treatments may be considered.

Pre-implantation balloon-aortic valvuloplasty before transcatheter aortic valve implantation: is this still needed?

Balloon aortic valvuloplasty (BAV) has historically been recommended prior to transcatheter aortic valve implantation (TAVI). Pre-implantation BAV (pBAV) creates fractures at the level of calcified leaflets, thereby facilitating delivery of the transcatheter valve system across the diseased aortic valve and, enhances prosthesis implantation and expansion within the calcified aortic valve annulus. New device designs, lower profile delivery systems and increasing operator experience have enabled direct-TAVI (without pBAV), and its appeal amongst TAVI operators enhanced the dissemination of a direct TAVI approach across many centres. In this review, we discuss contemporary evidence that inform the debate on the need for routine pBAV for TAVI candidates and present a framework that may assist operators in selecting patients for pBAV.

Computed Tomography Assessment for Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement has become a mainstream therapeutic option for patients with severe aortic stenosis who are at intermediate risk or high risk for surgical valve replacement. Computed tomography (CT) is now the standard imaging modality for preoperative vascular access planning an aortic annular sizing. This article reviews the established and potential future roles of CT in transcatheter aortic valve replacement.

Hypertrophic Cardiomyopathy and Left Ventricular Outflow Tract Obstruction: Expecting the Unexpected

Hypertrophic cardiomyopathy is an increasingly recognized clinical disease that carries perioperative risk. Patients may or may not carry a preoperative diagnosis, but provocable left ventricular outflow tract gradients place them at risk for hemodynamic compromise under surgical conditions. Early recognition of obstructive patterns and rapid management alterations in the face of instability are imperative for the treatment of these patients. This review focuses on the diagnostic criteria, risk factors, and management strategies for the perioperative hypertrophic cardiomyopathy patient. Finally, novel diagnostic modalities are discussed.

Intensive care unit management of transcatheter aortic valve recipients

Severe aortic stenosis is an increasingly prevalent disease that continues to be associated with significant mortality. Transcatheter aortic valve replacements have been used as an alternative to surgical aortic valve replacement in high-risk patients with multiple comorbidities. In this review, we discuss postoperative considerations pertinent to the successful management of these complicated patients in the intensive care unit.

Myocardial injury associated with transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) has emerged as an important treatment option for elderly patients with symptomatic aortic stenosis whose risk is too high or prohibitive for conventional surgery. Despite notable progress during the past decade, continuous efforts directed at further improvement of procedural safety and performance are required, especially considering expanding indications for interventional treatment options among lower-risk populations. One issue that needs to be addressed is myocardial damage, which can frequently be observed after TAVI and has been linked to worse prognosis. Yet, knowledge concerning the underlying mechanisms and clinical impact remains scarce, and further investigation in this field is warranted. In this review, we provide a contemporary summary of the types of myocardial injury associated with TAVI, including access-related injury, mechanical trauma and ischemia, the role of myocardial biomarkers, and the impact on left ventricular function, with emphasis on potential mechanisms and clinical implications.

Cardiac critical care after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a new therapy for severe aortic stenosis now available in the United States. Initial patients eligible for TAVR are defined by high operative risk, with advanced age and multiple comorbidities. Following TAVR, patients experience acute hemodynamic changes and several possible complications, including hypotension, vascular injury, anemia, stroke, new-onset atrial fibrillation, conduction disturbances and kidney injury, requiring an acute phase of intensive care. Alongside improvements in TAVR technology and technique, improvements in care after TAVR may contribute to improved outcomes. This review presents an approach to post-TAVR critical care and identifies directions for future research.

Transcatheter aortic valve implantation

With the improvement in the overall life expectancy, the incidence of aortic stenosis has been increasing. Although aortic valve replacement is a standard therapy, many patients do not undergo surgery for various reasons, including advanced age or the presence of multiple comorbidities. Transcatheter aortic valve implantation (TAVI) has been proposed as a less invasive and equally effective treatment for inoperable or high-risk symptomatic aortic stenosis. Numerous rigorous global clinical trials, as well as a pivotal clinical trial in Japan, have been conducted. In this review, we provide data on the development of TAVI worldwide and discuss the prospects for TAVI in Japan.

Patients with small left ventricular size undergoing balloon aortic valvuloplasty have worse intraprocedural outcomes

OBJECTIVES

To evaluate the impact of left ventricular (LV) chamber size on procedural and hospital outcomes of patients undergoing aortic valvuloplasty.

BACKGROUND

Balloon aortic valvuloplasty (BAV) is used as an integral step during transcatheter aortic valve implantation. Patients with small, thickened ventricles are thought to have more complications during and following BAV.

METHODS

Retrospective study of consecutive patients with severe, symptomatic calcific aortic stenosis who underwent retrograde BAV at Massachusetts General Hospital. We compared patients with left ventricular end-diastolic diameters (LVEDD) <4.0 cm (n = 31) to those with LVEDD ≥4.0 cm (n = 78). Baseline and procedural characteristics as well as clinical outcomes were compared. Multivariate logistic regression was used for the adjusted analysis.

RESULTS

Patients with smaller LV chamber size were mostly women (80.7% vs. 19.4%, P < 0.01) and had a smaller body surface area (BSA), (1.61 ± 0.20 m(2) vs. 1.79 ± 0.25 m(2) , P < 0.01). Patients with smaller LV chamber size had higher ejection fractions and thicker ventricles. Otherwise, baseline characteristics were similar. The intraprocedural composite of death, cardiopulmonary arrest, intubation, hemodynamic collapse, and tamponade was higher for patients with LVEDD < 4.0 cm (32.3% v. 11.5%, P = 0.01). Adjusting for age, gender, BSA, LV pressure, and New York Heart Association class, LVEDD < 4.0 cm remained an independent predictor of procedural (OR 5.1, 95% CI 1.4-18.2) and in-hospital complications (OR 3.8, 95% CI 1.2-11.6).

CONCLUSIONS

Compared to patients undergoing BAV with LVEDD ≥4.0 cm, those with smaller LV chambers had worse procedural and in-hospital outcomes.

Transcatheter aortic valve implantation: patient selection and procedural considerations

Transcatheter aortic valve implantation has risen exponentially as a treatment modality for severe aortic stenosis in patients considered to be at high risk for or inoperable by conventional surgical aortic valve replacement. It has shown both survival and quality of life benefit in a randomized comparison to conservative (palliative) therapy in nonoperative candidates. Fundamental to its success is appropriate patient selection and a rigorous attention to procedural steps. In this article we will discuss the key issues pertaining to each of these factors.