Transcatheter aortic valve implantation in patients with severely reduced left ventricular systolic function: a single-center experience

Procedural success and intra-hospital outcome related to left atrial appendage morphology in patients that receive an interventional left atrial appendage closure

BACKGROUND

The interventional left atrial appendage (LAA) closure represents an emerging alternative to oral anticoagulation for stroke prevention in certain atrial fibrillation patients. Preliminary results have suggested high procedural success rates and fewer peri-interventional complications; however, there persists an insufficient understanding of the role of many underlying confounding variables (e.g., anatomical characteristics).

HYPOTHESIS

It was investigated whether varying LAA morphologies influence procedural success as well as in-hospital outcome.

METHODS

Sixty-seven patients ineligible for long-term oral anticoagulation were included in this single-center, prospective, observational registry spanning from the years 2014 to 2016. Interventions were performed with the Watchman occluder (Boston Scientific, Natick, MA) or the Amplatzer Amulet (St. Jude Medical, St. Paul, MN), at the operator's discretion. Results derived from the data describing procedural success, fluoroscopy, and peri-interventional safety events were classified according to the presenting LAA morphology (cauliflower, cactus, windsock, and chicken wing).

RESULTS

Rates of successful implantation were high across all groups (≥98%; P = 0.326). Surrogate parameters underlining procedural complexity like median total duration (P = 0.415), median fluoroscopy time (P = 0.459), median dose area product (P = 0.698), and the median amount of contrast agent (P = 0.076) demonstrated similar results across all groups. Likewise, the periprocedural complication rate was not significantly different and was mainly restricted to minor bleeding events.

CONCLUSIONS

Irrespective of the varying morphological presentation of the LAA, the procedural success rates, interventional characteristics, and safety events did not significantly differ among patients receiving an interventional LAA closure.

Efficacy of transcatheter aortic valve implantation in patients with aortic stenosis and reduced LVEF. A systematic review

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is safe and effective for patients with aortic stenosis (AS) who have a high operative risk. However, there is still debate on the effect of TAVI in AS patients with reduced left ventricular ejection fraction (REF). The objective of the review is to clarify the efficacy of TAVI and the impact of REF on the 30-day and midterm mortality in these patients.

METHODS

Studies on TAVI were searched in PubMed, Embase, and the Cochrane Library databases and were included in this review following predefined criteria. Data were extracted and pooled risk ratios (RR) were synthesized to explore the relationship between REF and 30-day plus midterm mortality.

RESULTS

Twenty-eight studies comprising 14,099 patients were included in the analysis of the association of REF with the prognosis of patients after TAVI. An average increase in left ventricular ejection fraction of 8-10 % was observed among these patients after TAVI. REF was not related to the 30-day mortality [RR = 1.90, 95 % confidence interval (CI) = 0.80-4.47]; however, it was related to the midterm mortality (RR = 1.49, 95 %CI = 1.14-1.93) of patients undergoing TAVI. Patients with low-flow and low-gradient AS had a higher 30-day mortality (RR = 1.54, 95 %CI = 1.11-2.13) and midterm mortality rate (RR = 1.69, 95 %CI = 1.33-2.14) compared with AS patients without these characteristics. The mortality of TAVI patients was significantly lower than that of those undergoing conservative therapy, and was similar to that of patients undergoing surgical aortic valve replacement.

CONCLUSION

REF was not associated with 30-day mortality, but it was associated with the midterm mortality of TAVI patients. Patients with REF could benefit from TAVI compared with conservative therapy.