Valve Academic Research Consortium 3: Updated Endpoint Definitions for Aortic Valve Clinical Research

Anticoagulation therapy for the prevention of subclinical leaflet thrombosis after transcatheter aortic valve replacement: A comprehensive literature review and future directions

Leaflet thrombosis after transcatheter aortic valve replacement (TAVR) presents a significant challenge, leading to adverse clinical outcomes. Subclinical leaflet thrombosis (SLT) is increasingly recognized, and there is a growing concern about its role in clinical events and hemodynamic valve deterioration. Current recommendations for prophylactic anticoagulation or antiplatelet therapy following TAVR are primarily based on expert consensus rather than definitive evidence from randomized trials, resulting in a variety of antithrombotic strategies in clinical practice. While observational data suggest that prophylactic anticoagulation may be beneficial, clinical trial results are inconsistent, particularly for patients without an existing indication for OAC. Given the conflicting findings and potential safety concerns associated with prophylactic anticoagulation, further research is imperative. This review aims to summarize the existing literature on risk factors for SLT, preventive strategies, current recommendations, and future research directions to better understand the benefits and risks of prophylactic anticoagulation in this context.

Effect of Mechanical Circulatory Support on Mortality After Transcatheter Aortic Valve Replacement: An Analysis

A proportion of patients still need mechanical circulatory support (MCS) during the transcatheter aortic valve replacement (TAVR) because of intraoperative hemodynamic instability. However, the outcomes of patients with different MCS type during TAVR are still controversial. A total of 538 patients who underwent TAVR procedure in four centers were included. The time-related outcomes and their predictors of patients who did not have MCS (MCS-, n = 498) were compared with those who underwent emergency MCS (eMCS+, n = 18) and prophylactic MCS (pMCS+, n = 22). We evaluated the association between different MCS groups and all-cause mortality using conditional landmark analysis with Cox regression. There was a significant increase in 30-day mortality in the eMCS+ group ( plog-rank < 0.001) and no significant difference in 31-day to 1-year mortality among the groups ( plog-rank = 0.789). A significant improvement in the left ventricular ejection fraction was observed in the pMCS+ group at 1 year after TAVR. Emergency MCS was independently associated with 30-day mortality, as well as 1-year mortality. Prophylactic MCS showed good clinical outcomes and might be considered for high-risk patients. Further studies are needed to investigate the predictors that lead to MCS usage and long-term mortality in TAVR patients with MCS.

Flaring of Protruding Coronary Stents Before Transcatheter Aortic Valve Replacement to Minimize Interaction-A Feasibility Study

BACKGROUND

Protruding coronary artery stents can adversely affect transcatheter aortic valve replacement (TAVR) procedure. Current evidence on the topic is limited.

AIMS

We aim to study the clinical feasibility and safety of flaring of protruding coronary artery stents before TAVR to reduce interaction with transcatheter heart valves.

METHODS

Twenty consecutive patients with 22 protruding coronary stents were optimized with a dual-diameter balloon before TAVR. Procedural success, stent and valve geometry on angiogram, periprocedural and subsequent clinical outcomes as well as valve hemodynamics on echocardiography were evaluated.

RESULTS

Procedural success was achieved in 100% of coronary procedure and TAVR without any major complication directly related to the flaring of stents. There was no coronary artery obstruction after TAVR or visible stent or valve deformity. All valves had normal hemodynamics immediately post-deployment with none having clinically significant aortic insufficiency. One patient had inpatient mortality unrelated to coronary stent optimization. One valve had hemodynamic valve degeneration on follow-up which was unrelated to coronary stent flaring and the patient was asymptomatic.

CONCLUSION

Flaring of protruding coronary stents before TAVR is technically feasible and safe and can potentially minimize stent-valve interaction for during of after TAVR.

Valve Thrombosis Following Transcatheter Aortic Valve Replacement: State-of-the-Art Review

Transcatheter aortic valve replacement (TAVR) is a well-established treatment for severe aortic stenosis, especially in patients over 75 or those at high surgical risk. While these prosthetic valves have a lower thrombogenic profile than mechanical heart valves, leaflet thrombosis in transcatheter aortic valves (TAV) occurs in an estimated 5%-40% of cases. Most TAV thromboses are subclinical and can be detected via cardiac computed tomography (CCT), which reveals hypo-attenuating leaflet thickening and reduced leaflet motion in asymptomatic patients without elevated transprosthetic gradients on echocardiography. The mechanisms behind TAV thrombosis involve local mechanical triggers, patient predisposing factors, and device and procedure-related aspects. The ideal antithrombotic therapy post-TAVR depends on individual patient characteristics, balancing bleeding risks with the need for oral anticoagulants. Data on the optimal management of TAV thrombosis and the routine use of CT post-TAVR are limited. While anticoagulation effectively resolves clinically significant prosthesis thrombosis, its benefit in subclinical cases is unclear. There is an ongoing debate about whether subclinical leaflet thrombosis precedes clinical valve thrombosis, making the ideal follow-up after valve implantation uncertain. This article aims to provide a comprehensive review, summarizing current data on the incidence of TAVR thrombosis, underlying mechanisms, clinical and imaging diagnosis, management strategies, preventive measures, and long-term follow-up.

Clinical Outcomes According to the Extent of Atherosclerotic Disease in Female Patients Undergoing Transcatheter Aortic Valve Replacement: An Analysis From the WIN-TAVI Registry

BACKGROUND

Limited data exist on the impact of polyvascular disease (PolyVD) on clinical outcomes in female patients undergoing transcatheter aortic valve replacement (TAVR). We therefore sought to investigate clinical outcomes in women with versus without PolyVD undergoing TAVR.

METHODS

Female participants from the multicentre Women's International Transcatheter Aortic Valve Implantation (WIN-TAVI) registry were categorized based on the presence or absence of PolyVD. The PolyVD population was defined as the presence of atherosclerotic disease affecting ≥ 2 arterial systems from coronary, cerebral, or lower limb peripheral vessels, whilst patients with either no atherosclerosis or atherosclerotic disease in one vascular system were included in the non-PolyVD population. The primary endpoint was the Valve Academic Research Consortium-2 consensus (VARC-2) efficacy endpoint at 1 year, whilst secondary endpoints included VARC-2 safety events, VARC-2 major bleeding and major vascular complications. Cox regression analysis were computed adjusting for various cofounders.

RESULTS

Among 996 participants, 543 (54.5%) had PolyVD, while 453 (45.5%) did not. Across the subgroups no differences in age was noted, whilst patients with PolyVD were more likely to have a history of hypercholesterolemia and a previous cardiac surgery. The incidence of the primary endpoint was higher in the PolyVD group (19.4%) compared to the non-PolyVD group (13.3%, plog-rank = 0.014), though the difference was attenuated after multivariable adjustments (p = 0.093). Of note, no statistically significant differences concerning incident VARC-2 safety events, VARC-2 major bleeding and major vascular complications were noted according to PolyVD status.

CONCLUSION

PolyVD is a common comorbidity and is associated with elevated rates of adverse clinical events, but no increase in safety events, vascular complications, or bleeding among women undergoing TAVR.

Comparison of patients with occlusive or hemorrhagic access site complications requiring reintervention after percutaneous transfemoral transcatheter aortic valve implantation

Background: Transcatheter aortic valve implantation (TAVI) via transfemoral (TF) access is increasingly integral to aortic valve disease treatment, expanding beyond high-risk patients. Despite technical advancements, access-related vascular complications, occurring in approximately 10% of TAVI procedures, remain a substantial challenge. Objective: This study investigated the clinical and morphological characteristics of percutaneous TF-TAVI patients experiencing occlusive (OC) and hemorrhagic (HC) complications managed with surgical or endovascular reintervention. Methods: The cohort included patients from a Dutch and a German tertiary referral hospital, managed with TF-TAVI procedures between 2017 and 2021 that required reintervention for OC or HC. Demographics, comorbidities, procedural details, and preoperative imaging data were collected and compared between groups. Results: Among 109 TF-TAVI patients, 32 with OC and 77 with HC required reintervention. The OC group presented significantly smaller access arterial diameters (common femoral artery: OC 6.7 mm vs. HC 8.9 mm, p<.001; external iliac artery: OC 7.2 mm vs. HC 8.3 mm, p<.001; common iliac artery: OC 9.4 mm vs. HC 10.5 mm, p=.012) while the HC group presented higher tortuosity index (TI) (OC 1.24 vs. HC 1.30; p=.017). No differences were observed regarding baseline characteristics, vessel calcification or vascular closure device use. Conclusions: In patients requiring reintervention following TF-TAVI, smaller arterial diameters were associated with OC, while higher TI was linked to HC. These findings emphasize the importance of preoperative imaging in developing individualized prevention strategies.

Association of cardiac damage and computed tomography-derived extracellular volume in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Extra-valvular cardiac damage (EVCD) and extracellular volume (ECV) are key determinants of poor outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). We aimed to assess the association of ECV derived at cardiac computed tomography (CT) with EVCD pre and post-TAVI, its impact on left ventricular reverse remodeling and functional improvements at 3-month follow-up in patients with severe AS undergoing TAVI.

METHODS

Prospective study of 73 consecutive patients undergoing TAVI, with CT-derived ECV assessment, baseline and follow-up echocardiographic evaluation of EVCD. After identifying the best ECV cut-off for predicting EVCD progression and advanced EVCD (Stages 3-4) at follow-up by Youden index, patients were divided into low (n=39) and high ECV (n=34) groups. Predictors of EVCD progression, advanced EVCD and functional improvements at follow-up were identified at logistic regression analysis.

RESULTS

At 3-month follow-up, 34.2% of patients showed EVCD progression. ECV≥32% accurately predicted EVCD progression and Stages 3-4 (AUC=0.66, p<0.001). At follow-up, patients with high ECV were more frequently in Stages 3-4 (p=0.011) and had a 50% progression rate (p=0.012). Conversely, patients with low ECV exhibited greater LV reverse remodeling (p=0.004) and improvement in NYHA Class at both 3-month (p=0.020) and 6-month follow-up (p=0.001) compared to high ECV ones. High ECV emerged as independent predictor of EVCD progression (OR=4.34, 95%CI 1.36-13.78, p=0.013), Stages 3-4 (OR=5.71, 95%CI 1.77-18.42, p=0.004) and lack of improvement in NYHA class (OR=3.22, 95%CI 1.14-9.09, p=0.027) at 3-month follow-up.

CONCLUSIONS

Elevated CT-derived ECV was associated with EVCD progression and reduced functional improvement after TAVI.

Late Clinical Outcomes of Balloon-Expandable Valves in Small Annuli: Results From the PARTNER Trials

BACKGROUND

Short-term clinical outcomes after transcatheter aortic valve replacement (TAVR) are similar in individuals with small or large annuli. The longer term impact of prosthesis-patient mismatch (PPM) and mean gradient (MG) post-TAVR in these patients remains controversial.

OBJECTIVES

The aim of this study was to investigate 5-year outcomes in patients with small vs large annuli.

METHODS

Patients from the PARTNER (Placement of Aortic Transcatheter Valves) 2 SAPIEN 3 intermediate-risk registry and the PARTNER 3 low-risk randomized controlled trial were grouped according to small (≤430 mm2) or large (>430 mm2) annular size. The primary endpoint was a composite of all-cause death, disabling stroke, or heart failure hospitalization. In addition, the relationships between both PPM and post-TAVR MG and clinical outcomes were analyzed.

RESULTS

In total, 1,355 patients were included: 476 with small annuli (376.7 ± 41.9 mm2) and 879 with large annuli (518.3 ± 58.0 mm2). Patients with small annuli were older (age 79.6 ± 7.1 years vs 78.7 ± 7.8 years; P = 0.047), were more often female (75.0% vs 16.2%; P < 0.0001), had higher baseline Society of Thoracic Surgeons scores (4.3% ± 1.93% vs 4.0% ± 1.93%; P < 0.0001), and had higher left ventricular ejection fractions (66.3% ± 15.82% vs 59.7% ± 13.68%; P < 0.0001). Primary endpoint rates were similar at 1 year (7.8% vs 8.0%; P = 0.94) and 5 years (36.3% vs 35.8%; P = 0.83). Bioprosthetic valve failure was infrequent at 5 years in both groups (2.9% vs 2.1%; P = 0.46). Among female patients, outcomes were similar for small vs large annuli (primary endpoint; 33.6% vs 34.2%; P = 0.90). Among patients with small annuli, there was no association between 5-year outcomes and any severity of PPM (P = 0.22) or 30-day MG (P for nonlinearity = 0.96).

CONCLUSIONS

Five-year clinical outcomes were excellent and comparable between patients with small vs large aortic annuli. Outcomes in patients with small annuli were not affected by 30-day MG or PPM.

Protocolised Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock in Australia-Initial Experience From a Hub-and-Spoke Model

BACKGROUND

Acute myocardial infarction complicated by cardiogenic shock (AMICS) confers short-term mortality of 40%-50%. Protocolised network management of AMICS patients as part of a hub-and-spoke model supported by upstream mechanical circulatory support (MCS) is gaining traction globally to treat AMICS.

METHOD

We conducted a prospective multicenter study in Melbourne, Australia describing our 5-year experience utilizing a protocolised hub-and-spoke model of care for patients with AMICS supported by planned upstream use of Impella CP (Abiomed, Danvers, MA).

RESULTS

From December 2019 to August 2024, 31 patients were treated for AMICS with Impella MCS support. Median age was 60 years and 87% were males. ST-elevation myocardial infarction accounted for 84% of presentations, and 29% were complicated by cardiac arrest. The majority of patients treated were in SCAI-CSWG stage D (52%), and stage C (26%) shock. Upstream Impella prior to PCI occurred in 84% of patients. The 30-day survival rate was 74%. An adverse event occurred in 39% of patients. Device-related complications were due to hemolysis (32%) and arrhythmia (3%). Escalation of MCS support was required in five patients (16%). Multivariate analysis identified patients requiring transfer to the hub center prior to revascularisation as an independent predictor of mortality (OR 13.2 [1.34-129.3] p = 0.027).

CONCLUSION

In this first protocolised hub-and-spoke model of care for AMICS supported by planned upstream use of Impella in Australia, 30-day survival was high compared to published historical rates. Patient and device-related complication rates were low. Expansion of the hub-and-spoke model for the treatment of AMICS appears warranted.

The First International Consortium for Health Outcomes Measurement (ICHOM) Standard Dataset for Reporting Outcomes in Heart Valve Disease: Moving From Device- to Patient-Centered Outcomes

OBJECTIVE

Globally significant variation in treatment and course of heart valve disease (HVD) exists, and outcome measurement is procedure focused instead of patient focused. This article describes the development of a patient-related (International Consortium for Health Outcomes Measurement) standard set of outcomes and case mix to be measured in patients with HVD.

METHODS

A multisociety working group was formed that included patient representatives and representatives from scientific cardiology and cardiothoracic surgery societies that publish current guidelines for HVD. The standard set was developed to monitor the patient's journey from diagnosis to treatment with either a surgical or transcatheter procedure. Candidate clinical and patient-reported outcome measures (PROMs) and case mix were identified through benchmark analyses and systematic reviews. Using an online modified Delphi process, the working group voted on final outcomes/case mix and corresponding definition.

RESULTS

Patients with aortic/mitral/tricuspid valve disease or root/ascending aorta >40 mm were included in the standard set. Patients entered the dataset when the diagnosis of HVD was established, allowing outcome measurement in the preprocedural, periprocedural, and postprocedural phases of patients' lives. The working group defined 5 outcome domains: vital status, patient-reported outcomes, progression of disease, cardiac function and durability, and complications of treatment. Subsequently, 16 outcome measures, including 2 patient-reported outcomes, were selected to be tracked in patients with HVD. Case-mix variables included demographic factors, demographic variables, echocardiographic variables, heart catheterization variables, and specific details on aortic/mitral/tricuspid valves and their specific interventions.

CONCLUSIONS

Through a unique collaborative effort between patients and cardiology and cardiothoracic surgery societies, a standard set of measures for HVD was developed. This dataset focuses on outcome measurement regardless of treatment, moving from procedure- to patient-centered outcomes. Implementation of this dataset will facilitate global standardization of outcome measurement, allow meaningful comparison between health care systems and evaluation of clinical practice guidelines, and eventually improve patient care for those experiencing HVD worldwide.

Impact of Transcatheter Aortic Valve Implantation on Right Ventricular Function

BACKGROUND

The prevalence and predictors of right ventricular (RV) dysfunction before and after transcatheter aortic valve implantation (TAVI) are not known. We aimed to document this and sought to identify specific RV echo thresholds, below which RV improvement was unlikely to occur.

METHOD

Consecutive patients who underwent TAVI between 2017 and 2021 at Macquarie University Hospital (MUH) were included if ≥2 RV functional parameters were available on baseline echo; tricuspid annular plane systolic excursion, tissue Doppler (S') and/or RV fractional area change. Prevalence and predictors of baseline RV dysfunction were documented. Patients with a repeat echo performed at MUH at 1-3 months post-TAVI were included in further analyses to assess serial changes in RV function.

RESULTS

Overall, 343 patients had an eligible baseline echo and 97 of these patients (28.2%) had RV dysfunction, pre-TAVI. These patients had significantly higher rates of atrial fibrillation, ischaemic heart disease, and chronic lung disease, than those without (p<0.05 for all). Of 239 patients with 1-3 month follow-up echo data, 66 of these had had baseline RV dysfunction; of these, 20 (30.3%) patients showed improvement and 46 (69.7%) patients showed persistent RV dysfunction. Thresholds with a greater than 90% predictive value for persistent RV dysfunction were identified for each baseline RV functional parameter: tricuspid annular plane systolic excursion <1.4 cm, S'<6, fractional area change <25%.

CONCLUSIONS

Baseline RV dysfunction was present in over a quarter of pre-TAVI patients and persisted at short-term follow-up in over two-thirds of such patients. There were clear thresholds to identify patients where RV recovery was unlikely, after TAVI.

Age-Related Outcomes of Valve-in-Valve Transcatheter Aortic Valve Replacement for Structural Valve Deterioration

BACKGROUND

Valve-in-valve transcatheter aortic valve replacement (TAVR) is a recognized alternative for treating the structural valve deterioration of bioprosthetic valves. Recent guidelines and trials have expanded the indications for TAVR to include younger patients with structural valve deterioration. In this study, we aimed to examine the outcomes of valve-in-valve TAVR across different age groups to understand the age-related clinical outcomes of treating structural valve deterioration following surgical aortic valve replacement and TAVR.

METHODS AND RESULTS

In this retrospective study, we included patients who underwent valve-in-valve TAVR at our center. We compared procedural complications and clinical outcomes among patients <75 years of age (n=99), those 75 to 84 years of age (n=103), and those ≥85 years of age (n=71). Echocardiography and computed tomography were used for follow-up evaluations. This study included 273 patients and revealed a low in-hospital complication rate across all age groups. Although the 3-year risk of all-cause mortality was higher in patients >85 years of age, no significant differences in the incidence of stroke/transient ischemic attack were observed among age groups. All groups exhibited significant improvements in valve hemodynamics that persisted for 3 years. Although leaflet thrombosis assessed using computed tomography imaging 30 days post-TAVR was more prevalent in the older group, age was not an independent predictor of this outcome.

CONCLUSIONS

Valve-in-valve TAVR was associated with an increased 3-year mortality risk among older patients despite consistent hemodynamic benefits across all age groups. Age-related differences in leaflet thrombosis did not predict hypoattenuated leaflet thickening, indicating that further studies are necessary to elucidate its implications.

One-Year Functional Outcome of Patients After Surgery for Acute Stanford Type A Aortic Dissection

BACKGROUND

Our aim was to report the functional outcome of Stanford type A aortic dissection (TAAD) after 1 year as well as morbidity and mortality.

METHODS AND RESULTS

This is a retrospective analysis including 642 patients with TAAD from January 2005 to December 2021. Mean age at TAAD was 62 years (95% CI, 61-63), and 30% of the population were women. One year after surgery for TAAD, 75% of patients were living at home with New York Heart Association functional class I. No patients were observed with New York Heart Association functional class IV. Less than 2% resided in an assisted-living facility. Eighty-five percent of nonretired patients had returned to work. Two hundred twelve (33%) patients were retired after 1 year at a mean age of 73 years (95% CI, 72-74). Stroke (defined as any kind of neurological symptoms) occurred in 148 (23%) patients and was the cause of death in 33 patients. Of the remaining patients with stroke, 115 (30%) had no residual limitations 1 year after TAAD. The cross-clamp time was significantly higher in patients with stroke (98 minutes [95% CI, 94.0-101.1] in patients without stroke versus 106 minutes [95% CI, 98.5-114.1] in patients with stroke; P=0.026). Sixty-nine percent of patients with stroke lived at home, 28% lived at home with support, and 3% lived in an assisted-living facility. One year after stroke, 77% of the patients achieved a modified Rankin Scale score ≤2, whereas no patient had a modified Rankin Scale score of 5. There was no significant correlation between sex and recovery rate (P=0.48). However, experiencing a stroke significantly increased the likelihood of residing in an assisted-living facility or receiving support at home 1 year after TAAD (odds ratio, 9.46 [95% CI, 5.06-17.70]; P<0.001). Thirty-day mortality was 11.8%, and 92 patients (14%) died within the first year after TAAD. There was no significant sex difference in mortality (P=0.101).

CONCLUSIONS

One year after surgery for Stanford acute type A aortic dissection, almost 3 out of 4 patients lived unassisted at home. Stroke survivors have a favorable outcome, with the majority having mild or no residual neurological deficits at 1 year.

The first International Consortium for Health Outcomes Measurement (ICHOM) standard dataset for reporting outcomes in heart valve disease: moving from device- to patient- centered outcomes

BACKGROUND

Globally significant variation in treatment and course of heart valve disease (HVD) exists, and outcome measurement is procedure focused instead of patient focused. This article describes the development of a patient-related (International Consortium for Health Outcomes Measurement) standard set of outcomes and case mix to be measured in patients with HVD.

METHODS

A multisociety working group was formed that included patient representatives and representatives from scientific cardiology and cardiothoracic surgery societies that publish current guidelines for HVD. The standard set was developed to monitor the patient's journey from diagnosis to treatment with either a surgical or transcatheter procedure. Candidate clinical and patient-reported outcome measures (PROMs) and case mix were identified through benchmark analyses and systematic reviews. Using an online modified Delphi process, the working group voted on final outcomes/case mix and corresponding definition.

RESULTS

Patients with aortic/mitral/tricuspid valve disease or root/ascending aorta >40 mm were included in the standard set. Patients entered the dataset when the diagnosis of HVD was established, allowing outcome measurement in the preprocedural, periprocedural, and postprocedural phases of patients' lives. The working group defined 5 outcome domains: vital status, patient-reported outcomes, progression of disease, cardiac function and durability, and complications of treatment. Subsequently, 16 outcome measures, including 2 patient-reported outcomes, were selected to be tracked in patients with HVD. Case-mix variables included demographic factors, demographic variables, echocardiographic variables, heart catheterization variables, and specific details on aortic/mitral/tricuspid valves and their specific interventions.

CONCLUSIONS

Through a unique collaborative effort between patients and cardiology and cardiothoracic surgery societies, a standard set of measures for HVD was developed. This dataset focuses on outcome measurement regardless of treatment, moving from procedure- to patient-centered outcomes. Implementation of this dataset will facilitate global standardization of outcome measurement, allow meaningful comparison between health care systems and evaluation of clinical practice guidelines, and eventually improve patient care for those experiencing HVD worldwide.

The First International Consortium for Health Outcomes Measurement (ICHOM) Standard Dataset for Reporting Outcomes in Heart Valve Disease: Moving From Device- to Patient-Centered Outcomes

BACKGROUND

Globally significant variation in treatment and course of heart valve disease (HVD) exists, and outcome measurement is procedure focused instead of patient focused. This article describes the development of a patient-related (International Consortium for Health Outcomes Measurement) standard set of outcomes and case mix to be measured in patients with HVD.

METHODS

A multisociety working group was formed that included patient representatives and representatives from scientific cardiology and cardiothoracic surgery societies that publish current guidelines for HVD. The standard set was developed to monitor the patient's journey from diagnosis to treatment with either a surgical or transcatheter procedure. Candidate clinical and patient-reported outcome measures (PROMs) and case mix were identified through benchmark analyses and systematic reviews. Using an online modified Delphi process, the working group voted on final outcomes/case mix and corresponding definition.

RESULTS

Patients with aortic/mitral/tricuspid valve disease or root/ascending aorta >40 mm were included in the standard set. Patients entered the dataset when the diagnosis of HVD was established, allowing outcome measurement in the preprocedural, periprocedural, and postprocedural phases of patients' lives. The working group defined 5 outcome domains: vital status, patient-reported outcomes, progression of disease, cardiac function and durability, and complications of treatment. Subsequently, 16 outcome measures, including 2 patient-reported outcomes, were selected to be tracked in patients with HVD. Case-mix variables included demographic factors, demographic variables, echocardiographic variables, heart catheterization variables, and specific details on aortic/mitral/tricuspid valves and their specific interventions.

CONCLUSIONS

Through a unique collaborative effort between patients and cardiology and cardiothoracic surgery societies, a standard set of measures for HVD was developed. This dataset focuses on outcome measurement regardless of treatment, moving from procedure- to patient-centered outcomes. Implementation of this dataset will facilitate global standardization of outcome measurement, allow meaningful comparison between health care systems and evaluation of clinical practice guidelines, and eventually improve patient care for those experiencing HVD worldwide.

The Impact of Frailty on VARC-3 Integrated Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

TAVR is preferred over surgical aortic valve replacement in frail patients with aortic stenosis. The assessment of the treatment benefit of TAVR in this population is however equivocal.

OBJECTIVES

The purpose of this study was to investigate the impact of frailty on clinical and patient-reported outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Patients in the SCOPE I (Safety and Efficacy of the ACURATE Neo/TF Compared to the SAPIEN 3 Bioprosthesis) trial were stratified according to frailty, defined as a multicomponent index that included loss of independence criteria based on activities of daily living, lean body mass, serum albumin, and cognitive impairment or dementia. The outcomes of interest included an endpoint integrating vital and patient-reported disease-specific health status, as well as clinical efficacy according to the Valve Academic Research Consortium (VARC)-3 definition.

RESULTS

Among 739 randomized patients, 122 patients (16.5%) met the definition of frailty. Mean age, comorbidities, and surgical risk were comparable between groups. Patients with and without frailty had similar improvement in patient-reported health status measures after TAVR, while patients with frailty had an increased risk of VARC-3 unfavorable outcome (risk ratio: 1.38, 95% CI: towards reduced VARC-3 clinical efficacy (risk ratio: 0.82; 95% CI: 0.65-1.03) at 3 years after TAVR.

CONCLUSIONS

More than 1 in 6 patients with severe aortic stenosis undergoing TAVR were considered frail in the SCOPE I trial. Patients with frailty had a similar improvement in patient-reported health status measures after TAVR, but a higher risk of unfavorable outcomes throughout 3 years of follow-up.

The First International Consortium for Health Outcomes Measurement (ICHOM) Standard Dataset for Reporting Outcomes in Heart Valve Disease: Moving From Device- to Patient-Centered Outcomes: Developed by a multisociety taskforce coordinated by the Heart Valve Society (HVS) including the American Heart Association (AHA), the American College of Cardiology (ACC), the European Association for Cardio-Thoracic Surgery (EACTS), the European Society of Cardiology (ESC), The Society of Thoracic Surgeons (STS), the Australian & New Zealand Society of Cardiac & Thoracic Surgeons (ANZSCTS), the International Society for Applied Cardiovascular Biology (ISACB), the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS), the South African Heart Association (SHA), Heart Valve Voice, and Global Heart Hub

BACKGROUND

Globally significant variation in treatment and course of heart valve disease (HVD) exists, and outcome measurement is procedure focused instead of patient focused. This article describes the development of a patient-related (International Consortium for Health Outcomes Measurement) standard set of outcomes and case mix to be measured in patients with HVD.

METHODS

A multisociety working group was formed that included patient representatives and representatives from scientific cardiology and cardiothoracic surgery societies that publish current guidelines for HVD. The standard set was developed to monitor the patient's journey from diagnosis to treatment with either a surgical or transcatheter procedure. Candidate clinical and patient-reported outcome measures (PROMs) and case mix were identified through benchmark analyses and systematic reviews. Using an online modified Delphi process, the working group voted on final outcomes/case mix and corresponding definition.

RESULTS

Patients with aortic/mitral/tricuspid valve disease or root/ascending aorta >40 mm were included in the standard set. Patients entered the dataset when the diagnosis of HVD was established, allowing outcome measurement in the preprocedural, periprocedural, and postprocedural phases of patients' lives. The working group defined 5 outcome domains: vital status, patient-reported outcomes, progression of disease, cardiac function and durability, and complications of treatment. Subsequently, 16 outcome measures, including 2 patient-reported outcomes, were selected to be tracked in patients with HVD. Case-mix variables included demographic factors, demographic variables, echocardiographic variables, heart catheterization variables, and specific details on aortic/mitral/tricuspid valves and their specific interventions.

CONCLUSIONS

Through a unique collaborative effort between patients and cardiology and cardiothoracic surgery societies, a standard set of measures for HVD was developed. This dataset focuses on outcome measurement regardless of treatment, moving from procedure- to patient-centered outcomes. Implementation of this dataset will facilitate global standardization of outcome measurement, allow meaningful comparison between health care systems and evaluation of clinical practice guidelines, and eventually improve patient care for those experiencing HVD worldwide.

Predictors and Prognostic Effects of Perioperative Myocardial Injury After Transcatheter Aortic Valve Replacement According to VARC-3 Criteria

Purpose

The impact of periprocedural myocardial injury (PPMI) according to VARC-3 criteria in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to investigate the incidence, risk factors, and prognosis of PPMI in patients with severe aortic who underwent TAVR in China.

Materials and Methods

Between September 2012 and November 2021, 516 patients with severe aortic stenosis who underwent TAVR at the Fuwai Hospital were consecutively enrolled. PPMI was defined according to the VARC-3 criteria as a 70-fold increase of upper reference limit in cardiac troponin I (cTnI) levels. We compared the baseline characteristics, perioperative conditions, and in-hospital and long-term endpoints between the PPMI and non-PPMI groups. Logistic regression analysis was used to determine the predictors of PPMI. Survival probabilities for outcomes between the PPMI and non-PPMI groups were estimated using the Kaplan-Meier method.

Results

Of the enrolled patients (mean age: 75.5±7.2 years, 57.5% male), the incidence of PPMI was 20.5%. The median cTnI was 24.9 (interquartile range: 11.4-60.2) times the upper reference limit. After multivariable adjustment, female sex (odds ratio [OR]: 3.01, 95% confidence interval [CI]: 1.88-4.82, P < 0.001), anticoagulant use (OR: 0.27, 95% CI: 0.08-0.96, P = 0.043), balloon-expandable valve (OR: 0.27, 95% CI: 0.09-0.79, P = 0.017), and secondary valve implantation (OR: 2.66, 95% CI: 1.40-5.03, P = 0.003) were significantly associated with PPMI. Patients with PPMI had short- and long-term outcomes similar to those without PPMI.

Conclusion

Female sex and secondary valve implantation are predictors of an increased risk of PPMI, whereas baseline anticoagulant use and the use of balloon-expandable valves are protective factors. The presence of PPMI does not seem to indicate poor short- or long-term prognosis in patients undergoing TAVR.

Transfemoral Transcatheter Aortic Valve Implantation at Hospitals Without On-Site Cardiac Surgery (TAVI at Home): A Multicenter Prospective Interventional Study

Transcatheter aortic valve implantation (TAVI) has become the standard of care for elderly patients with aortic stenosis. International guidelines recommend that TAVI should be performed only in centers with on-site cardiac surgery (CS). However, rapidly evolving TAVI technology and increasing operator expertise have significantly reduced peri-procedural complications, including those requiring rescue surgery, which occur in less than 0.5% of cases. Furthermore, only a minority of major complications are treated with CS, and the outcomes remain unfavorable. TAVI in centers without CS could represent a solution to reduce waiting times and ensure continuity of care for fragile patients. "TAVI at Home" is a single-arm prospective interventional study. According to sample size calculations based on literature data, the study aims to enroll a total of 200 patients, beginning with a run-in phase of 20 patients to establish safety. The primary endpoint is 30-day all-cause mortality. Secondary endpoints include technical success and the evaluation of single complications 30 days after the procedure. Hospitals without CS that are eligible to perform TAVI must have a high volume of coronary percutaneous interventions, operators with established TAVI experience, collaboration with vascular surgeons, and regular Heart Team meetings to ensure rigorous patient selection.

The importance of tissue science and valve design in relation to durability and hemodynamics of the DurAVR aortic heart valve

Introduction

Clinical evidence highlighting the efficacy and safety of transcatheter aortic valve replacement (TAVR) and the 2019 Food and Drug Administration (FDA) approval for TAVR in low-risk (younger) patients has created a demand for durable and long-lasting bioprosthetic heart valve (BHV) leaflet materials. Over the life of an implanted BHV mechanical stress, immunogenicity, calcification, and hemodynamic dysfunction lead to failure via structural valve deterioration (SVD). Consequently, the durability of the bioprosthetic materials selected for valve manufacture is of utmost importance.

Technology

The ADAPT™ tissue engineering process, an anti-calcification preparation that transforms xenograft tissue (bovine pericardium) into a durable valve bioscaffold, shows significant clinical benefits in mitigating the interrelated mechanisms leading to SVD. The novel acellular, biostable and non-calcifying biomaterial has recently been molded into a single-piece 3D biomimetic valve (DurAVR™) with excellent early clinical results and the potential to meet the growing demand of durable BHVs for the treatment of aortic stenosis.

Discussion

The unique design of the DurAVR biomimetic valve in combination with the superior biostability of ADAPT tissue could advance the BHV space by providing superior performance and durability to aortic stenosis patients in need of TAVR.

Outcomes of aortic stenosis in patients with cardiac amyloidosis: A systematic review and meta-analysis

BACKGROUND

Cardiac amyloidosis (CA) results from the deposition of abnormally folded protein fibrils, leading to restrictive cardiomyopathy, valvular heart disease, and arrhythmias. Up to 15 % of patients with severe aortic stenosis (AS) have concomitant CA (AS-CA). We conducted this systematic review and meta-analysis to compare medical management, transcatheter aortic valve replacement (TAVR), and surgical AVR (SAVR) in AS-CA.

METHODS

A comprehensive literature search was conducted for relevant studies from inception through January 20, 2024. Studies exploring outcomes in adult AS patients with and without CA receiving medical therapy, TAVR, or SAVR were included in this analysis.

RESULTS

Fifteen studies including 253,334 patients (AS-CA 6704; AS alone 246,630) were identified. AS-CA patients had significantly higher all-cause mortality (RR = 2.60, 95 % CI 1.48-4.57, P = 0.0009) compared to AS alone. Among patients with AS-CA, TAVR was associated with lower all-cause mortality compared to both medical therapy (RR = 0.50, 95 % CI 0.29-0.89, P = 0.02) and SAVR (RR = 0.41, 95 % CI 0.22-0.78, P = 0.007). AS-CA patients undergoing TAVR were more likely to have paradoxical low-flow, low-gradient AS (RR = 1.56, 95 % CI 1.15-2.12, P = 0.04) at baseline and had a higher risk of post-TAVR acute kidney injury (RR = 1.95, 95 % CI 1.35-2.80, P = 0.0003) compared to patients undergoing TAVR for AS alone. There were similar risks of other post-TAVR complications, including major bleeding, vascular complications, stroke, and new pacemaker implantation between AS-CA and AS alone.

CONCLUSION

CA is associated with a higher mortality in patients with severe AS. In patients with concomitant AS and CA, TAVR is safe and associated with better survival than medical therapy or SAVR. SOCIAL MEDIA ABSTRACT: #Meta-Analysis: Cardiac amyloidosis is associated with increased mortality in severe AS. #TAVR is safe in amyloidosis & improves survival more than medical therapy or SAVR.

Safety and efficacy of the unilateral, suture-based, dry-closure technique in percutaneous trans-axillary aortic valve implantation

BACKGROUND

Transaxillary transcatheter aortic valve implantation (TAx-TAVI) is the most used alternative access when severe iliofemoral disease renders transfemoral access infeasible. Compared to surgical transaxillary access, a true percutaneous approach using vascular closure devices (VCD) has advantages but can be challenging. Herein, we describe the impact of the "unilateral, suture-mediated, dry-closure technique" on vascular safety and efficacy in patients undergoing true percutaneous TAx-TAVI.

METHODS

A total of 77 patients undergoing percutaneous TAx-TAVI were categorized into a cohort before (C1, n = 40) and after (C2, n = 37) implementation of the suture-based dry-closure technique using an upstream occlusion balloon. In C1, arteriotomy closure mainly consisted of plug-based VCD. The primary (safety) endpoint was occurrence of major or minor access-site related vascular complications in accordance with Valve Academic Research Consortium 3 criteria. Technical success rates (at exit from procedure room) were used to assess procedural efficacy.

RESULTS

The mean age of the study population was 79 ± 7 years and 49 % were male. From C1 to C2, the Society of Thoracic Surgeons Predicted Risk of Mortality reduced numerically (from 4.1 to 3.6 %, p = 0.060). Procedures became more streamlined with use of local anesthesia in 100 % (83 % in C2) and the left axillary artery in 76 % (68 % in C2). The primary (safety) endpoint occurred in 34 % of the patients, but reduced from 45 % in C1 to 16 % in C2 (p = 0.011). Concurrently, there was a reduction in VCD failure (45 vs 14 % [incomplete arteriotomy closure in all 5 cases], p = 0.003), bleeding complications (45 vs 14 %, p = 0.003) and bailout vascular surgery/stenting (40 % vs. 16 %, p = 0.021). Technical success was 80 % in C1 and 87 % in C2 (p = 0.45) and median length of hospital stay reduced from 5 (25th-75th percentile: 2-7) to 3 days (25th-75th percentile: 2-5, p = 0.080).

CONCLUSIONS

The unilateral, suture-based dry-closure technique facilitates safe and effective access management in high-risk patients selected for percutaneous TAx-TAVI procedures.

Case Report: Leaflet thrombosis after transcatheter valve-in-valve aortic valve replacement in prosthetic valve endocarditis

A 70-year-old female patient with a history of bioprosthetic aortic valve replacement and coronary artery bypass graft presented with bioprosthetic valve failure secondary to prosthetic valve endocarditis. The patient was deemed unsuitable for surgery by the heart team, following which she underwent transcatheter aortic valve-in-valve replacement. This resulted in early death due to myocardial infarction and acute heart failure. A computed tomography revealed subclinical leaflet thrombosis. This case highlights the importance of postoperative anticoagulation therapy.

Comparison of Long-Term Performance of Porcine versus Pericardial Bioprostheses

BACKGROUND

 The long-term comparative results between porcine and pericardial bioprostheses for surgical aortic valve replacement (SAVR) are debated. Scarce information exists concerning direct comparative evaluation among contemporary devices. We compared late and very late results in a single center series (n = 3,983 cases).

METHODS

 From a prospectively collected database we included 3,983 recipients of two current porcine bioprostheses (porcine group) or one current pericardial bioprosthesis (pericardial group). We evaluated the long-term freedom from structural valve deterioration (SVD) with both Kaplan-Meier and competing risk methods (primary endpoint). We distinguished between SVD and patient-prosthesis mismatch (PPM). Secondary endpoints were late survival, freedom from valve-related mortality, freedom from reoperation for SVD, freedom from nonstructural valve dysfunction (NSVD) and freedom from endocarditis.

RESULTS

 Median follow-up was 10.4 years (99.7% complete, 32,219 patients/years). Overall survival was significantly lower in the porcine group (p = 0.002), related to baseline intergroup differences. At 10 years, Kaplan-Meier freedom from SVD was significantly better in the porcine group (98.0% ± 0.3 vs. 96.3% ± 0.8; p = 0.003). Competing risk freedom from SVD at 10 years was 98.6% ± 0.2 and 97.2% ± 0.6 (porcine and pericardial group, respectively; p = 0.001). The porcine group displayed a higher rate of PPM.

CONCLUSION

 Despite the augmented risk of PPM compared with pericardial valves, in this series porcine bioprostheses seem to perform better concerning protection from late (>10 years) SVD. Smaller valve sizes (19-21 mm) may negatively impact the SVD risk among porcine valves but not among pericardial valves. These elements need to be considered for valve choice and surgical strategy in SAVR candidates according to their life expectancy, clinical context, and annulus size.

Long-Term Results in Minimally Invasive Non-Resectional Mitral Valve Repair for Barlow Mitral Valve Disease

Objective: The aim was to assess the long-term outcomes, safety, and durability of total endoscopic mitral valve repair for Barlow mitral valve disease. Methods: A retrospective analysis of 98 patients undergoing minimal invasive total endoscopic mitral valve repair for Barlow mitral valve disease was conducted between May 2009 and December 2023. A non-resectional repair approach using artificial neochordae and/or ring annuloplasty was performed. Clinical and echocardiographic follow-ups were completed. Rates per patient-years with 95% confidence intervals (CI) for all time-to-event outcomes were calculated. Results: The mean age was 59 ± 12, and 43% were female. Minimally invasive mitral valve repair was successfully performed in all 98 patients with no conversions to sternotomy or mitral valve replacement. There was no mitral valve-related reoperation during the hospital stay. Procedural safety was as follows: no in-hospital mortality, no stroke, and no perioperative myocardial infarction. The mean follow-up was 4.1 ± 3.1 years. Survival at seven years was 87% (95% CI 63% to 96%). Freedom from myocardial infarction, stroke, and congestive heart failure was 89% (95% CI 60% to 97%), 93% (95% CI 82% to 97%), and 100%, respectively. Recurrent mitral valve insufficiency at Grade ≥ 2 was diagnosed in n = 4 (4.1%) of cases. Conclusions: Minimally invasive mitral valve repair using a non-resectional technique for Barlow disease can be performed with a low complication rate. The total endoscopic approach is safe in the long term, with minimal risk of reoperation and recurrent mitral valve insufficiency.

Integrated double redo percutaneous valve replacement: simultaneous transcatheter aortic and mitral valve management

OBJECTIVES

The growing elderly population contributes to an increasing prevalence of severe degenerative native aortic valve (AV) or mitral valve (MV) disease in combination with bio-prosthetic valve failure of prior implanted (aortic or mitral) bio-prostheses, as well as concomitant failure of both aortic and mitral bio-prosthetic valves. A combined surgical AV and MV replacement carries a markedly higher risk, especially in the redo setting. Transcatheter double-valve implantation (TDVI) is emerging as a promising alternative that may mitigate the risks of redo surgery. The evidence for TDVI is very limited. This study aims to address the current gap in the literature by analysing a large institutional series of single-stage TDVI.

METHODS

Single-centre retrospective analysis of all patients (n = 13) undergoing simultaneous transcatheter aortic valve implantation (TAVI) and transcatheter mitral valve implantation (TMVI) from October 2018 until April 2024. Primary end-points were Valve Academic Research Consortium-3 (VARC-3) and Mitral Valve Academic Research Consortium (MVARC) technical success, 30-day device success and early safety (MVARC procedural success). Secondary end-points included echocardiographic TDVI performance, adverse events, symptom change and survival.

RESULTS

The median age of patients was 77 years, with 7/13 (53.8%) females. Median EuroSCORE II was 16.9%. All patients presented with structural valve degeneration with severe haemodynamic valve deterioration according to the VARC-3 definition. Procedural outcomes showed 100% technical success. There was absence of 30-day mortality (0%). Thirty-day device success and early safety/MVARC procedural success were 100%. No major adverse events occurred. After TDVI, the median New York Heart Association functional class improved from III to II.

CONCLUSIONS

TDVI appears to be a safe and effective alternative to surgical redo double-valve replacement for selected patients. Our findings support the feasibility of TDVI with excellent early outcomes. Further prospective multicentre studies with larger cohorts are needed to validate the long-term effects and to establish TDVI as a guideline consideration.

The First International Consortium for Health Outcomes Measurement (ICHOM) Standard Dataset for Reporting Outcomes in Heart Valve Disease: Moving From Device- to Patient-Centered Outcomes

BACKGROUND

Globally significant variation in treatment and course of heart valve disease (HVD) exists, and outcome measurement is procedure focused instead of patient focused. This article describes the development of a patient-related (International Consortium for Health Outcomes Measurement) standard set of outcomes and case mix to be measured in patients with HVD.

METHODS

A multisociety working group was formed that included patient representatives and representatives from scientific cardiology and cardiothoracic surgery societies that publish current guidelines for HVD. The standard set was developed to monitor the patient's journey from diagnosis to treatment with either a surgical or transcatheter procedure. Candidate clinical and patient-reported outcome measures (PROMs) and case mix were identified through benchmark analyses and systematic reviews. Using an online modified Delphi process, the working group voted on final outcomes/case mix and corresponding definition.

RESULTS

Patients with aortic/mitral/tricuspid valve disease or root/ascending aorta >40 mm were included in the standard set. Patients entered the dataset when the diagnosis of HVD was established, allowing outcome measurement in the preprocedural, periprocedural, and postprocedural phases of patients' lives. The working group defined 5 outcome domains: vital status, patient-reported outcomes, progression of disease, cardiac function and durability, and complications of treatment. Subsequently, 16 outcome measures, including 2 patient-reported outcomes, were selected to be tracked in patients with HVD. Case-mix variables included demographic factors, demographic variables, echocardiographic variables, heart catheterization variables, and specific details on aortic/mitral/tricuspid valves and their specific interventions.

CONCLUSIONS

Through a unique collaborative effort between patients and cardiology and cardiothoracic surgery societies, a standard set of measures for HVD was developed. This dataset focuses on outcome measurement regardless of treatment, moving from procedure- to patient-centered outcomes. Implementation of this dataset will facilitate global standardization of outcome measurement, allow meaningful comparison between health care systems and evaluation of clinical practice guidelines, and eventually improve patient care for those experiencing HVD worldwide.

Revisiting ascending aortic resection in the elective valve-sparing root replacement: assessing the benefits and necessity of hemiarch replacement at three centres†

OBJECTIVE

The aim of this study was to determine the indication and optimal timing for performing a hemiarch procedure in patients undergoing valve-sparing root replacement (VSRR).

METHODS

We conducted a retrospective study on 986 patients undergoing VSRR at three tertiary care centres. Inclusion criteria were all patients undergoing elective VSRR. Exclusion criteria were age <18 years, Stanford type A dissection, dissection in the arch, total aortic arch replacement or previous aortic arch replacement. We performed propensity score matching in a 1:1 ratio. The primary end-point is a composite outcome that includes mortality, aortic arch reintervention, new aortic dissection during follow-up and cerebrovascular incidents within the first 30 days.

RESULTS

A total of 401 patients (41%) had a hemiarch replacement, while 585 (59%) did not. Root phenotype was present in 565 (57%). The mean follow-up time was 4.7 years (SD ± 4.6). In the matched population, there was no significant difference in the 10-year freedom from the composite outcome between the non-hemiarch and hemiarch groups (87.3% vs 85.0%, P > 0.999). Similarly, no difference was found for aortic reinterventions (P = 0.13) or survival (P = 0.5). This was also true for patients with heritable thoracic aortic disease. However, in patients with a bicuspid aortic valve, the intervention rate was significantly higher in the hemiarch group (10.8% vs 0%, P = 0.016). There was no significant difference in the 30-day incidence of cerebrovascular accidents between the groups (5% vs 2.7% in the hemiarch group, P = 0.117). Only the distal ascending diameter showed a tendency with better outcome over 45 mm for the hemiarch procedure; otherwise, we found no reliable cut-off values based on ascending length, diameter-to-height index or ascending length-to-height index.

CONCLUSIONS

Our findings conclusively demonstrate that concomitant hemiarch replacement does not increase the perioperative risk in young patients undergoing VSRR. However, concomitant replacement does not seem to protect from aortic reinterventions during medium-term follow-up.

Edoxaban Monotherapy and Incidence of Transcatheter Heart Valve Leaflet Thrombosis - The Rotterdam Edoxaban (REDOX) Study

BACKGROUND

Trials comparing non-vitamin K oral anticoagulant (NOAC) versus antiplatelet-based strategies have shown a reduction of subclinical leaflet thrombosis at the cost of increased mortality and major-bleedings. NOACs were often combined with antiplatelet therapy.

AIMS

The Rotterdam Edoxaban (REDOX) study aimed to evaluate the impact of edoxaban monotherapy on the incidence of hypo-attenuated leaflet thickening (HALT) and reduced leaflet motion (RLM) and to evaluate safety in terms of mortality, thromboembolic events and major bleeding.

METHODS

The REDOX study is a single-arm, open-label trial including patients after successful transcatheter aortic valve implantation (TAVI) with no formal indication for oral anticoagulation or dual antiplatelet therapy. Patients received edoxaban monotherapy for 3 months, followed by multislice computed tomography (MSCT). The primary endpoint was the occurrence of HALT. Clinical follow-up continued up to 1 year after TAVI.

RESULTS

We included 58 patients, of which 50 reached study completion including MSCT scanning and eight withdrew consent before end of study. At 3-months follow-up, HALT of any grade was detected in 12.0% (95% confidence interval (CI): 5.0%-23.1%) of patients. HALT grade ≥ 3 occurred in 4.0% (95% CI: 0.8%-12.2%) of patients. At 1 year follow-up, all patients were alive and free of disabling strokes. Three patients had a non-disabling stroke and one patient had a major bleeding.

CONCLUSIONS

In the REDOX study, edoxaban monotherapy after TAVI was associated with a 12.0% incidence of any HALT and a 4.0% incidence of HALT grade ≥ 3. HALT was not associated with clinical events.

Transcatheter aortic-valve implantation with or without on-site cardiac surgery: The TRACS trial

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has emerged as an effective and safe treatment for patients with symptomatic aortic stenosis. The indication to TAVI should be agreed upon by a Heart Team, and the procedure should be performed in centers with on-site cardiac surgery. However, TAVI complications requiring emergent cardiac surgery (ECS) have become very rare. Concurrently, access disparities and prolonged waiting times are pressing issues due to increasing clinical demand of TAVI. Many solutions have been proposed and one of them is the possibility of performing TAVI in centers without on-site cardiac surgery.

METHODS AND DESIGN

The Transcatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery (TRACS) trial is a prospective, randomized, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients with symptomatic severe aortic stenosis and deemed inoperable, at high surgical risk, or presenting with at least 1 clinical factor compromising the benefit/risk ratio for ECS, will be randomized to undergo TAVI either in centers with or without on-site cardiac surgery. The primary endpoint will be the composite occurrence of all-cause death, stroke, and hospital readmission for cardiovascular causes at one year. The safety endpoint will include death attributable to periprocedural complications actionable by ECS. The study aims to enroll 566 patients.

IMPLICATIONS

The TRACS trial aims to address critical gaps in knowledge regarding the safety and efficacy of TAVI procedures performed in centers without on-site cardiac surgery, potentially improving access and outcomes for high-risk patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05751577.

Protruding and Ulcerated Aortic Atheromas as Predictors of Periprocedural Ischemic Stroke Post-Transcatheter Aortic Valve Replacement

BACKGROUND

Aortic atherosclerosis can affect the strategy and outcomes of transcatheter aortic valve replacement (TAVR). Limited investigation exists into how aortic atheroma morphology influences outcomes post-TAVR.

OBJECTIVES

This study aimed to assess the influence of protruding and ulcerated aortic atheromas on periprocedural ischemic stroke post-TAVR.

METHODS

This analysis included 977 patients who underwent TAVR between February 2010 and May 2019, with available contrast-enhanced computed tomography data. Protruding aortic atheroma was defined as atheroma of ≥3 mm thickness with protruding components. Ulcerated aortic atheroma was defined as atheroma with ulcer-like intimal disruption. The primary endpoint was periprocedural ischemic stroke within 30 days post-TAVR.

RESULTS

In total, 43 (4.4%) experienced periprocedural ischemic stroke. Patients with protruding or ulcerated aortic atheroma had a significantly higher incidence of periprocedural stroke compared with those without (8.0% [95% CI: 4.9%-12.2%] vs 3.2% [95% CI: 2.1%-4.8%]; P = 0.003). Protruding or ulcerated atheroma (adjusted OR [aOR]: 2.55 [95% CI: 1.37-4.74]), particularly in the aortic arch (aOR: 3.86 [95% CI: 1.69-8.83]), independently increased periprocedural stroke risk. Among patients undergoing transfemoral TAVR with self-expandable valves (n = 315, 32%), protruding or ulcerated atheroma in the aortic arch was independently associated with periprocedural stroke (aOR: 9.04 [95% CI: 1.59-51.4]), whereas it was not among those with balloon-expandable valves (n = 580, 59%) (aOR: 2.85 [95% CI: 0.92-8.84]).

CONCLUSIONS

Protruding and ulcerated aortic atheromas are associated with a higher risk of periprocedural ischemic stroke post-TAVR. Careful selection of TAVR strategy, including valve type and procedural approach, is essential for patients with such aortic lesions.

Impact of Baseline Left Ventricular Ejection Fraction on Midterm Outcomes in Women Undergoing Transcatheter Aortic Valve Implantation: Insight from the WIN-TAVI Registry

Limited evidence exists concerning the prognostic impact of baseline left ventricular ejection fraction (LVEF) on outcomes among women undergoing transcatheter aortic valve implantation (TAVI), which we aimed to investigate in the present analysis. Patients from the Women's International Transcatheter Aortic Valve Implantation (WIN-TAVI) registry were categorized according to baseline LVEF into 3 groups: reduced (LVEF ≤40%), mildly reduced (LVEF between 41% and 49%), and preserved (LVEF ≥50%) LVEF. The primary (Valve Academic Research Consortium 2 [VARC-2]) efficacy point was defined as a composite of mortality, stroke, myocardial infarction, hospitalization for valve-related symptoms or heart failure, or valve-related dysfunction at 1 year. The primary (VARC-2) safety end point included all-cause mortality, stroke, major vascular complication, life-threatening bleeding, stage 2 to 3 acute kidney injury, coronary artery obstruction requiring intervention, or valve-related dysfunction requiring repeated procedures. A Cox regression model was performed using the preserved LVEF group as the reference. Among the 944 patients included, 764 (80.9%) exhibited preserved, 80 (8.5%) had mildly reduced, and 100 (10.6%) had reduced LVEF. The 1-year incidence of VARC-2 efficacy end point was numerically higher in patients with reduced LVEF, albeit not resulting in a significant risk difference. Notably, reduced LVEF was associated with a higher risk of the 1-year VARC-2 safety end point, still significant after adjustment (28.0% vs 19.6%, Hazard Ratio 1.78, 95% Confidence Interval 1.12- 2.82, p = 0.014). These differences were primarily driven by trends toward increased rates of all-cause mortality, cardiovascular mortality, and major vascular complications. Clinical outcomes were similar between patients with mildly reduced and preserved LVEF. In conclusion, when performed in women with reduced LVEF, TAVI was associated with a worse (VARC-2) safety profile at 1-year follow-up. In contrast, patients with mildly reduced LVEF appeared to align more closely with outcomes observed in the preserved LVEF group than with the reduced LVEF group.

Multiorgan Dysfunction and its Association With Congestion and Outcome in Aortic Stenosis Treated With TAVI

Background

Degenerative severe aortic stenosis (AS) is treated by valve replacement to improve outcome. Despite diagnostic advancements, many AS patients are still diagnosed late with advanced heart failure.

Objectives

The aim of the study was to assess multiorgan dysfunction in severe AS using blood biomarkers and their association with quantitative fluid levels and clinical outcomes after transcatheter aortic valve implantation (TAVI).

Methods

Consecutive AS patients undergoing TAVI received comprehensive preinterventional assessment with serum biomarker profiles reflecting organ dysfunction and quantitative fluid overload (FO) using bioelectrical impedance spectroscopy. FO by bioelectrical impedance spectroscopy was defined according to a previously established cut-off (≥1.0 L). Time to first heart failure hospitalization or death served as composite primary endpoint.

Results

Among 880 patients (age 81 ± 7 years, 47% female), 41% had FO and 89% had biomarker abnormalities of at least one domain. Ascending fluid levels were independently associated with distorted biomarkers across domains of myocyte stress, hepatic dysfunction, renal dysfunction, inflammation, and anemia. After 2.4 ± 1.0 years of follow-up, 27% had reached the primary endpoint (29 heart failure hospitalization, 194 deaths, 13 both). Biomarkers across all domains were individually and independently associated with outcomes. In a multidomain approach, every affected extra-cardiac domain was associated with a 71% increase in event hazard (adjusted HR: 1.71; 95% CI: 1.39-2.11). Also, for each domain, the combination of distorted biomarkers and FO had the highest event risk.

Conclusions

Biomarker abnormalities are highly prevalent in severe AS, influenced by congestion, and associated with impaired prognosis post-TAVI. Multiorgan dysfunction faces a particularly dismal outcome.

Unilateral-access vs. bilateral-access in transfemoral transcatheter aortic valve replacement: A slim fit approach

BACKGROUND

Vascular complications remain prevalent on transfemoral transcatheter aortic valve replacement (TF-TAVR) with a significant proportion related to the secondary arterial access. We hypothesized that placing the second sheath ipsilateral and distal to the delivery sheath could reduce vascular complications with similar safety and efficacy.

OBJECTIVES

Comparing vascular complications and clinical outcomes when placing the secondary arterial sheath in the ipsilateral (unilateral-access) versus in the contralateral (bilateral-access) femoral artery during TF-TAVR.

METHODS

Patients who underwent TF-TAVR using unilateral-access as first-choice approach were retrospectively compared with a contemporaneous bilateral-access group. The primary endpoint was the incidence of vascular complications related to femoral access according to the VARC-3 criteria. A propensity-score analysis was performed accounting for the differences in clinical, vascular, and procedural characteristics.

RESULTS

A total of 217 patients were included, of whom 150 (69.1 %) underwent TF-TAVR through bilateral- and 67 (30.9 %) through unilateral-access. Vascular complications occurred in 16.0 % of the bilateral-access group and 10.4 % of the unilateral-access group (p = 0.280). The unilateral-access group achieved high procedural success with normalization of peak aortic velocity and low rates of paravalvular leaks, valve migration and pacemaker requirement. After propensity-score matching, the overall complications rate was superior in the bilateral-access group (54.4 % vs 35.1 %, p = 0.038) due to a trend of higher vascular complications (26.3 % vs 12.3 %, p = 0.058) and a significant higher occurrence of bleeding complications (17.5 % vs 1.8 %, p = 0.008).

CONCLUSIONS

Unilateral-access TF-TAVR is feasible, safe, and potentially enhances procedural efficiency and patient satisfaction while maintaining the capacity for bailout interventions in managing vascular complications.

Pathology of Self-Expanding Transcatheter Aortic Bioprostheses and Hypoattenuated Leaflet Thickening

BACKGROUND

Hypoattenuated leaflet thickening (HALT) is believed to reflect leaflet thrombosis; however, no systematic histological examination of HALT has ever been performed. The aim of this study was to evaluate histological findings of explanted self-expanding transcatheter aortic bioprosthetic valves from clinical trials and to compare microCT findings of suspected HALT with histology findings of valve thrombosis and its characterization over time.

METHODS

A total of 123 self-expanding transcatheter aortic valves were collected through autopsy (n=89) or surgical explant (n=34) from 11 CoreValve/Evolut clinical trials. Histological findings in transcatheter aortic valve leaflets were evaluated. MicroCT imaging was used to evaluate HALT in histology. Cases with infective endocarditis (10/123) or transcatheter aortic valve-in-surgical aortic valve procedures (3/123) were excluded.

RESULTS

A total of 110 cases were divided into 3 groups based on implant duration: <30 days (n=42), 30 to 365 days (n=35), and >365 days (n=33). Thrombus and inflammation scores were consistent across groups, while scores for pannus, calcification, and structural change increased over time. The analysis of leaflet thickening by histology was performed on 320 leaflets and any degree of leaflet thickening was observed in 46.5% (149/320) of leaflets. Histologically, leaflet thickening was confirmed as an acute, organizing, and organized thrombus (ie, pannus). In the <30 days group, all leaflet thickening was due to acute thrombus, while most thrombi were organized >30 days. The types of thrombi could not be differentiated by microCT imaging.

CONCLUSIONS

HALT represents the presence of a thrombus and its progression. Our data suggest that treatment of HALT would likely be most effective in the early stages before the thrombus becomes organized and emphasizes the need for early detection.

Extremely Small 20-mm Versus Standard-Size Balloon-Expandable Transcatheter Heart Valves: Propensity-Matched Analysis From the OCEAN-TAVI Registry

BACKGROUND

The 20-mm balloon-expandable transcatheter heart valve (THV) represents the smallest available option for transcatheter aortic valve replacement (TAVR). Its current underutilization stems from concerns regarding prosthesis-patient mismatch, durability, and potential adverse outcomes.

OBJECTIVES

The purpose of this study was to compare the long-term outcomes between the 20-mm balloon-expandable THVs and standard-size balloon-expandable THVs.

METHODS

Patients who underwent transfemoral TAVR with SAPIEN THVs were sourced from the OCEAN-TAVI (Optimized Transcatheter Valvular Intervention) registry, an ongoing, multicenter cohort study that has enrolled over 7,000 TAVR patients in Japan. A 1:3 propensity-matched analysis, based on 24 baseline clinical and echocardiographic variables, was used to contrast the 20-mm with >20-mm balloon-expandable THVs.

RESULTS

Of 5,086 eligible patients, 284 (5.6%) received the 20-mm balloon-expandable THV. After propensity-matching, the 20-mm THV group (n = 276) and the >20-mm THV group (n = 828) demonstrated balanced baseline characteristics, with an absolute standardized difference <0.10. The average follow-up duration for patients who were alive was 955 ± 512 days, and the average time to death was 584 ± 543 days. The 20-mm group showed a higher frequency of prosthesis-patient mismatch (PPM) (moderate PPM: 29.2% vs 10.8%; severe PPM: 4.9% vs 1.5%; P < 0.001). Over a 5-year period, all-cause mortality and heart failure rehospitalization rates were comparable between the 2 groups (all-cause mortality: 34.2% vs 38.0%; HR: 1.01; 95% CI: 0.74-1.37; P = 0.970; heart failure rehospitalization: 15.2% vs 16.3%; HR: 0.81; 95% CI: 0.50-1.29; P = 0.371).

CONCLUSIONS

This registry-based study suggests that the initially observed inferior forward hemodynamics associated with the 20-mm THV do not translate into heightened long-term mortality or heart failure rehospitalization risks. (The OCEAN-TAVI registry [Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation]; UMINID:000020423).

Impact of porcelain aorta on outcomes in transfemoral aortic valve implantation (TAVI) with balloon-expandable valves

BACKGROUND

Current guidelines recommend transcatheter aortic valve implantation (TAVI) for patients with aortic stenosis and porcelain aorta (PA). Neurological outcomes of patients with PA undergoing TAVI with modern valves require clarification as most trials examined balloon-expandable valves (BEV) and self-expandable valves in intermediate or high-risk patients, but not specifically in patients with PA. Our aim was to compare outcomes, including stroke and mortality, in well-matched patients with and without PA who received BEV during transfemoral TAVI procedures.

METHODS

Consecutive patients undergoing TAVI were entered into a registry. For this single-centre (Zentralklinik Bad Berka, Germany), retrospective analysis, we only selected patients who received BEV. PA diagnosis was made when non-contrast axial CT images fulfilled Valve Academic Research Consortium-2 criteria for PA. There was 2:1 nearest neighbour matching of patients without and with PA. The primary outcome measure was 30-day mortality or stroke within 72 hours. Secondary outcome measures were 30-day mortality, stroke within 72 hours, technical success and 30-day device success.

RESULTS

After matching patients with (n=141) and without PA (n=282), the primary outcome of mortality at <30 days or stroke within 72 hours was higher in PA versus non-PA (7.8% vs 2.5%; OR 3.32 (95% CI 1.25 to 8.85); p=0.019). With regard to secondary outcomes, PA was not associated with mortality at 30 days (4.3% vs 2.1%; OR 2.04 (95% CI 0.65 to 6.48); p=0.23); however, stroke within 72 hours was significantly higher in PA versus non-PA (3.5% vs 0.4%; OR 10.33 (95% CI 1.17 to 91.12); p=0.017). Technical and device success were uninfluenced by PA.

CONCLUSIONS

Transfemoral TAVI with BEV in patients with PA was associated with a higher risk of the primary combined endpoint of mortality at 30 days or stroke within 72 hours, which was primarily driven by stroke within 72 hours. These findings might influence cerebral embolic protection device use in patients with PA.

Early and late bleeding events according to Valve Academic Research Consortium 3 criteria following transcatheter aortic valve implantation

BACKGROUND

Transcatheter aortic valve implantation may be associated with significant haemorrhagic complications.

AIMS

To evaluate the timing, incidence, predictors and clinical impact of bleeding events after transcatheter aortic valve implantation, according to the updated Valve Academic Research Consortium (VARC)-3 criteria, compared with the VARC-2 criteria.

METHODS

A retrospective observational study involving 487 consecutive patients who underwent transcatheter aortic valve implantation between July 2017 and May 2019 was performed. Bleeding events were classified according to the VARC-2 and VARC-3 definitions.

RESULTS

Bleeding events occurred in 17.6% of patients, with early bleeding (in-hospital) in 12.5% and late bleeding (occurring after discharge) in 6.1%. The primary vascular access site was the most common source of early bleeding, whereas gastrointestinal bleeding was predominant in late events. Significant predictors of early VARC-3-defined bleeding included active cancer, previous implantable cardioverter-defibrillator, history of mitral valve surgery, a non-transfemoral approach and occurrence of an in-hospital major vascular complication or new-onset atrial fibrillation. Late bleeding was independently associated with a history of myocardial infarction and treatment with vitamin K antagonists at discharge. Early bleeding events were not associated with increased late all-cause mortality. No significant difference was observed based on the VARC-2 and VARC-3 bleeding definitions.

CONCLUSIONS

Bleeding events occurred in one sixth of patients undergoing transcatheter aortic valve implantation without significant difference in their incidence between the VARC-2 and VARC-3 classifications. Early bleeding events were not associated with poorer long-term survival, regardless of the classification used. Larger studies with greater statistical power, including more contemporary patients, are needed to confirm these findings.

Evaluation of Prospective ECG-Triggered CT Scan as a Practical Alternative to Standard Retrospective ECG-Gated Scan for Pre-TAVI Patients

Purpose: CT-TAVI is a critical component of pre-TAVI assessment. The conventional method, retrospective ECG-gated scan, covering a complete cardiac cycle, measures the annulus during optimal systolic phases. Recently, prospective ECG-triggered scans acquiring images at a specific interval of the cardiac cycle were evaluated, allowing faster acquisition and lower contrast doses. Moreover, these scans might be beneficial for elderly patients, reducing the need for breath-holding and easing cooperation requirements. Still, their impact on annular measurement and procedural success has yet to be fully evaluated. Methods: This retrospective, single-center study included 419 patients who underwent CT-TAVI scans, by either prospective or retrospective scanning methods. Baseline data and calculated surgical risk scores were collected, with propensity score matching performed, followed by univariate analysis, Cox regression, and multivariable regression analysis. Results: A total of 171 patient pairs were generated via propensity score matching, ensuring that both groups had similar distributions of age (81 ± 8 years), sex (55% males), and baseline comorbidities. The patients in the prospective ECG-triggered group were exposed to a smaller amount of contrast material (40.0 ± 12 mL vs. 70.0 ± 48 mL, p < 0.001) and radiation (4.4 ± 3.6 mSv vs. 8.0 ± 10.3 mSv, p < 0.001). The prospective ECG-triggered group had a smaller aortic annulus area and diameter (426.6 ± 121.0 mm2 vs. 469.1 ± 130.8 mm2, p = 0.006 and 23.3 ± 3.2 mm vs. 24.5 ± 3.6 mm, p = 0.004) but no excess paravalvular leak was observed. Multivariable analysis showed no significant differences in mortality and composite endpoints between the two groups after 23 months of follow-up. Conclusion: Prospective ECG-triggered, ultra-fast, low-dose, high-pitch scan protocol, used in selected patients offers comparable safety and clinical procedural outcomes along with time and contrast savings.

Anatomical Predictors of Access-Related Vascular Complications Following Transfemoral Transcatheter Aortic Valve Replacement

BACKGROUND

Access-related vascular complications (VCs) after percutaneous transfemoral transcatheter aortic valve replacement (TAVR) are associated with poor clinical outcomes and remain a significant challenge despite technological advances. The aim of this study was to identify anatomic predictors of access-related VCs after TAVR on preprocedural contrast-enhanced multidetector computed tomography (MDCT).

AIMS

The aim of this study was to identify anatomical predictors of access-related VCs after TAVR on preprocedural contrast-enhanced MDCT.

METHODS

A total of 348 consecutive patients with symptomatic severe AS who underwent transfemoral TAVR were included retrospectively. The primary endpoint of the study was the composite of minor and major access site complications as defined by the Valve Academic Research Consortium-3 (VARC-3) criteria. The study population was divided into two groups according to the VC including VC (+) and VC (-).

RESULTS

A total of 101 patients (29%) developed VC (8.7% major, 20.3% minor) following TAVR. Regression analysis identified severe CFA calcification (p = 0.004), CFA depth (p < 0.001), minimum CFA diameter (p < 0.001), CFA depth-to-diameter ratio ≥ 5.6 (p < 0.001), and sheath-to-femoral artery ratio (SFAR) (p < 0.001) as significant predictors of VC. ROC curves generated for the occurrence of VC, the AUC for the femoral artery depth-to-diameter ratio (0.720) was higher than the AUC for the SFAR and the depth of the femoral artery (0.636, 0.630).

CONCLUSION

Complications related to vascular access sites continue to be a significant concern for patients undergoing TF-TAVR. The CFA depth-to-diameter ratio has demonstrated superior predictive performance for VC compared to SFAR as expressed in the literature. Utilizing this criterion may enhance risk stratification for VC in high-risk patients, potentially reducing associated morbidity and mortality.

Timing and Outcomes of PCI in Conjunction With TAVR With Balloon-Expandable Valves

BACKGROUND

The optimal timing for percutaneous coronary intervention (PCI) in patients undergoing transcatheter aortic valve replacement (TAVR) is debatable.

OBJECTIVES

The aim of this study was to compare outcomes based on the timing of PCI in stable coronary artery disease patients undergoing TAVR.

METHODS

Leveraging the STS/ACC TVT Registry and Medicare Linkage, we analyzed patients with stable coronary artery disease undergoing PCI and TAVR between 2015 and 2023 using the SAPIEN 3 balloon-expandable valve platform. This analysis included patients who underwent PCI within ±90 days of the index TAVR procedure. All-cause mortality, stroke, and a composite of mortality and stroke were analyzed up to 3 years using Medicare Linkage.

RESULTS

Of the 51,480 patients who underwent PCI and TAVR with SAPIEN 3 platforms during the study period, 84.7% had PCI within 90 days before TAVR, 13.9% had concomitant PCI, and 1.4% had PCI within 90 days after TAVR. In the propensity-matched analysis, patients undergoing PCI before TAVR had better outcomes in terms of all cause-mortality (38.1% vs 38.8%; P = 0.013) and a composite of mortality and stroke (42.8% vs 43.5%; P = 0.012) compared with the ones undergoing concomitant PCI at 3-year follow-up. Major vascular complications were higher in patients undergoing concomitant PCI and TAVR (2% vs 1.4%; P = 0.003) CONCLUSIONS: Patients undergoing concomitant PCI and TAVR had higher major vascular complications, and slightly higher composite of all-cause mortality and stroke compared with those who underwent PCI within 90 days before the TAVR procedure.

Impact of Body Mass Index on the Initial Phase of a Minimally Invasive Aortic Valve Program

BACKGROUND

 In obese patients, minimally invasive surgical aortic valve replacement (MIS-AVR) presents challenges, and the risk of patient-prosthesis mismatch (PPM) is elevated. This retrospective single-center study evaluates the impact of body mass index (BMI) on the outcome of an initial MIS-AVR program.

MATERIAL AND METHODS

 A total of 307 patients underwent MIS-AVR between January 2013 and December 2015, the initial phase of our MIS-AVR program. They were divided into normal/overweight (BMI <30 kg/m2) versus obese patients (BMI ≥30 kg/m2). Primary endpoints included 30-day and 2-year mortality and stroke. Secondary endpoints comprised type 3 bleeding, PPM, paravalvular leakage, wound healing disorders (WHDs), and pacemaker rates.

RESULTS

 In all 191 patients exhibited a BMI <30 kg/m2, while 116 patients had a BMI ≥30 kg/m2. The BMI groups did not differ in baseline characteristics, excepting a higher peripheral arterial disease incidence among obese patients (15.7% vs. 26.7%; p = 0.01). Aortic clamp time (75 ± 29 min vs. 87 ± 37 min; p = 0.001), cardiopulmonary bypass (104 ± 36 min vs. 124 ± 56 min; p = 0.0002), and ventilation times (26 ± 6 h vs. 44 ± 8 h; p = 0.03) were longer in obese patients. They demonstrated a higher risk for bleeding (2.6% vs. 9.5%; p = 0.008) but lower pacemaker rates (9% vs. 3%; p = 0.02). PPM, paravalvular leakage, and WHD exhibited no group differences. No BMI-related differences revealed in 30-day mortality (4.7% vs. 3.4%) and stroke rates (2% vs. 2.6%), as well as 2-year mortality (12.6% vs. 11.2%) and stroke rates (2.1% vs. 2.6%).

CONCLUSION

 In the initial phase of an MIS-AVR program, the 30-day mortality may be elevated. Despite longer operative times and an increased risk for bleeding in obese patients, no influence of BMI on postoperative morbidity, mortality, or stroke rates was observed.

Early and Long-Term Outcomes of Patients Undergoing Surgery for Native and Prosthetic Valve Endocarditis: The Role of Preoperative Neutrophil-to-Lymphocyte Ratio, Neutrophil-to-Platelet Ratio, and Monocyte-to Lymphocyte Ratio

Background/Objectives: Previous studies evaluated the prognostic role of hematological parameters in predicting outcome in patients with infective endocarditis (IE). However, only a few studies evaluated the role of hematological parameters in patients undergoing surgery for IE. The aim of this study was to review our 20-year experience with the treatment of native (NVE) and prosthetic (PVE) valve endocarditis and to evaluate the role of neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-platelet ratio (NPR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), neutrophil-to monocyte ratio (NMR), and systemic inflammatory index (SII) on early and long-term outcomes of patients undergoing surgery for NVE and PVE. Methods: All adult patients undergoing surgery for NVE and PVE at our institution between January 2001 and December 2022 were included in the study. Preoperative NLR, NPR, PLR, MLR, NMR, and SII were calculated using hemograms with complete blood count. Results: During the study period, 503 patients, 371 (74%) males, median age 65 (52-73) years, underwent surgery for NVE (n = 337, 67%) or PVE (n = 166, 33%). Patients with PVE had significantly more aortic annulus abscess (95 (57%) vs. 51 (15%); p < 0.001), longer CPB (180 (131-235) vs. 105 (84-145) min; p < 0.001) and aortic cross-clamping times (129 (96-175) vs. 82 (64-114) min; p < 0.001), and received more aortic homografts (47 (28%) vs. 28 (9%); p < 0.001) and postoperative pacemaker implantation (25 (15%) vs. 20 (6%); p < 0.001 compared to patients with NVE. Preoperative NLR was 3.7 (2.4-6.1), NPR was 23 (16-37), PLR was 159 (106-210), NMR was 8.4 (6.6-12), MRL was 0.41 (0.29-0.62], and SII was 790 (485-1396). NLR, NPR, and MLR were significantly lower in patients with NVE compared to patients with PVE and in survivors compared to non-survivors. Overall mean survival time was 12.2 ± 0.5 years, with patients with NVE having better early and late survival compared to patients with PVE. Patients with preoperative NLR < 3.8, NPR < 30.9, and MLR < 0.4 had significantly better mean survival time compared to patients with preoperative NLR > 3.8, NPR > 30.9, and MLR > 0.4, respectively. Conclusions: In patients undergoing surgery for IE, preoperative higher NLR, NPR, and MLR are associated with increased early and long-term mortality.

Prognostic utility of dynamic changes in epicardial adipose tissue in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Epicardial Adipose Tissue (EAT) volume is associated with the risk of cardiovascular events, which can be assessed by cardiac computed tomography. However, he optimal method and their prognostic utility in patients following transcatheter aortic valve replacement (TAVR) is unknown.

METHODS

We evaluated 258 participants, focusing on changes in EAT volume using cardiac CT enhancement. EAT volume was automatically computed as three-dimensional voxels between -190 to -30 HU on contrast-enhanced slices. Univariate and multivariable Cox regression analyses were conducted to assess the association of various clinical parameters and EAT volume indices with major adverse cardiovascular events (MACE).

RESULTS

During a median follow-up of 2.0 years [IQR, 1.8-2.3 years], 34 participants (median age 73 [IQR: -13.1 to -8.3) years, 55.4 % male) experiencing MACE. The optimal cutoff values for EAT volume change fraction (EATVCF) was 15.2 %, determined by the Youden-index. Kaplan-Meier curve analysis revealed that patients with high EATVCF were at higher risk (p < .01). In Cox regression, EATVCF (hazard ratio [HR]: 0.92, 95 % CI: 0.87 to 0.97, p = .001) remained significantly associated with MACE after adjusting for clinical factors. The addition of EATVCF to the clinical model increased the net Reclassification Improvement (NRI) by 30.1 % (95 % CI: 0.07-1.16).

CONCLUSION

EAT volume change fraction emerged as a significant predictor of MACE post-TAVR, highlighting the clinical value of EAT volume assessment in cardiovascular risk stratification.

Initial Findings Concerning the Latest Self-Expandable Evolut FX Valve: A Report Using OCEAN-TAVI Registry Data

Data concerning the clinical effect of the latest-generation self-expandable transcatheter heart valve (Evolut FX) remain limited. We aimed to assess the in-hospital outcomes of 3 bioprosthetic valves (Evolut EPO, PRO+, and FX). We analyzed data from a Japanese multicenter registry involving 634 consecutive patients who underwent transcatheter aortic valve replacement with Evolut FX up until October 2023. Patients who underwent transcatheter aortic valve replacement with Evolut EPO between 2018 and 2020 (n = 1,128), and those with Evolut EPO+ between 2020 and 2023 (n = 1,696) served as the control groups. The exclusion criteria comprised patients on dialysis with a history of infective endocarditis or with insufficient data. Unmatched comparisons among the 3 valves were conducted, followed by a propensity score-matched comparison between Evolut EPO+ and FX. In the unmatched cohort, among the Evolut EPO, PRO+, and FX groups, all vascular complications (7.8% vs 5.2% vs 4.5%, respectively, p <0.01) and new pacemaker implantation rates (11.2% vs 6.1% vs 7.7%, respectively, p <0.01) differed significantly. In the propensity score-matched analysis, the rate of all bleeding events was significantly higher in the Evolut EPO+ group (11.0%) than in the FX group (7.0%) (p = 0.02), whereas all vascular complications (4.6% vs 4.6%, respectively, p = 1.00) and new pacemaker implantation (5.9% vs 7.6%, respectively, p = 0.28) rates were comparable. The incidence of stroke in the FX group was approximately half that of the EP+ group (3.7% vs 1.9%, p = 0.095), without statistical significance. In conclusion, compared with the Evolut EPO+, Evolut FX was associated with a lower incidence of in-hospital bleeding complications and may reduce the incidence of in-hospital stroke.

Association between delirium severity and prognosis following Transcatheter aortic valve implantation

BACKGROUND

Delirium is associated with patient prognosis after transcatheter aortic valve implantation (TAVI). However, the prognostic impact of subsyndromal delirium, described as an intermediate stage between delirium and normal cognition, is uncertain. The present study aimed to investigate the prognostic impact of delirium severity in patients undergoing TAVI.

METHODS AND RESULTS

We prospectively assessed the delirium status of 1617 consecutive patients who underwent TAVI at Kokura Memorial Hospital using the Intensive Care Delirium Screening Checklist (ICDSC). The patients were divided into the following three groups: no-delirium [ICDSC score 0, n = 1035 (64.0 %)], subsyndromal delirium [ICDSC 1-3, n = 348 (21.5 %)], and delirium [ICDSC 4-8, n = 234 (14.5 %)] groups. A worse delirium status was associated with older age, higher degree of frailty, and higher prevalence of comorbidities, including atrial fibrillation, dementia, and peripheral arterial disease. At 2 years post-procedure with a clinical follow-up rate of 92.6 %, the cumulative all-cause mortality rate was significantly higher in the subsyndromal delirium (21.8 %) (p < 0.001) and delirium (29.1 %) (p < 0.001) groups than in the no-delirium group (11.9 %). After adjusting for pre- and post-procedural confounders, subsyndromal delirium and delirium were associated with an increased mortality risk [adjusted hazard ratio (HR) for subsyndromal delirium, 1.38; 95 % CI, 1.00-1.90; p = 0.049; adjusted HR for delirium, 1.61; 95 % CI, 1.15-2.17; p = 0.006].

CONCLUSIONS

Delirium conditions, including delirium and subsyndromal delirium, occurred in more than one-third of patients who had undergone TAVI and were associated with increased mortality.