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Zaid S, Attizzani GF, Krishnamoorthy P, Yoon SH, Palma Dallan LA, Chetcuti S, Fukuhara S, Grossman PM, Goel SS, Atkins MD, Kleiman NS, Puri R, Bakhtadze B, Byrne T, Ibrahim AW, Grubb KJ, Tully A, Herrmann HC, Faggioni M, Ramlawi B, Khera S, Lerakis S, Dangas GD, Kini AS, Sharma SK, Reardon MJ, Tang GHL. First-in-Human Multicenter Experience of the Newest Generation Supra-Annular Self-Expanding Evolut FX TAVR System. JACC Cardiovasc Interv 2023; 16:1626-1635. [PMID: 37438029 DOI: 10.1016/j.jcin.2023.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND The latest-generation Evolut FX TAVR system (Medtronic) offers several potential design improvements over its predecessors, but early reported experience has been limited. OBJECTIVES This study sought to report our multicenter, limited market release, first-in-human experience of transcatheter aortic valve replacement (TAVR) with the Evolut FX system and compare it with a single-center PRO+ (Medtronic) experience. METHODS From June 27 to September 16, 2022, 226 consecutive patients from 9 US centers underwent transfemoral TAVR with the Evolut FX system for native aortic stenosis (89.4%) or prosthetic valve degeneration (10.6%). Commissural alignment was defined as 0° to 30° between native and FX commissures. Patient, anatomical, and procedural characteristics were retrospectively reviewed, and 30-day clinical and echocardiographic outcomes per Valve Academic Research Consortium-3 definitions were reported. RESULTS Of 226 patients, 34.1% were low risk, 4% had a bicuspid valve, and 11.5% had a horizontal root (≥60°). Direct Inline sheath (Medtronic) was used in 67.6% and Lunderquist stiff wire (Cook Medical) in 35.4% of cases. Optimal hat marker orientation during deployment was achieved in 98.4%, with commissural alignment in 96.5%. At 30 days, 14.3% mild, 0.9% moderate, and no severe paravalvular leak were observed. Compared with the Evolut PRO+ experience from 1 center, FX had a more symmetrical implantation with shallower depth at the left coronary cusp (P < 0.001), fewer device recaptures (26.1% vs 39.5%; P = 0.004), and improved commissural alignment (96.5% vs 80.2%; P < 0.001). CONCLUSIONS The Evolut FX system demonstrated favorable 30-day outcomes with a significant improvement over PRO+ in achieving commissural alignment, fewer device recaptures, and more symmetrical implantation. These features may benefit younger patients undergoing TAVR with the supra-annular, self-expanding valve, where lifetime management would be important.
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Affiliation(s)
- Syed Zaid
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | | | | | - Sung-Han Yoon
- University Hospitals of Cleveland, Cleveland, Ohio, USA
| | | | | | | | | | - Sachin S Goel
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Marvin D Atkins
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Neal S Kleiman
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | | | | | - Timothy Byrne
- Abrazo Arizona Heart Hospital, Phoenix, Arizona, USA
| | | | | | | | - Howard C Herrmann
- University of Pennsylvania Perlman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michela Faggioni
- University of Pennsylvania Perlman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Basel Ramlawi
- Lankenau Medical Center, Wynnewood, Pennsylvania, USA
| | - Sahil Khera
- Mount Sinai Hospital, New York, New York, USA
| | | | | | | | | | - Michael J Reardon
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
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Chandrasekar B, AlMerri K, AlEnezi A, AlRashdan I, AlKhdair D, AlKandari F. Native aortic leaflets and permanent pacemaker implantation risk following balloon-expandable transcatheter aortic valve implantation. Indian Heart J 2023; 75:268-273. [PMID: 37406856 PMCID: PMC10421988 DOI: 10.1016/j.ihj.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/17/2023] [Accepted: 06/30/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVE Permanent pacemaker implantation (PPI) risk is higher following transcatheter aortic valve implantation (TAVI) than surgical valve replacement. Native aortic leaflets are retained in patients undergoing TAVI, unlike in surgical valve replacement. Whether the retained leaflets influence PPI risk because of their proximity to the conduction system is unknown. The study sought to determine the association between infra-annular extension of native right coronary cusp/noncoronary cusp (RCC/NCC) post balloon-expandable TAVI and PPI risk. METHODS We performed a retrospective analysis of 190 patients undergoing balloon-expandable TAVI at a single center. Manifestation of infra-annular extension of RCC/NCC was considered to be present when part of leaflet extended below aortic-annular plane on post-implantation aortic-root angiography. RESULTS Infra-annular extension of RCC/NCC was observed in 33 patients (17.37%). PPI incidence post-TAVI was higher in patients with infra-annular extension of RCC/NCC than in those without (36.36% versus 8.92%, relative-risk: 4.08, p˂0.0001). On logistic-regression analysis, preexisting right bundle-branch block (RBBB) (odds-ratio: 12.73, 95% confidence-interval: 2.16-74.93, p = 0.005), and infra-annular extension of RCC/NCC (odds-ratio: 5.63, 95% confidence-interval: 2.17-14.58, p < 0.0001) were independently associated with PPI risk. Preexisting RBBB (φ = +0.25, p = 0.001) and infra-annular extension of RCC/NCC (φ = +0.30, p < 0.0001) showed a positive-correlation with PPI risk. Infra-annular extension of RCC/NCC was a significant predictor of PPI risk on receiver-operating-characteristic curve analysis (area under-the-curve 0.67; 95% confidence-interval: 0.54-0.79, p = 0.006). CONCLUSION The retained native aortic leaflets play a significant role in PPI risk following balloon-expandable TAVI. Infra-annular extension of RCC/NCC is a novel predictor, and is associated with a four-fold higher risk of PPI.
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Affiliation(s)
| | - Khaled AlMerri
- Department of Cardiology, Chest Diseases Hospital, Kuwait
| | | | | | - Darar AlKhdair
- Department of Cardiology, Chest Diseases Hospital, Kuwait
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Micro-dislodgement of a self-expanding transcatheter heart valve: Incidence, predictors, and outcomes. Int J Cardiol 2022; 358:77-82. [DOI: 10.1016/j.ijcard.2022.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 11/20/2022]
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Kim WK, Renker M, Doerr O, Hofmann S, Nef H, Choi YH, Hamm CW. Impact of implantation depth on outcomes of new-generation balloon-expandable transcatheter heart valves. Clin Res Cardiol 2021; 110:1983-1992. [PMID: 34476559 DOI: 10.1007/s00392-021-01932-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little is known about the impact of the ID on outcomes and device success using balloon-expandable devices. This study sought to analyze the impact of implantation depth (ID) on procedural outcomes. METHODS In consecutive patients (n = 969) undergoing transfemoral TAVR with new-generation balloon-expandable prostheses, the mean ID (IDMean) was determined by aortography and categorized into low, correct, and high device position. Outcomes of interest were device success (VARC-2), paravalvular regurgitation (PVR) ≥ moderate, severe prosthesis-patient mismatch (PPM), permanent pacemaker implantation (PPI), and the composite of the three latter outcome measures (COMPPPP). RESULTS IDMean was greater among patients with PPI (median 4.0 [interquartile range 2.0; 4.0] vs. 3.5 [1.5; 5.5] mm; p = 0.002), severe PPM (3.5 [1.5; 5.0] vs. 4.0 [2.0; 6.0] mm; p = 0.028), and COMPPPP (4.0 [2.0; 6.0] vs. 3.0 [1.5; 5.5] mm; p < 0.001) when compared with the respective groups without these complications. There was no significant association between IDMean and device success or PVR ≥ moderate. Categorization into low (7.3%), correct (90.7%), and high (2.0%) device position showed significant discrimination with an increase of severe PPM, PPI, and COMPPPP with lower position, whereas device success was not significantly affected by position. Only PVR ≥ moderate showed an asymmetric distribution with highest rates in the high and low position group, which was non-significant. However, among patients without correct position the rate of device success was 45.6%. CONCLUSIONS A higher device position was associated with improved outcomes. Malpositioning without functional impairment should not be classified as device failure. The odds ratio of IDMean was calculated by univariate logistic regression for each outcome variable, showing that with higher values of IDMean (i.e., low implantation depth), the risk of severe PPM, PPI, and COMPPPP increases. The bar charts under the heading "Position category" denote the frequency of each outcome measure across patients with high, correct, and low device position. The p values are derived from chi-squared test.
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Affiliation(s)
- Won-Keun Kim
- Department of Cardiology, Kerckhoff Heart Center, 61231, Bad Nauheim, Germany. .,Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany. .,Department of Cardiology, Justus-Liebig University of Giessen, Giessen, Germany. .,German Centre for Cardiovascular Research (DZHK), Rhine-Main Affiliate, Frankfurt am Main, Germany.
| | - Matthias Renker
- Department of Cardiology, Kerckhoff Heart Center, 61231, Bad Nauheim, Germany.,Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
| | - Oliver Doerr
- Department of Cardiology, Kerckhoff Heart Center, 61231, Bad Nauheim, Germany.,Department of Cardiology, Justus-Liebig University of Giessen, Giessen, Germany.,German Centre for Cardiovascular Research (DZHK), Rhine-Main Affiliate, Frankfurt am Main, Germany
| | - Simon Hofmann
- Department of Cardiology, Justus-Liebig University of Giessen, Giessen, Germany
| | - Holger Nef
- Department of Cardiology, Kerckhoff Heart Center, 61231, Bad Nauheim, Germany.,Department of Cardiology, Justus-Liebig University of Giessen, Giessen, Germany.,German Centre for Cardiovascular Research (DZHK), Rhine-Main Affiliate, Frankfurt am Main, Germany
| | - Yeong-Hoon Choi
- Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), Rhine-Main Affiliate, Frankfurt am Main, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart Center, 61231, Bad Nauheim, Germany.,Department of Cardiology, Justus-Liebig University of Giessen, Giessen, Germany.,German Centre for Cardiovascular Research (DZHK), Rhine-Main Affiliate, Frankfurt am Main, Germany
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Li L, Liu Y, Jin P, Tang J, Lu L, Zhu G, Xu C, Ma Y, Yang J. Effect of Eccentric Calcification of an Aortic Valve on the Implant Depth of a Venus-A Prosthesis During Transcatheter Aortic Valve Replacement: A Retrospective Study. Front Physiol 2021; 12:718065. [PMID: 34421660 PMCID: PMC8378511 DOI: 10.3389/fphys.2021.718065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/16/2021] [Indexed: 11/13/2022] Open
Abstract
Object Our goal was to assess the implant depth of a Venus-A prosthesis during transcatheter aortic valve replacement (TAVR) when the areas of eccentric calcification were distributed in different sections of the aortic valve. Methods A total of 53 patients with eccentric calcification of the aortic valve who underwent TAVR with a Venus-A prosthesis from January 2018 to November 2019 were retrospectively analyzed. The patients were divided into three groups (A, B, and C) according to the location of the eccentric calcification, which was determined by preprocedural computerized tomography angiography (CTA) images. The prosthesis release process and position were evaluated by contrast aortography during TAVR, and the differences in valve implant depths were compared among the three groups. The effects of different aortic root structures and procedural strategies on prosthesis implant depth were analyzed. Results Eleven patients had eccentric calcification in region A; 19 patients, in region B; and 23 patients, in region C. The patients with eccentric calcification in region B had a higher risk of prosthesis migration (10.5% upward and 21.1% downward), and the position of the prosthesis after TAVR in group B was the deepest among the three groups. When eccentric calcification was located in region A or C, the prosthesis was released at the standard position with more stability, and the location of the prosthesis was less deep after TAVR (region A: 4.12 ± 3.4 mm; region B: 10.2 ± 5.3 mm; region C: 8.4 ± 4.0 mm; region A vs. region B, P = 0.0004; region C vs. region B; and P = 0.0360). In addition, the left ventricular outflow tract (LVOT) (P = 0.0213) and aortic root angulation (P = 0.0263) also had a significant effect on implant depth in the aortic root structure of the patients. The prosthesis size was 28.3 ± 2.4 in the deep implant group and 26.4 ± 2.0 in the appropriate implant group (P = 0.0068). Conclusion The implant depth of the Venus-A prosthesis is closely related to the distribution of eccentric calcification in the aortic valve during TAVR. Surgeons should adjust the surgical strategy according to aortic root morphology to prevent prosthesis migration.
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Affiliation(s)
- Lanlan Li
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Yang Liu
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Ping Jin
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Jiayou Tang
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Linhe Lu
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Guangyu Zhu
- School of Energy and Power Engineering, Xi'an Jiaotong University, Xi'an, China
| | - Chennian Xu
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China.,Department of Cardiovascular Surgery, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yanyan Ma
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Jian Yang
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
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Sammour Y, Banerjee K, Kumar A, Lak H, Chawla S, Incognito C, Patel J, Kaur M, Abdelfattah O, Svensson LG, Tuzcu EM, Reed GW, Puri R, Yun J, Krishnaswamy A, Kapadia S. Systematic Approach to High Implantation of SAPIEN-3 Valve Achieves a Lower Rate of Conduction Abnormalities Including Pacemaker Implantation. Circ Cardiovasc Interv 2021; 14:e009407. [PMID: 33430603 DOI: 10.1161/circinterventions.120.009407] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The conventional method of implanting balloon-expandable SAPIEN-3 (S3) valve results in a final 70:30 or 80:20 ratio of the valve in the aorta:left ventricular outflow tract with published rates of permanent pacemaker around 10%. We sought to evaluate whether higher implantation of S3 reduces conduction abnormalities including the need for permanent pacemaker. METHODS We included consecutive patients who underwent transfemoral transcatheter aortic valve replacement using S3 between April 2015 and December 2018 and compared outcomes with typical valve deployment strategy to our more contemporary high deployment technique (HDT). We excluded patients with nontransfemoral access or valve-in-valve. RESULTS Among 1028 patients, HDT was performed in 406 patients (39.5%). Mean implantation depth under the noncoronary cusp was significantly smaller with HDT compared with conventional technique (1.5±1.6 versus 3.2±1.9 mm; P<0.001). Successful implantation was achieved in 100% of the patients in both groups with no cases of conversion to open heart surgery, second valve implantation within the first transcatheter aortic valve replacement, or coronary occlusion during transcatheter aortic valve replacement. One patient (0.2%) had valve embolization with HDT (P=0.216). Thirty-day permanent pacemaker rates were lower with HDT (5.5% versus 13.1%; P<0.001), as were rates of complete heart block (3.5% versus 11.2%; P<0.001) and new-onset left bundle branch block (5.3% versus 12.2%; P<0.001). There were no differences in mild (16.5% versus 15.9%; P=0.804), or moderate-to-severe aortic regurgitation (1% versus 2.7%; P=0.081) at 1 year. HDT was associated with slightly higher 1-year mean gradients (13.1±6.2 versus 11.8±4.9 mm Hg; P=0.042) and peak gradients (25±11.9 versus 22.5±9 mm Hg; P=0.026). However, Doppler velocity index was similar (0.47±0.15 versus 0.48±0.13; P=0.772). CONCLUSIONS Our novel technique for balloon-expandable S3 valve positioning consistently achieves higher implantation resulting in substantial reduction in conduction abnormalities and permanent pacemaker requirement after transcatheter aortic valve replacement without compromising procedural safety or valve hemodynamics. Operators should consider this as an important technique to improve patient outcomes.
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Affiliation(s)
- Yasser Sammour
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - Kinjal Banerjee
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - Arnav Kumar
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - Hassan Lak
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - Sanchit Chawla
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | | | - Jay Patel
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - Manpreet Kaur
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | | | - Lars G Svensson
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - E Murat Tuzcu
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - Grant W Reed
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - Rishi Puri
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | - James Yun
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
| | | | - Samir Kapadia
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH
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