Early and mid-term outcomes following redo surgical aortic valve replacement in patients with previous transcatheter aortic valve implantation

OBJECTIVES

To analyze the early and mid-term outcomes after redo surgical aortic valve replacement (SAVR) in patients with previous transcatheter aortic valve implantation (TAVI).

METHODS

Retrospective single-center analysis of early and mid-term outcomes following redo SAVR in patients with previous TAVI between 2013 and 2020. Primary outcomes were in-hospital mortality and mid-term survival.

RESULTS

During the study period a total of 5756 patients underwent TAVI. Amongst them, 28 (0.5%) patients required redo SAVR after TAVI. During periods 2013-2016 and 2017-2020, 4/2184 (0.2%) patients and 24/3572 (0.7%) patients required SAVR after TAVI, respectively. Median logistic EuroSCORE was significantly higher at the time of SAVR than at the time of the index TAVI (5.9% vs 11.6%; P < 0.001). Median elapsed time between TAVI and redo SAVR was 7 months (3.5 -14 months). Infective endocarditis (IE) was the most frequent indication for surgery [19 (67.8%) patients]. A total of 11 (39.3%) patients underwent isolated SAVR and 17 (60.7%) SAVR + additional cardiac surgical procedures. The overall in-hospital mortality was 14.3% (4/28). In-hospital mortality was 15.8% (3/19) among IE patients and 11.1% (1/9) among non-IE patients (p = 0.7). Overall estimated survival was 66.5%, 59.9% and 48.0% at 12, 18 and 24 months, respectively. Patients with IE showed a trend towards a lower estimated mid-term survival compared to non-IE patients [41.6% (95% CI; 22.0% - 78.0%) vs 58.3% (95% CI; 30.0% - 100%) survival at 24 months (p = 0.3)].

CONCLUSION

SAVR can be successfully performed in patients with prior TAVI despite the increased surgical risk and technical difficulty. IE is associated with decreased mid-term survival.

Extensive calcification of the mitral valve annulus in transcatheter aortic valve implants

 

OBJECTIVES

This study sought to report the calcification pattern of the mitral valve annulus and its implications for procedural and safety outcomes in transcatheter aortic valve implantation.

METHODS

Between November 2018 and September 2019, a total of 305 patients had transcatheter aortic valve implants at our institution. The extent of calcification of the mitral valve annulus was analysed, and the impact on safety outcomes was evaluated.

RESULTS

The prevalence of mitral annular calcification (MAC) was 43%. Calcification of the mitral valve annulus was either less than or at least one-third of the posterior annulus (34% and 32%), the whole posterior annulus (28%) or the extension to the attachment of the anterior leaflets (7%). Severe circumferential MAC revealed moderate paravalvular leaks in 5/8 (63%) patients and was associated with right branch bundle block [odds ratio (OR) 2.01 (0.39–3.06); P = 0.098] and low cardiac output [OR 3.12 (1.39–7.04); P = 0.033]. Subannular calcification at the anterolateral trigonum represented a risk factor for left ventricular outflow tract injury [OR 3.54 (1.38–8.27); P = 0.001] in balloon-expandable valves, associated with relevant rhythm disorders [OR 2.26 (1.17–5.65); P = 0.014] and female gender (7/8, 88%). The 30-day all-cause mortality in circumferential MAC reaching into the anterior annulus (grade IV) compared to patients with less MAC (grade I–III) was 13% vs 2% with a mean valve size of 24.6 vs 25.7 mm.

CONCLUSIONS

Extensive MAC was associated with moderate paravalvular leaks, with implications for the prosthesis size and survival in transcatheter aortic valve implants. In severe MAC, we recommend implanting oversized self-expandable prostheses, the goal being to reduce the risk of right branch bundle block and paravalvular leaks.

Subj collection

122, 125

Catastrophic Cardiac Events during Transcatheter Aortic Valve Replacement

BACKGROUND

Perioperative complications of transcatheter aortic valve replacement (TAVR) are decreasing but can be catastrophic when they occur. Systematic reports of the nature of these events are lacking in the contemporary era. Our study aimed to report the incidence, outcomes, and perioperative management of catastrophic cardiac events in patients undergoing TAVR and to propose a working strategy to address these complications.

METHODS

This is a retrospective cohort study of patients who developed catastrophic cardiac events during or immediately after TAVR between 2015 and 2019 at a single academic center.

RESULTS

Of 2102 patients who underwent TAVR, 51 (2.5%) developed catastrophic cardiac events. The causes included cardiac perforation and tamponade (n=19, 37.3%), acute left ventricular failure (n=10, 19.6%), coronary artery obstruction (n=10, 19.6%), aortic root disruption (7, 13.7%), and device embolization (n=5, 9.8%). Twenty-four patients (47.0%) with catastrophic cardiac events required stabilization by either intra-aortic balloon counter-pulsation or extracorporeal membrane oxygenation. The in-hospital mortality rate increased by 11.7-fold for patients with catastrophic cardiac events compared to those without (25.5% vs 2.0%, p<0.001). Patients who developed aortic root disruption had the highest mortality rate (42.8%) compared with the others. The incidence of catastrophic cardiac events remained stable over a 5-year period, but the associated mortality decreased from 38.5% in 2015 to 9.1% in 2019.

CONCLUSIONS

Catastrophic cardiac events during TAVR are rare, but they account for a dramatic increase in perioperative mortality. Early recognition and development of a standardized perioperative team approach can help manage patients experiencing these complications.

Clinical and economical impact of the presence of an extended heart team throughout the balloon-expandable transcatheter aortic valve implantation procedure

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a standard therapy for aortic valve stenosis in patients at intermediate-to-high surgical risk. Previously, TAVI at our site was performed by a minimalist heart team (MHT), comprised of two interventional cardiologists, echocardiography staff and two cardiac catheterization laboratory nurses. After revision of German Federal Joint Committee (G-BA) guidelines in September 2015, the presence of an extended heart team (EHT; including a full cardiac surgical team) became mandatory throughout the TAVI procedure. We aimed to evaluate the impact of the EHT on clinical and economical outcomes.

METHODS

Data was retrospectively extracted from the medical records of patients receiving an Edwards SAPIEN 3 valve at the University Hospital Tübingen, Germany, between 2014 and 2017 and matched with cost data from the national invoice system of hospitals (InEK). For comparison, patients were grouped according to whether they underwent TAVI with or without the EHT.

RESULTS

Overall, data for 341 patients (MHT 233; EHT 118) were analysed. Baseline characteristics were largely similar between groups (mean age 81.0 years; 54.5% female), though EHT patients had a lower mean logEuroSCORE (17.5% vs. 19.8%; p = 0.011) and more prior PCI/stenting (39.0% vs. 26.9%; p = 0.022). The rate of immediate procedural death (1.7%) was comparable between groups, as was mortality at 30 days (4.2%). Overall, 1.2% of patients required conversion to surgery. The cost of the index hospitalisation (minus the prosthesis) was higher in the EHT condition (difference + €1604), largely driven by expenditure on physicians (difference + €581; p < 0.001), medical technicians (difference + €372; p < 0.001) and medical supplies (difference +€244; p = 0.001).

CONCLUSION

At our site, the presence of an EHT throughout the TAVI procedure appears to substantially increase hospital expenditure without significantly improving patient outcomes. We suggest that TAVI by a minimalist HT with a surgical team on call in case of emergency may be sufficient.

Distal embolization of a transcatheter valve in a valve complex: a bail-out surgical approach

Transcatheter aortic valve replacement has emerged as an alternative to surgical aortic valve replacement for high-risk and inoperable patients. Although transcatheter aortic valve replacement avoids the use of extracorporeal circulation and sternotomy, it is nonetheless associated with inherent complications. We aim to present an embolized valve-in-valve complex in the ascending aorta, which required emergency surgery with deep hypothermic circulatory arrest and proximal aortic cannulation.

Deep sedation versus general anesthesia in percutaneous edge-to-edge mitral valve reconstruction using the MitraClip system

BACKGROUND

Percutaneous edge-to-edge mitral valve reconstruction (PMVR) has emerged as a treatment option in patients with severe mitral regurgitation not considered suitable candidates for surgery. The majority of PMVR procedures are performed under general anesthesia (GA), although deep sedation (DS) appears to be an attractive alternative. We thus sought to assess the impact on intensive care unit (ICU) length of stay, efficacy, and safety of DS in comparison to GA in patients undergoing PMVR using the MitraClip(®) system.

METHODS

Sixty consecutive patients underwent PMVR procedures at two centers. The first 30 patients were treated by GA followed by 30 patients undergoing DS under different settings. The primary clinical endpoint was ICU length of stay. The primary efficacy endpoint included procedural success and procedural duration. The safety endpoint was defined as a composite of death, stroke, cardiogenic shock, moderate and severe bleeding as well as pneumonia.

RESULTS

The ICU length of stay was significantly shorter in the DS group in comparison to GA patients (p = 0.001). The hospital length of stay did not differ following DS in comparison to GA (p = 0.96). Procedural success was high in both groups (100 versus 96.7 %, p = 0.34) at similar procedural duration time (p = 0.60). No difference between GA and DS was observed with respect to the occurrence of the combined safety endpoint (p = 0.47).

CONCLUSIONS

In comparison to GA, DS reduces the ICU length of stay in PMVR without negative effects on safety and efficacy. Prospective randomized trials are needed to confirm these findings.