Early clinical and echocardiographic outcomes after SAPIEN 3 transcatheter aortic valve replacement in inoperable, high-risk and intermediate-risk patients with aortic stenosis

Durability of transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is now utilised as a less invasive alternative to surgical aortic valve replacement (SAVR) across the whole spectrum of surgical risk. Long-term durability of the bioprosthetic valves has become a key goal of TAVI as this procedure is now considered for younger and lower-risk populations. The purpose of this article is to present a state-of-the-art overview on the definition, aetiology, risk factors, mechanisms, diagnosis, clinical impact, and management of bioprosthetic valve dysfunction (BVD) and failure (BVF) following TAVI with a comparative perspective versus SAVR. Structural valve deterioration (SVD) is the main factor limiting the durability of the bioprosthetic valves used for TAVI or SAVR, but non-structural BVD, such as prosthesis-patient mismatch and paravalvular regurgitation, as well as valve thrombosis or endocarditis may also lead to BVF. The incidence of BVF related to SVD or other causes is low (<5%) at midterm (5- to 8-year) follow-up and compares favourably with that of SAVR. The long-term follow-up data of randomised trials conducted with the first generations of transcatheter heart valves also suggest similar valve durability in TAVI versus SAVR at 10 years, but these trials suffer from major survivorship bias, and the long-term durability of TAVI will need to be confirmed by the analysis of the low-risk TAVI versus SAVR trials at 10 years.

Transfemoral-only transcatheter aortic valve replacement: A single center experience of 400 consecutive patients

BACKGROUND

In transcatheter aortic valve replacement (TAVR), transfemoral (TF) access offers several advantages over alternative access routes. Advances in sheaths and valve delivery technology have catalyzed the feasibility of TF-TAVR, even in challenging anatomies.

AIMS

Report procedural characteristics and outcomes of a TAVR program aiming for a 100% TF access rate.

METHODS

Consecutive patients undergoing TAVR were enrolled in a prospective registry. Equipment used to facilitate TF-access in challenging anatomies included low-profile sheaths, dilatators, peripheral balloons, covered and uncovered self-expanding and balloon-expandable stents, and intravascular lithotripsy (IVL).

RESULTS

A total of 400 patients with a mean age of 81 ± 6 years (42% female) were analyzed. Minimal iliofemoral artery diameter (MLD) of the main access side was <5 mm in 42 (10.5%), extreme tortuosity was present in 65 (16.3%), and severe calcification in 59 (14.8%). TF-access was successful in 399 (99.8%) patients. A transaxillary access was used in one patient. In multivariable analysis, an MLD < 5 mm was the strongest predictor for vascular complications (11.9% vs. 3.9%, OR: 3.86, 95% CI: 1.38-10.8, p = 0.01). Such patients also had more major/life-threatening bleeding (14.2% vs. 3.1%, p < 0.001) and required more planned and unplanned peripheral interventions to enable TF access (35.8% vs. 3.4%, p < 0.001).

CONCLUSION

Our study shows that utilization of dedicated sheaths, peripheral balloons, stents, and IVL enables TAVR via TF access in >99% of patients. However, rates of vascular and bleeding complications in patients with narrow iliofemoral arteries (MLD < 5 mm) were high.

Transcatheter Aortic Valve Replacement With the Navitor System: Real-World United Kingdom Experience

The Navitor transcatheter heart valve (THV) is the latest iteration of the Portico self-expanding valve system. Early prospective studies have shown promising outcomes, however, there is a lack of complementary 'real-world' data. This study aimed to assess early safety and efficacy outcomes of the Navitor THV using registry data from 6 high-volume United Kingdom transcatheter aortic valve replacement (TAVR) centers. Demographic, procedural, and in-hospital outcome data were retrieved from 6 United Kingdom centers. The primary safety end point was 30-day mortality. Primary efficacy end points were procedural success, mean aortic gradient, and ≥moderate paravalvular leak. Secondary end points included rates of new permanent pacemaker implantation, stroke, and vascular injury. A total of 574 patients (mean age 83.4 years; 54.5% female) underwent Navitor TAVR between January 2020 and May 2023. The 30-day mortality in this patient cohort was 1.6%. Procedural success was 98.1%, mean echo-derived gradient post-TAVR was 7.7 ± 4.8 mm Hg (95% confidence interval [CI] 7.2 to 8.3, p <0.001) and 5.1% of patients had ≥moderate paravalvular leak (sample proportion estimate [p̂] = 0.051, 95% CI [0.035, 0.073], p <0.001). New permanent pacemaker implantation to discharge was required in 11% (p̂ = 0.119, 95% CI 0.088 to 0.158, p <0.001), stroke occurred in 1.2% of patients (p̂ = 0.017, 95% CI 0.006 to 0.036, p <0.001) and significant vascular injury in 1.6% (p̂ = 0.014, 95% CI 0.005 to 0.032, p <0.001). In conclusion, early procedural outcomes with Navitor TAVR compare favorably to new-generation THVs. Procedural success was high with a low incidence of complications.

Predictors and 5-Year Clinical Outcomes of Pacemaker After TAVR: Analysis From the PARTNER 2 SAPIEN 3 Registries

BACKGROUND

Conduction disturbances requiring a permanent pacemaker (PPM) are a frequent complication of transcatheter aortic valve replacement (TAVR) with few reports of rates, predictors, and long-term clinical outcomes following implantation of the third-generation, balloon-expandable SAPIEN 3 (S3) transcatheter heart valve (THV).

OBJECTIVES

The aim of this study was to investigate the rates, predictors, and long-term clinical outcomes of PPM implantation following TAVR with the S3 THV.

METHODS

The current study included 857 patients in the PARTNER 2 S3 registries with intermediate and high surgical risk without prior PPM, and investigated predictors and 5-year clinical outcomes of new PPM implanted within 30 days of TAVR.

RESULTS

Among 857 patients, 107 patients (12.5%) received a new PPM within 30 days after TAVR. By multivariable analysis, predictors of PPM included increased age, pre-existing right bundle branch block, larger THV size, greater THV oversizing, moderate or severe annulus calcification, and implantation depth >6 mm. At 5 years (median follow-up 1,682.0 days [min 2.0 days, max 2,283.0 days]), new PPM was not associated with increased rates of all-cause mortality (Adj HR: 1.20; 95% CI: 0.85-1.70; P = 0.30) or repeat hospitalization (Adj HR: 1.22; 95% CI: 0.67-2.21; P = 0.52). Patients with new PPM had a decline in left ventricular ejection fraction at 1 year that persisted at 5 years (55.1 ± 2.55 vs 60.4 ± 0.65; P = 0.02).

CONCLUSIONS

PPM was required in 12.5% of patients without prior PPM who underwent TAVR with a SAPIEN 3 valve in the PARTNER 2 S3 registries and was not associated with worse clinical outcomes, including mortality, at 5 years. Modifiable factors that may reduce the PPM rate include bioprosthetic valve oversizing, prosthesis size, and implantation depth.

Self-Expanding or Balloon-Expandable TAVR in Patients with a Small Aortic Annulus

BACKGROUND

Patients with severe aortic stenosis and a small aortic annulus are at risk for impaired valvular hemodynamic performance and associated adverse cardiovascular clinical outcomes after transcatheter aortic-valve replacement (TAVR).

METHODS

We randomly assigned patients with symptomatic severe aortic stenosis and an aortic-valve annulus area of 430 mm2 or less in a 1:1 ratio to undergo TAVR with either a self-expanding supraannular valve or a balloon-expandable valve. The coprimary end points, each assessed through 12 months, were a composite of death, disabling stroke, or rehospitalization for heart failure (tested for noninferiority) and a composite end point measuring bioprosthetic-valve dysfunction (tested for superiority).

RESULTS

A total of 716 patients were treated at 83 sites in 13 countries (mean age, 80 years; 87% women; mean Society of Thoracic Surgeons Predicted Risk of Mortality, 3.3%). The Kaplan-Meier estimate of the percentage of patients who died, had a disabling stroke, or were rehospitalized for heart failure through 12 months was 9.4% with the self-expanding valve and 10.6% with the balloon-expandable valve (difference, -1.2 percentage points; 90% confidence interval [CI], -4.9 to 2.5; P<0.001 for noninferiority). The Kaplan-Meier estimate of the percentage of patients with bioprosthetic-valve dysfunction through 12 months was 9.4% with the self-expanding valve and 41.6% with the balloon-expandable valve (difference, -32.2 percentage points; 95% CI, -38.7 to -25.6; P<0.001 for superiority). The aortic-valve mean gradient at 12 months was 7.7 mm Hg with the self-expanding valve and 15.7 mm Hg with the balloon-expandable valve, and the corresponding values for additional secondary end points through 12 months were as follows: mean effective orifice area, 1.99 cm2 and 1.50 cm2; percentage of patients with hemodynamic structural valve dysfunction, 3.5% and 32.8%; and percentage of women with bioprosthetic-valve dysfunction, 10.2% and 43.3% (all P<0.001). Moderate or severe prosthesis-patient mismatch at 30 days was found in 11.2% of the patients in the self-expanding valve group and 35.3% of those in the balloon-expandable valve group (P<0.001). Major safety end points appeared to be similar in the two groups.

CONCLUSIONS

Among patients with severe aortic stenosis and a small aortic annulus who underwent TAVR, a self-expanding supraannular valve was noninferior to a balloon-expandable valve with respect to clinical outcomes and was superior with respect to bioprosthetic-valve dysfunction through 12 months. (Funded by Medtronic; SMART ClinicalTrials.gov number, NCT04722250.).

Effect of Sex and Flow Status on Outcomes After Surgical or Transcatheter Aortic Valve Replacement

Background

Low stroke volume index <35 ml/m2 despite preserved ejection fraction (paradoxical low flow [PLF]) is associated with adverse outcomes in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). However, whether the risk associated with PLF is similar in both sexes is unknown.

Objectives

The purpose of this study was to analyze the risk associated with PLF in severe aortic stenosis for men and women randomized to TAVR or SAVR.

Methods

Patients with ejection fraction ≥50% from the PARTNER (Placement of Aortic Transcatheter Valves) 2 and 3 trials were stratified by sex and treatment arm. The impact of PLF on the 2-year occurrence of the composite of death or heart failure hospitalization (primary endpoint) and of all-cause mortality alone (secondary endpoint) was analyzed. Analysis of variance was used to assess baseline differences between groups. Multivariate Cox regression analysis was used to identify predictors of the endpoint.

Results

Out of 2,242 patients, PLF was present in 390 men and 239 women (30% vs 26%, P = 0.06). PLF was associated with a higher rate of NYHA functional class III to IV dyspnea (60% vs 54%, P < 0.001) and a higher prevalence of atrial fibrillation (39% vs 24%, P < 0.001). PLF was a significant predictor of the primary endpoint among women undergoing SAVR in multivariate analysis (adjusted HR: 2.25 [95% CI: 1.14-4.43], P = 0.02) but was not associated with a worse outcome in any of the other groups (all P > 0.05).

Conclusions

In women with PLF, TAVR may improve outcomes compared to SAVR. PLF appears to have less impact on outcomes in men.

Cost-effectiveness analysis of transcatheter aortic valve implantation in aortic stenosis patients at low- and intermediate-surgical risk in Japan

OBJECTIVE

To analyze the cost-effectiveness of transcatheter aortic valve implantation (TAVI) using the SAPIEN 3 (Edwards Lifesciences, Irvine, CA) compared to surgical aortic valve replacement (SAVR) in low- and intermediate-risk patients from a Japanese public healthcare payer perspective.

METHODS

A Markov model cost-effectiveness analysis was developed. Clinical and utility data were extracted from a systematic literature review. Cost inputs were obtained from analysis of the Medical Data Vision claims database and supplemented with a targeted literature search. The robustness of the results was assessed using sensitivity analyses. Scenario analyses were performed to determine the impact of lower mean age (77.5 years) and the effect of two different long-term mortality hazard ratios (TAVI versus SAVR: 0.9-1.09) on both risk-level populations. This analysis was conducted according to the guidelines for cost-effectiveness evaluation in Japan from Core 2 Health.

RESULTS

In intermediate-risk patients, TAVI was a dominant procedure (TAVI had lower cost and higher effectiveness). In low-risk patients, the incremental cost effectiveness ratio (ICER) for TAVI was ¥750,417/quality-adjusted-life-years (QALY), which was below the cost-effectiveness threshold of ¥5 million/QALY. The ICER for TAVI was robust to all tested sensitivity and scenario analyses.

CONCLUSIONS

TAVI was dominant and cost-effective compared to SAVR in intermediate- and low-risk patients, respectively. These results suggest that TAVI can provide meaningful value to Japanese patients relative to SAVR, at a reasonable incremental cost for patients at low surgical risk and potentially resulting in cost-savings in patients at intermediate surgical risk.

Diastolic Dysfunction and Health Status Outcomes After Transcatheter Aortic Valve Replacement

Background

Baseline left ventricular diastolic dysfunction (LVDD) is associated with poor health status in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), but health status improvement after TAVR appears similar across all grades of LVDD. Here, we aim to examine the relationship between changes in LVDD severity and health status outcomes following TAVR.

Methods

Patients who underwent TAVR and had evaluable LVDD at both baseline and 1 year in the PARTNER (Placement of Aortic Transcatheter Valves) 2 SAPIEN 3 registries and PARTNER 3 trial were analyzed. LVDD grade was evaluated using echocardiography core lab data and an adapted definition of American Society of Echocardiography guidelines. Health status was assessed using the Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS) score. The association between ΔLVDD severity and ΔKCCQ-OS was examined using linear regression models adjusted for baseline KCCQ-OS.

Results

Of 1100 patients, 724 (65.8%), 283 (25.7%), and 93 (8.5%) had grade 0/1, 2, and 3 LVDD at baseline, respectively. At 1 year, LVDD severity was unchanged in 790 (71.8%) patients, improved in 189 (17.2%), and worsened in 121 (11.0%). Among 376 patients with baseline grade 2 or 3 LVDD, 50.3% had improvement in LVDD. In the overall cohort, KCCQ-OS score improved by 21.9 points at 1 year. There was a statistically significant association between change in LVDD severity (improved, unchanged, and worsened) and ΔKCCQ-OS at 1 year (p = 0.007).

Conclusions

Change in LVDD grade was associated with change in health status 1 year following TAVR.

Evolut PRO/PRO+ versus Evolut R system for transcatheter aortic valve replacement

BACKGROUND

The self-expanding CoreValve Evolut PRO/PRO+ transcatheter aortic valve was designed to overcome the limitations of its forerunner, Evolut R. Evolut PRO/PRO+ offers the lowest delivery profile for 23-29 mm valves, with an external tissue wrap on all valve sizes. We compared safety and efficacy of Evolut PRO/PRO+ and Evolut R.

METHODS

We analyzed 300 patients enrolled in the EPROMPT Registry against a historical control cohort of 242 patients who received Evolut R. The two arms were matched (1:1) via propensity-score methodology by accounting for differences in Society of Thoracic Surgeons Predicted Risk of Mortality scores, yielding 440 patients. The endpoints included in-hospital safety clinical outcomes, all-cause mortality, and echocardiographic parameters at 30 days and 1 year.

RESULTS

After propensity-score matching, cardiac death (0.5% vs. 0.5%, p = 0.995), stroke (1.6% vs. 2.8%, p = 0.410), life-threatening bleeding (1.1% vs. 3.3%, p = 0.139), major vascular complications (0.5% vs. 0.9%, p = 0.653), and pacemaker implantation (16.9% vs. 13.6%, p = 0.345) were comparable between the Evolut PRO/PRO+ and Evolut R groups. Likewise, the rates of all-cause mortality were similar both at 30 days (0.5% vs. 1.4%, p = 0.315) and 1 year (1.8% vs. 4.1%, p = 0.159). The rates of moderate paravalvular leak (5.7% vs. 2.6%, p = 0.402), and mean gradient (7.27 ± 3.25 mmHg vs. 8.84 ± 4.36 mmHg, p = 0.105) were also comparable between groups at 1 year.

CONCLUSION

Our largest-to-date observational study suggests that the Evolut PRO/PRO+ system is safe and effective in treating severe aortic stenosis, with commensurate 30-day and 1-year mortality and similar 1-year echocardiographic hemodynamic outcomes in comparison to Evolut R.

CardioVision: A fully automated deep learning package for medical image segmentation and reconstruction generating digital twins for patients with aortic stenosis

Aortic stenosis (AS) is the most prevalent heart valve disease in western countries that poses a significant public health challenge due to the lack of a medical treatment to prevent valve calcification. Given the aging population demographic, the prevalence of AS is projected to rise, resulting in a progressively significant healthcare and economic burden. While surgical aortic valve replacement (SAVR) has been the gold standard approach, the less invasive transcatheter aortic valve replacement (TAVR) is poised to become the dominant method for high- and medium-risk interventions. Computational simulations using patient-specific models, have opened new research avenues for optimizing emerging devices and predicting clinical outcomes. The traditional techniques of generating digital replicas of patients' aortic root, native valve, and calcification are time-consuming and labor-intensive processes requiring specialized tools and expertise in anatomy. Alternatively, deep learning models, such as the U-Net architecture, have emerged as reliable and fully automated methods for medical image segmentation. Two-dimensional U-Nets have been shown to produce comparable or more accurate results than trained clinicians' manual segmentation while significantly reducing computational costs. In this study, we have developed a fully automatic AI tool capable of reconstructing the digital twin geometry and analyzing the calcification distribution on the aortic valve. The developed automatic segmentation package enables the modeling of patient-specific anatomies, which can then be used to simulate virtual interventional procedures, optimize emerging prosthetic devices, and predict clinical outcomes.

Correlation between measured and predicted mismatch with valve hemodynamics in transcatheter aortic valve replacement: A sex-based analysis

BACKGROUND

Data regarding the reliability of predicted effective orifice area indexed (pEOAi) is scarce in transcatheter aortic valve replacement (TAVR).

AIMS

To assess the validity of the pEOAi in TAVR by correlating its value with echocardiography-derived hemodynamic data.

METHODS

A single-center retrospective cohort study of TAVR patients from 2012 to 2021 with available echocardiograms was conducted. Patient-prosthesis mismatch (PPM) was defined based on the Valve Academic Research Consortium 3 criteria. The main endpoints were the congruence of measured effective orifice area indexed (EOAi) and pEOAi with the hemodynamic data obtained by echocardiography. The secondary endpoint included a correlation of predicted PPM (pPPM) and measured PPM (mPPM) with postoperative New York Heart Association (NYHA) status.

RESULTS

A total of 318 patients were included. pPPM was more frequent than mPPM (54 [17%]; all moderate PPM vs. 39 [12.3%]: 32 moderate and 7 severe PPM). Predicted and measured EOAi were statistically correlated with postprocedural transvalvular mean gradient and Doppler velocity index (all p < 0.001), including in both sex-based subgroups. The positive predictive value and negative predictive value (NPV) of pPPM for postprocedural transvalvular mean gradient ≥ 20 mmHg were 16% and 97%, respectively. Only pPPM was significantly more prevalent in the group in which NYHA failed to improve than in those with symptom improvement (30.1% vs. 16%, p = 0.027).

CONCLUSION

Predicted PPM has an excellent NPV for postprocedural transvalvular mean gradient ≥ 20 mmHg and seems to be a good predictor of NYHA status evolution as opposed to measured PPM. Predicted EOAi can be used in procedural planning to reduce the risk of PPM in both TAVR male and female patients.

Renin-angiotensin system inhibitors reduce cardiovascular mortality in hypertensive patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: insights from the EffecTAVI registry

Objectives

Arterial hypertension is associated with the triggering of the renin-angiotensin system, leading to left ventricle fibrosis and worse cardiovascular outcomes. In this study, patients with comorbid arterial hypertension and severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) were selected from the EffecTAVI registry to evaluate the impact of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) on cardiovascular mortality.

Methods

We enrolled 327 patients undergoing TAVI from the EffecTAVI registry. Using Kaplan-Meier event rates and study-stratified multivariable Cox proportional hazards regression models, we evaluated 2-year clinical outcomes according to the ACEI/ARB therapy status at enrollment.

Results

Among the included patients, 222 (67.9%) were on ACEIs/ARBs at baseline, whereas 105 (32.1%) were not. Treatment with ACEIs/ARBs was significantly associated with a 2-year decrease in the rate of cardiovascular mortality (HR = 0.44, 95% CI: 0.23-0.81, p = 0.009). This association remained stable after both multivariable adjustment and propensity score matching.

Conclusion

In a cohort of hypertensive patients with severe AS who were selected from the EffecTAVI registry, ACEI/ARB treatment at baseline was found to be independently associated with a lower risk of 2-year cardiovascular mortality, suggesting a potential benefit of this treatment. More trials are needed to validate this finding and to understand the full benefit of this treatment.

Outcomes of SAPIEN 3 Transcatheter Aortic Valve Replacement Compared With Surgical Valve Replacement in Intermediate-Risk Patients

BACKGROUND

Previous studies demonstrated transcatheter aortic valve replacement (TAVR) with an earlier generation balloon-expandable valve to be noninferior to surgical aortic valve replacement (SAVR) for death and disabling stroke in intermediate-risk patients with symptomatic, severe aortic stenosis at 5 years. However, limited long-term data are available with the more contemporary SAPIEN 3 (S3) bioprosthesis.

OBJECTIVES

The aim of this study was to compare 5-year risk-adjusted outcomes in intermediate-risk patients undergoing S3 TAVR vs SAVR.

METHODS

Propensity score matching was performed to account for baseline differences in intermediate-risk patients undergoing S3 TAVR in the PARTNER 2 (Placement of Aortic Transcatheter Valves) S3 single-arm study and SAVR in the PARTNER 2A randomized clinical trial. The primary composite endpoint consisted of 5-year all-cause death and disabling stroke.

RESULTS

A total of 783 matched pairs of intermediate-risk patients with severe aortic stenosis were studied. There were no differences in the primary endpoint between S3 TAVR and SAVR at 5 years (40.2% vs 42.7%; HR: 0.87; 95% CI: 0.74-1.03; P = 0.10). The incidence of mild or greater paravalvular regurgitation was more common after S3 TAVR. There were no differences in structural valve deterioration-related stage 2 and 3 hemodynamic valve deterioration or bioprosthetic valve failure.

CONCLUSIONS

In this propensity-matched analysis of intermediate-risk patients, 5-year rates of death and disabling stroke were similar between S3 TAVR and SAVR. Rates of structural valve deterioration-related hemodynamic valve deterioration were similar, but paravalvular regurgitation was more common after S3 TAVR. Longer-term follow-up is needed to further evaluate differences in late adverse clinical events and bioprosthetic valve durability. (PII S3i [PARTNER II Trial: Placement of Aortic Transcatheter Valves II - S3 Intermediate], NCT03222128; PII A (PARTNER II Trial: Placement of Aortic Transcatheter Valves II - XT Intermediate and High Risk], NCT01314313).

The Role of ECG Strain Pattern in Prognosis after TAVI: A Sub-Analysis of the DIRECT Trial

BACKGROUND

The presence of an electrocardiographic (ECG) strain pattern-among other ECG features-has been shown to be predictive of adverse cardiovascular outcomes in asymptomatic patients with aortic stenosis. However, data evaluating its impact on symptomatic patients undergoing TAVI are scarce. Therefore, we tried to investigate the prognostic impact of baseline ECG strain pattern on clinical outcomes after TAVI.

METHODS

A sub-group of patients of the randomized DIRECT (Pre-dilatation in Transcatheter Aortic Valve Implantation Trial) trial with severe aortic stenosis who underwent TAVI with a self-expanding valve in one single center were consecutively enrolled. Patients were categorized into two groups according to the presence of ECG strain. Left ventricular strain was defined as the presence of ≥1 mm convex ST-segment depression with asymmetrical T-wave inversion in leads V5 to V6 on the baseline 12-lead ECG. Patients were excluded if they had paced rhythm or left bundle branch block at baseline. Multivariate Cox proportional hazard regression models were generated to assess the impact on outcomes. The primary clinical endpoint was all-cause mortality at 1 year after TAVI.

RESULTS

Of the 119 patients screened, 5 patients were excluded due to left bundle branch block. Among the 114 included patients (mean age: 80.8 ± 7), 37 patients (32.5%) had strain pattern on pre-TAVI ECG, while 77 patients (67.5%) did not exhibit an ECG strain pattern. No differences in baseline characteristics were found between the two groups. At 1 year, seven patients reached the primary clinical endpoint, with patients in the strain group demonstrating significantly higher mortality in Kaplan-Meier plots compared to patients without left ventricular strain (five vs. two, log-rank p = 0.022). There was no difference between the strain and no strain group regarding the performance of pre-dilatation (21 vs. 33, chi-square p = 0.164). In the multivariate analysis, left ventricular strain was found to be an independent predictor of all-cause mortality after TAVI [Exp(B): 12.2, 95% Confidence Intervals (CI): 1.4-101.9].

CONCLUSION

Left ventricular ECG strain is an independent predictor of all-cause mortality after TAVI. Thus, baseline ECG characteristics may aid in risk-stratifying patients scheduled for TAVI.

Transapical TAVI: Survival, Hemodynamics, Devices and Machine Learning. Lessons Learned After 10-Year Experience

Aim of this single-center, retrospective study was to assess early and long-term clinical and hemodynamic results of transapical aortic valve implantation (TA-TAVI), and to identify predictors of survival at follow-up. All patients undergoing TA-TAVI for severe aortic valve stenosis at our institution were reviewed. A hybrid approach based on machine-learning techniques was employed to identify survival predictors, using a Bagging-Decision-Tree algorithm and a Random-Forest algorithm, respectively. Two-hundred-thirty-four consecutive patients underwent TA-TAVI (March 2009-May 2019). All-cause 30-day mortality was 5.1%. Device success was 95.7%. Median follow-up time was 35.2 months. Kaplan-Meier overall survival rates at 2, 5, and 8 years were 75%, 44%, and 15%, respectively. Structural-valve-deterioration occurred in 25 patients (11.3%) overall. The strongest predictors of survival at follow-up were age, body-mass-index, and ejection fraction. TA-TAVI provided valid early and long-term outcomes. These data support its choice as an optimal alternative access whenever the transfemoral route is not feasible.

Evaluation of the second-generation whole-heart motion correction algorithm (SSF2) used to demonstrate the aortic annulus on cardiac CT

The main purpose of pre-transcatheter aortic valve implantation (TAVI) cardiac computed tomography (CT) for patients with severe aortic stenosis is aortic annulus measurements. However, motion artifacts present a technical challenge because they can reduce the measurement accuracy of the aortic annulus. Therefore, we applied the recently developed second-generation whole-heart motion correction algorithm (SnapShot Freeze 2.0, SSF2) to pre-TAVI cardiac CT and investigated its clinical utility by stratified analysis of the patient's heart rate during scanning. We found that SSF2 reconstruction significantly reduced aortic annulus motion artifacts and improved the image quality and measurement accuracy compared to standard reconstruction, especially in patients with high heart rate or a 40% R-R interval (systolic phase). SSF2 may contribute to improving the measurement accuracy of the aortic annulus.

Effectiveness of high implantation of SAPIEN 3 in preventing pacemaker implantation: A propensity score analysis

BACKGROUND

In transcatheter aortic valve implantation, high implantation on the aortic annulus may prevent conduction pathway injury, leading to a decrease in the rate of permanent pacemaker implantation.

AIM

To assess the impact of high implantation of SAPIEN 3 on the prevention of permanent pacemaker implantation.

METHODS

Since August 2020, we have performed high implantation by fluoroscopically positioning the lower part of the lucent line at the virtual basal ring line on a coplanar view before valve implantation. Patients treated before the adoption of this method were defined as the conventional group. We compared the high implantation group with the conventional group using propensity score analysis.

RESULTS

Overall, the high implantation group (n=95) showed a significantly shorter ventricular strut length than the conventional group (n=85): median 1.3 (interquartile range 0.2-2.4) mm vs 2.8 (1.8-4.1) mm (P<0.001). The permanent pacemaker implantation rate was significantly lower in the high implantation group than in the conventional group (2.1% vs 11.8%; P=0.009). According to 100 propensity score analyses based on multiple imputation and the selection of appropriate covariates, the median P value for the comparison of permanent pacemaker implantation rates after transcatheter aortic valve implantation between the high implantation group and the conventional group ranged between 0.001 and 0.017, indicating a more significant reduction in the permanent pacemaker implantation rate in the high implantation group than in the conventional group. Neither valve dislodgement nor the need for a second valve was observed in either group.

CONCLUSIONS

The high implantation of SAPIEN 3 successfully decreases ventricular strut length, reducing the permanent pacemaker implantation rate after transcatheter aortic valve implantation.

How accurate are manufacturers' recommendations in determining ineligibility for transfemoral transcatheter aortic valve implantation?

INTRODUCTION

Up to one-third of patients indicated for transcatheter aortic valve implantation (TAVI) may be unsuitable for transfemoral TAVI (TF-TAVI) according to manufacturers' recommendations and numerous professional societies.

OBJECTIVE

This study aimed to investigate the predictive value of manufacturers' guidelines for major vascular access site complications using the Perclose ProGlide device.

METHODS

Among 208 patients undergoing TF-TAVI, 144 patients (69.2%) were deemed eligible for TF-TAVI according to the manufacturer's instructions. A minimal lumen diameter (MLD) of the femoral artery below the manufacturer's specified limits and/or the presence of circumferential calcification were the reasons for ineligibility. Calcium score (CS), sheath-to-femoral artery ratio (SFAR) and MLD were estimated from computed tomography imaging. Vascular complications (VCs) (defined according to VARC-2 criteria) were retrospectively compared.

RESULTS

Patients in the ineligible group had higher SFAR (1.13±0.15 vs. 0.88±0.107, p<0.001) and CS (1.66±0.99 vs. 1.24±0.73; p=0.003), and significantly lower MLD (7.72±1.03 vs. 6.31±0.96 mm; p<0.001) compared to the eligible group. Major (6.3% vs. 12.3%, p=0.13) and minor VCs (10.4% vs. 15.6%, p=0.29) were similar in the eligible and ineligible groups. The ineligible group had higher rates of rupture (0.7% vs. 6.3%; p=0.03). SFAR was the only independent predictor of major VCs (OR 469.1, 95% CI 4.95-44466.57, p=0.008).

CONCLUSION

The TAVI team should not decide whether the patient is suitable for a femoral approach based solely on the manufacturer's criteria, and should incorporate additional factors that could be predictive of major VCs.

Economics of Minimalist Transcatheter Aortic Valve Replacement: Results From the 3M-TAVR Economic Study

BACKGROUND

The 3M-TAVR trial (3M-Transcatheter Aortic Valve Replacement) demonstrated the feasibility and safety of next-day hospital discharge after transfemoral TAVR with implementation of a minimalist pathway. However, the economic impact of this approach is unknown. Therefore, we evaluated costs for patients undergoing minimalist TAVR compared with conventional TAVR.

METHODS

We used propensity matching to compare resource utilization and costs (from a US health care system perspective) for patients in the 3M-TAVR trial with those for transfemoral TAVR patients enrolled in the contemporaneous S3i trial (PARTNER SAPIEN-3 Intermediate Risk). Procedural costs were estimated using measured resource utilization for both groups. For the S3i group, all other costs through 30-day follow-up were assessed by linkage with Medicare claims; for 3M, these costs were assessed using regression models derived from S3i cost and resource utilization data.

RESULTS

After 1:1 propensity matching, 351 pairs were included in our study (mean age 82, mean Society of Thoracic Surgery risk score 5.3%). There were no differences in death, stroke, or rehospitalization between the 3M-TAVR and S3i groups through 30-day follow-up. Index hospitalization costs were $10 843/patient lower in the 3M-TAVR cohort, driven by reductions in procedure duration, anesthesia costs, and length of stay. Between discharge and 30 days, costs were similar for the 2 groups such that cumulative 30-day costs were $11 305/patient lower in the 3M-TAVR cohort compared with the S3i cohort ($49 425 versus $60 729, 95% CI for difference $9378 to $13 138; P<0.001).

CONCLUSIONS

Compared with conventional transfemoral TAVR, use of a minimalist pathway in intermediate-risk patients was associated with similar clinical outcomes and substantial in-hospital cost savings, which were sustained through 30 days.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02287662.

Prevalence and Prognostic Significance of Malnutrition in Older Japanese Adults at High Surgical Risk Undergoing Transcatheter Aortic Valve Implantation

Background The usefulness of preprocedural nutritional status to stratify prognosis after transcatheter aortic valve implantation has been evaluated; however, the studies conducted so far have been relatively small and/or focused on a single nutritional index. This study sought to assess the prevalence and prognostic impact of malnutrition in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. Methods and Results We applied the Controlling Nutritional Status score, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index to 1040 consecutive older Japanese patients at high surgical risk who underwent transcatheter aortic valve implantation. According to the Controlling Nutritional Status score, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index, 16.6%, 60.5%, and 13.8% patients had moderate or severe malnutrition, respectively; 89.3% were at least mildly malnourished by at least 1 score. Worse nutritional status was associated with older age, lower body mass index, higher degree of frailty, worse symptoms and renal function, atrial fibrillation, and anemia. During a median follow-up of 986 days (interquartile range, 556-1402 days), 273 (26.3%) patients died. Compared with normal nutrition, malnutrition was associated with an increased risk for all-cause death (adjusted hazard ratio for moderate and severe malnutrition, respectively: 2.19 (95% CI, 1.45-3.31; P<0.001) and 6.13 (95% CI, 2.75-13.70; P<0.001) for the Controlling Nutritional Status score, 2.02 (95% CI, 1.36-3.02; P=0.001) and 3.24 (95% CI, 1.86-5.65; P<0.001) for the Geriatric Nutritional Risk Index, and 1.60 (95% CI, 1.06-2.39; P=0.024) and 2.32 (95% CI, 1.50-3.60; P<0.001) for the Prognostic Nutritional Index). Conclusions Malnutrition is common in patients undergoing transcatheter aortic valve implantation and is associated with increased mortality.

Counting the cost of premature mortality with progressively worse aortic stenosis in Australia: a clinical cohort study

BACKGROUND

Aortic stenosis is the most common cardiac valve disorder requiring clinical management. However, there is little evidence on the societal cost of progressive aortic stenosis. We sought to quantify the societal burden of premature mortality associated with progressively worse aortic stenosis.

METHODS

In this observational clinical cohort study, we examined echocardiograms on native aortic valves of 98 565 men and 99 357 women aged 65 years or older across 23 sites in Australia, from Jan 1, 2003, to Dec 31, 2017. Individuals were grouped according to their peak aortic valve velocity in 0·50 m/s increments up to 4·00 m/s or more (severe aortic stenosis), using 1·00-1·99 m/s (no aortic stenosis) as the reference group. Sex-specific premature mortality and years of life lost during a 5-year follow-up were calculated, along with willingness-to-pay to regain quality-adjusted life years (QALYs).

FINDINGS

Overall, 20 701 (21·0%) men and 18 576 (18·7%) women had evidence of mild-to-severe aortic stenosis. The actual 5-year mortality in men with normal aortic valves was 32·1% and in women was 26·1%, increasing to 40·9% (mild aortic stenosis) and 52·2% (severe aortic stenosis) in men and to 35·9% (mild aortic stenosis) and 55·3% (severe aortic stenosis) in women. Overall, the estimated societal cost of premature mortality associated with aortic stenosis was AU$629 million in men and $735 million in women. Per 1000 men and women investigated, aortic stenosis was associated with eight more premature deaths in men resulting in 32·5 more QALYs lost (societal cost of $1·40 million) and 12 more premature deaths in women resulting in 57·5 more QALYs lost (societal cost of $2·48 million) when compared with those without aortic stenosis.

INTERPRETATION

Any degree of aortic stenosis in older individuals is associated with premature mortality and QALYs. In this context, there is a crucial need for cost-effective strategies to promptly detect and optimally manage this common condition within our ageing populations.

FUNDING

Edwards LifeSciences, National Health and Medical Research Council of Australia, and the National Heart, Lung, and Blood Institute.

Mid-term impact of underfilling and overfilling of the SAPIEN 3 balloon-expandable transcatheter aortic valve implantation on mortality and valve function

At present, underfilling or overfilling the volume of the balloon-expandable transcatheter heart valve (THV) is generally utilized in transcatheter aortic valve implantation (TAVI). However, no research has assessed the clinical impact of filling volume variations of the current-generation SAPIEN 3 THV. We analyzed the clinical data of 331 patients who underwent TAVI with SAPIEN 3 at our institution. Post-procedural echocardiographic and multidetector computed tomography (MDCT) scan data and 3-year prognoses according to each filling volume were assessed. The procedural outcomes and 3-year mortality rates were comparable among the underfilling, nominal filling, and overfilling groups. For all THV sizes, the THV area evaluated on post-procedural MDCT scan increased stepwise along with an elevated filling volume, thereby covering a wide range of native annulus area. Compared with patients in the nominal filling and overfilling groups, those with 23-mm THVs in the underfilling group had a smaller effective orifice area (EOA) (1.38 [IQR: 1.18-1.56] vs. 1.57 [IQR: 1.41-1.84] vs. 1.58 [IQR: 1.45-1.71] cm², P = 0.02) and a higher mean transvalvular gradient (13.6 [IQR: 11.0-15.7] vs. 12.1 [IQR: 9.0-14.9] vs. 12.0 [IQR: 8.1-14.8] cm², P = 0.04). In conclusion, by adjusting the filling volume of SAPIEN 3 using THV with limited sizes, continuously distributed native annulus areas were covered. The underfilling implantation technique had a minimal negative effect on the valve function of 23-mm THVs only. In the entire cohort, the filling volume variations did not affect the mid-term prognosis negatively.

Relation of Subacute Kidney Injury to Mortality After Transcatheter Aortic Valve Implantation

Acute kidney injury after transcatheter aortic valve implantation (TAVI) has been associated with adverse outcomes; however, data are limited on the subacute changes in renal function that occur after discharge and their impact on clinical outcomes. This study investigates the relation between subacute changes in kidney function at 30 days after TAVI and survival. Patients from 2 centers who underwent TAVI and survived beyond 30 days with baseline, in-hospital, and 30-day measures of renal function were retrospectively analyzed. Patients were stratified based on change in estimated glomerular filtration rate (eGFR) from baseline to 30 days as follows: improved (≥15% higher than baseline), worsened (≤15% lower), or unchanged (values in between). Univariable and multivariable models were constructed to identify predictors of subacute changes in renal function and of 2-year mortality. Of the 492 patients who met inclusion criteria, eGFR worsened in 102 (22%), improved in 110 (22%), and was unchanged in 280 (56%). AKI occurred in 90 patients (18%) and in only 27% of patients with worsened eGFR at 30 days. After statistical adjustment, worsened eGFR at 30 days (hazard ratio vs unchanged eGFR 2.09, 95% CI 1.37 to 3.19, p <0.001) was associated with worse survival, whereas improvement in renal function was not associated with survival (hazard ratio vs unchanged eGFR 1.30, 95% CI 0.79 to 2.11, p = 0.30). Worsened renal function at 30 days after TAVI is associated with increased mortality after TAVI. In conclusion, monitoring renal function after discharge may identify patients at high risk of adverse outcomes.

Effect of Radiolucent Line-Guided Balloon-Expandable Transcatheter Aortic Valve Implantation on Subsequent Pacemaker Rate

In the era of expanding transcatheter aortic valve implantation (TAVI) indications for low surgical risk patients, conduction disturbances requiring permanent pacemaker implantation (PPI) after TAVI remain a serious concern. We aimed to assess the impact of the radiolucent line-guided technique for the SAPIEN 3 implantation on reducing the rates of new-onset PPI after TAVI. A total of 326 patients treated with the SAPIEN 3 using either the radiolucent line-guided technique (lucent group, 170 patients [52.1%]) or the center marker-guided technique (conventional group, 156 patients [47.9%]) were prospectively included in our database. The prosthesis position, and 30-day and 3-year clinical outcomes were retrospectively assessed. Compared with the conventional group, the lucent group had a higher prosthesis position (1.7 ± 0.9 mm vs 4.2±1.5 mm, p <0.001) and lower 30-day PPI rates (2.9% vs 13.5%, p <0.001). The other periprocedural complications including valve dislodgement and coronary obstruction, and 30-day and 3-year mortality were comparable between the groups. However, the prosthesis frame extending above sinotubular junction was more frequently observed in the lucent group on the side of left coronary sinus (53.4% vs 31.4%, p <0.001) and right coronary sinus (35.0% vs 20.2%, p = 0.001), signifying a potential risk for "subsequent difficulties to access coronary ostia" and "coronary obstruction during future redo TAVI." In conclusion, the radiolucent line-guided technique predictably provided an extremely high position of the SAPIEN 3, reducing the postprocedural PPI rates compared with the center marker-guided technique.

The conjunction conundrum in Transcatheter Aortic Valve Implantation

A continuous discussion regarding the predictors for permanent pacemaker implantation (PPI) following transcatheter aortic valve implantation (TAVI) is ongoing, especially in the era of low and medium risk patients. The aim of this article is to review the data so far regarding the pathophysiology, risk factors, and the indications for permanent pacemaker implantation after TAVI. The factors that contribute to rhythm abnormalities post TAVI can be divided into pre-existing conduction abnormalities, patient-related anatomical factors, and peri-procedural technical factors. The latter components are potentially modifiable, and this is where attention should be directed, particularly now that in an era of TAVI expansion towards lower-risk patients.

Budget impact analysis of transcatheter aortic valve replacement in low, intermediate, and high-risk patients with severe aortic stenosis in Saudi Arabia

AIMS

A budget impact analysis (BIA) comparing transcatheter aortic valve replacement (TAVR) with SAPIEN 3 and surgical aortic valve replacement (SAVR) for severe, symptomatic aortic stenosis among patients of low, intermediate, and high surgical risk from the perspective of the public and private sectors in Saudi Arabia.

MATERIALS AND METHODS

A Markov model was developed with six states to calculate the budget impact from time of either TAVR or SAVR intervention up to 5 years. We compared the budget effects of new permanent pacemaker implantation (PPI), new onset atrial fibrillation (AF), major/disabling stroke (MDS), and surgical site infections (SSI). One-way sensitivity analyses (OWSA) were performed on cost and probability inputs.

RESULTS

Analysis of the base case parameters suggests TAVR vs. SAVR is budget saving among intermediate- and high-risk patients at 5 years. TAVR vs. SAVR for low surgical risk reaches budget neutrality at 5 years. TAVR is associated with higher costs for PPI and budget savings for MDS, AF, and SSI. TAVR also results in savings for non-device costs due to fewer human resource uses and shorter procedure durations. Similarly, TAVR is associated with cost savings due to shorter hospital intensive care unit (ICU) and non-ICU stays. The OWSA consistently revealed that SAVR non-device theater costs were the leading cost driver across all surgical risk levels.

LIMITATIONS

This is the first budget impact analysis of its kind in Saudi Arabia and future research is needed on costing TAVR and SAVR procedures, the economic impact of SSI, and corroborating estimates for the public and private sectors.

CONCLUSIONS

Payers, providers, and policymakers increasingly turn to results of BIA to inform technologies affordability decisions. TAVR with SAPIEN 3 appears to generate savings vs. SAVR from a budget impact perspective across various surgical risk levels in Saudi Arabia.

Novel Pressure-Regulated Deployment Strategy for Improving the Safety and Efficacy of Balloon-Expandable Transcatheter Aortic Valves

OBJECTIVES

The authors propose a novel pressure-regulated method for balloon-expandable transcatheter heart valve (THV) deployment, aimed at optimizing prosthesis-annulus apposition while preventing significant tissue injury.

BACKGROUND

The optimal method for balloon-expandable THV deployment remains debated. Current protocols are volume dependent, relying on under- and overfilling of the deployment apparatus. During deployment, the annular wall tension exerted by the expanding prosthesis is determined by maximal THV diameter and balloon pressure (Laplace's law).

METHODS

Three hundred thirty consecutive patients with severe native aortic stenosis who underwent TAVR with SAPIEN 3 THVs were included. One hundred and six patients were considered at high risk for annular rupture. THVs were deployed until reaching a predetermined balloon pressure. Postdilatation was performed to reduce mild or greater angiographic paravalvular regurgitation (PVR). Using a biomechanical model, annular wall stress was estimated for each case and assessed against rates of postdilatation, mild or greater PVR on transthoracic echocardiography, new permanent pacemaker placement or left bundle branch block, and annular rupture.

RESULTS

Patients with wall stress >3 MPa had reduced postdilatation rate (P < 0.001) and reduced final PVR (P = 0.014). Annular rupture occurred in 2 of 3 high-risk patients with wall stress >3.5 MPa (3.69 and 3.84 MPa); no rupture occurred in 95 high-risk patients with wall stress ≤3.5 MPa. We defined a single target deployment pressure per THV size to ensure deployment within target wall stress levels of 3 to 3.5 MPa: 6.25 atm for 23-mm THVs, 5.5 atm for 26-mm THVs, and 5 atm for 29-mm THVs. Patients within this target range (n = 136) had a 10.0% postdilatation rate, 12.7% mild PVR, and no moderate to severe PVR. The relationship between balloon filling volume and associated pressure and wall stress was inconsistent.

CONCLUSIONS

Pressure-regulated THV deployment is a simple, reproducible, safe, and effective method, regardless of high-risk anatomical complexities.

Cardiac Structural Remodeling and Hemodynamic Patterns Following Transcatheter Aortic Valve Replacement

Background Transcatheter aortic valve replacement (TAVR) is increasingly utilized for most patients with symptomatic severe aortic stenosis. TAVR is linked to enhanced long-term cardiac hemodynamics, reversal of left ventricle (LV) hypertrophy, and improved aortic valve gradients. We present a retrospective observational study assessing cardiac remodeling and valvular flow patterns post-TAVR. Methods Retrospective echocardiographic data were collected, evaluating cardiac function and valvular flow patterns before and after TAVR at a single institution. Data was compiled and statistically analyzed using a paired t-test evaluating variations at approximately 30 days and one-year post-TAVR. Results On echocardiogram 30 days and one-year post-TAVR, there was a reduction in LV mass index from 132 g/m² to 110 g/m² (95%CI: 98-122; p=0.01) and 118 g/m² (95%CI: 102-133; p=0.03), and a reduction in relative wall thickness from 0.54 to 0.49 (95%CI: 0.46-0.52; p=0.05) and 0.44 (95%CI: 0.38-0.49; p=0.03), respectively. Doppler velocity indices (DVI) increased from 0.24 to 0.61 (95%CI: 0.49-0.73; p<0.001) and 0.57 (95%CI: 0.48-0.65; p<0.001). Expected improvement in aortic valve velocities and gradients were observed post-TAVR. Conclusions Following TAVR, LV remodeling can be observed as early as 30 days. This is demonstrated by a reduction in LV mass index and relative wall thickness in conjugation with an anticipated improvement in valvular flow patterns and flow across the aortic valve.

Decoupling Between Pulmonary Artery Diastolic and Wedge Pressure Following Transcatheter Aortic Valve Replacement

BACKGROUND

Coexistent pulmonary hypertension with severe aortic stenosis confers a greater risk of mortality for patients undergoing transcatheter aortic valve replacement (TAVR). In this patient population, the impact of significant decoupling between pulmonary artery diastolic and pulmonary capillary wedge, as it relates to clinical risk, remained uncertain.Methods and Results:Patients with severe aortic stenosis who underwent TAVR and completed pre-procedural and post-procedural invasive hemodynamic assessments with right heart catheterization were retrospectively assessed. The impact of post-TAVR decoupling, defined as a pressure difference ≥3 mmHg, on 2-year all-cause mortality or risk of heart failure admission was analyzed. Among 77 included patients (median age 86 years, 23 men), 16 had post-TAVR decoupling. The existence of post-TAVR decoupling was associated with a higher cumulative incidence of the primary endpoint (44% vs. 7%, P=0.001), with an adjusted hazard ratio of 5.87 (95% confidence interval 1.58-21.9, P=0.008).

CONCLUSIONS

A greater risk of worse outcomes in those with post-TAVR decoupling was observed. A therapeutic strategy for post-TAVR decoupling and its clinical implication need to be created and investigated in the future.

A meta-analysis of transcarotid versus transfemoral transcatheter aortic valve replacement

BACKGROUND

Carotid access has shown promise as an excellent delivery route for transcatheter aortic valve replacement (TAVR). We aimed to compare outcomes of transcarotid (TC) and transfemoral (TF) TAVR by conducting a search and analysis of the best evidence in the literature to shed light on its safety and effectiveness.

METHODS

The PubMed/MEDLINE, Embase, and Cochrane library from inception to July 2020 were searched to identify articles reporting comparative data on TC versus TF approaches for TAVR. Patients' baseline characteristics and clinical outcomes were extracted from the articles and pooled for analysis.

RESULTS

Five studies, including a total of 2470 patients, were included in the study with 1859 patients in the TF group and 611 patients in the TC group. The TC group had higher prevalence of peripheral vascular disease, while the patients in the TF group was older. Meta-analysis revealed that there was no significant differences between the two groups with regard to 30-day mortality (p = 0.09), stroke (p = 0.28), new dialysis (p = 0.58), major bleeding (p = 0.69), or pacemaker implantation (p = 0.44). The TF group had a higher incidence of vascular complications (3.9% vs. 2.3%; OR 2.22; 95% CI [1.13, 4.38]; p = 0.02).

CONCLUSIONS

Compared with the TF approach, TC-TAVR is associated with comparable procedural and clinical outcomes. Our analysis found a lower rate of vascular complication in TC access compared with TF access. This supports consideration of such an alternative access when there are concerns over the feasibility of TF access.

Aortic Stenosis and Coronary Artery Disease: Cost of Transcatheter versus Surgical Management

BACKGROUND

Surgical aortic valve replacement with coronary artery bypass grafting (SAVR+CABG) is the recommended treatment for aortic stenosis (AS) and coronary artery disease (CAD), however percutaneous coronary intervention at the time of transcatheter aortic valve replacement (TAVR+PCI) is used with increasing frequency.

METHODS

Using the National Inpatient Sample, we identified all adult admissions with a diagnosis of AS. Sub-groups of SAVR+CABG and TAVR+PCI formed the study group. Outcomes of interest included total hospitalization charges, temporal trends, in-hospital mortality, and complications.

RESULTS

Between 2012 and 2017, a total of 97,955 (95.9%) admissions received SAVR+CABG, and 4240 (4.1%) received TAVR+PCI; the proportion of TAVR+PCI increased from 1.0% in 2012 to 9.2% in 2017 (p<0.001). Compared to those receiving TAVR+PCI, admissions receiving SAVR+CABG were younger, more likely to be male, and had lower comorbidity (all p<0.001). Adjusted in-hospital mortality was comparable in both groups (OR 0.94, 95% CI 0.79-1.11, p=0.45). Higher rates of pacemaker implantation, cardiac arrest, and vascular complications were seen in the TAVR+PCI group, while SAVR+CABG was associated with a greater requirement of prolonged ventilation. Admissions receiving TAVR+PCI had shorter lengths of hospital stay and were more likely to be discharged home. Nevertheless, TAVR+PCI had higher hospitalization charges compared to SAVR+CABG group (all p<0.001).

CONCLUSIONS

There has been a steady increase in the utilization of percutaneous strategies for AS and CAD management. In-hospital mortality was comparable in SAVR+CABG and TAVR+PCI groups, but despite shorter in-hospital stays, TAVR+PCI was associated with higher cardiac and vascular complication rates and hospitalization charges.

Transcatheter Aortic Valve Replacement With Self-Expandable Supra-Annular Valves for Degenerated Surgical Bioprostheses: Insights From Transcatheter Valve Therapy Registry

Background

Transcatheter aortic valve replacement with supra‐annular transcatheter heart valves has been adopted in patients with degenerated surgical aortic valves. The next generation self‐expanding Evolut PRO valve has not been evaluated in patients with surgical valve failure.

Methods and Results

Patients undergoing transcatheter aortic valve replacement in degenerated surgical aortic valve procedures using the Evolut R or Evolut PRO transcatheter heart valves in the Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapy Registry between April 2015 and June 2019 were evaluated. Transcatheter valve performance was evaluated by clinical site echocardiography. In‐hospital, 30‐day, and 1‐year clinical outcomes were based on the Society of Thoracic Surgeons‐American College of Cardiology‐Transcatheter Valve Therapy registry definitions. Transcatheter aortic valve replacement in degenerated surgical aortic valve was performed in 5897 patients (5061 [85.8%] patients received the Evolut R valve and 836 [14.2%] received the Evolut PRO valve). Thirty‐day transcatheter heart valves hemodynamic performance was excellent in both groups (mean gradient: Evolut PRO: 13.8±7.5 mm Hg; Evolut R: 14.5±8.1 mm Hg), while paravalvular regurgitation was significantly different between valve types (P=0.02). Clinical events were low at 30 days (Evolut PRO: for the all‐cause mortality, 2.8%, any stroke was 1.8%, new pacemaker implantation, 3.0%: Evolut R:all‐cause mortality, 2.5%, any stroke was 2.2%, new pacemaker implantation, 5.3%) and 1 year (Evolut PRO: all‐cause mortality, 9.2%; any stroke, 3.1%; Evolut R: all‐cause mortality, 9.8%; any stroke, 2.9%).

Conclusions

Transcatheter aortic valve replacement in degenerated surgical aortic valve with self‐expandable supra‐annular transcatheter heart valves is associated with excellent clinical outcomes and valve hemodynamics. Additional reductions in residual paravalvular regurgitation were obtained with the next generation Evolut PRO.

Conduction delays after transcatheter aortic valve implantation with balloon-expandable prosthesis and high implantation technique

Performing transcatheter aortic valve implantation with high implantation technique, i.e. with an aorto-ventricular ratio > 60/40, reduces the need of permanent pacemaker implantation. Valve calcification and prosthesis oversizing are predictors of permanent pacemaker implantation, but there are no available data on their role when transcatheter aortic valve implantation is performed with an aorto-ventricular ratio > 60/40. The aim of this study was to evaluate the effect of leaflets/annulus calcification and prosthesis oversizing on the incidence of permanent pacemaker implantation after transcatheter aortic valve implantation with a high implantation technique. Transcatheter aortic valve implantation was performed in 48 patients implanting a balloon-expandable transcatheter heart valve with an aorto-ventricular ratio > 60/40. Calcium burden was assessed by preprocedural multidetector computed tomography. An invasive electrophysiological study was performed before and after transcatheter aortic valve implantation. Five patients (10.4%) needed permanent pacemaker implantation. At univariate analysis, baseline right bundle branch block and postprocedural PR, QRS and His-ventricular interval elongation significantly predicted permanent pacemaker implantation (p < 0.05). Receiver-operating characteristic curve analysis showed a correlation between transcatheter heart valve oversizing and permanent pacemaker implantation need, with the best cut-off being 17% (AUC = 0.72, p = 0.033). Linear regression analysis demonstrated that QRS complex elongation was related to total, left and non-coronary leaflet calcification (p < 0.05). This study demonstrates that, when transcatheter aortic valve implantation is performed using a balloon-expandable transcatheter heart valve deployed with an aorto-ventricular ratio > 60/40, the presence of leaflets/annulus calcification or the need to oversize the prosthesis correlate with the occurrence of pathological cardiac conduction delays.

Clinical outcomes following transapical TAVR with ACURATE neo in the CHANGE neo TA study

Background

A transapical (TA) approach to transcatheter aortic valve replacement (TAVR) may be used when a transfemoral (TF) approach is not feasible. The CHANGE neo TA study evaluated patients treated in routine clinical practice via TA-TAVR with the ACURATE neo bioprosthetic aortic valve.

Methods and results

This single-arm post-market study had a planned enrolment of 200 subjects; enrolment was terminated early due to declining TA-TAVR procedures at participating centers. Final enrolment was 107 patients (mean age: 79.3 years; 54.2% female; mean STS score at baseline: 6.2%). The mortality rate in the intent-to-treat population was 11.2% at 30 days (primary endpoint) and 25.6% at 12 months. The VARC-2 composite endpoint for 30-day safety occurred in 24.3% of patients. Six patients (5.6%) received a permanent pacemaker within 30 days. Site-reported echocardiographic data showed early improvements in mean aortic valve gradient (baseline: 38.8 [SD 13.1] mmHg, discharge: 6.7 [SD 3.7] mmHg) and effective orifice area (baseline: 0.7 [SD 0.2] cm², discharge: 1.9 [SD 0.6] cm²), and the discharge rate of paravalvular regurgitation was low (74.7% none/trace, 24.2% mild, 1.1% severe).

Conclusions

TA-TAVR with the ACURATE neo valve system yields acceptable clinical outcomes, providing an alternative for patients with aortic stenosis who are not candidates for TF-TAVR.

Epidemiology, evaluation, and management of conduction disturbances after transcatheter aortic valve replacement

Aortic stenosis is the most common valvulopathy requiring replacement by means of the surgical or transcatheter approach. Transcatheter aortic valve replacement (TAVR) has quickly become a viable and often preferred treatment strategy compared to surgical aortic valve replacement. However, transcatheter heart valve system deployment not infrequently injures the specialized electrical system of the heart, leading to new conduction disorders including high-grade atrioventricular block and complete heart block (CHB) necessitating permanent pacemaker implantation (PPI), which may lead to deleterious effects on cardiac function and patient outcomes. Additional conduction disturbances (e.g., new-onset persistent left bundle branch block, PR/QRS prolongation, and transient CHB) currently lack clearly defined management algorithms leading to variable strategies among institutions. This article outlines the current understanding of the pathophysiology, patient and procedural risk factors, means for further risk stratification and monitoring of patients without a clear indication for PPI, our institutional approach, and future directions in the management and evaluation of post-TAVR conduction disturbances.

Real-World Experience With the SAPIEN 3 Ultra Transcatheter Heart Valve: A Propensity-Matched Analysis From the United States

[Figure: see text].

Relation between Modified Body Mass Index and Adverse Outcomes after Aortic Valve Implantation

We aimed to investigate the relationship of modified body mass index (mBMI), the product of BMI and serum albumin, with survival after transcatheter (TAVI) and surgical aortic valve implantation (SAVI). Frailty is associated with poor outcomes after TAVI and SAVI for severe aortic stenosis (AS). However, clinical frailty is not routinely measured in clinical practice due to the cumbersome nature of its assessment. Modified BMI is an easily measurable surrogate for clinical frailty that is associated with survival in elderly cohorts with non-valvular heart disease. We utilized individual patient-level data from a pooled database of the Placement of Aortic Transcatheter Valves (PARTNER) trials from the PARNTER1, PARTNER2 and S3 cohorts. We estimated cumulative mortality at 1 year for quartiles of mBMI with the Kaplan-Meier method and compared them with the log-rank test. We performed Cox proportional hazards modeling to assess the association of mBMI strata with 1-year mortality adjusting for baseline clinical characteristics. A total of 6593 patients who underwent TAVI or SAVI (mean age 83±7.3 years, 57% male) were included. mBMI was independently associated with all-cause one-year mortality with the lowest mBMI quartile as most predictive (HR 2.33, 95% CI 1.80-3.02, p < 0.0001). Notably, mBMI performed as well as clinical frailty index to predict 1-year mortality in this cohort. In conclusion, modified BMI predicts 1-year survival after both TAVI and SAVI. Given that it performed similar to the clinical frailty index, it may be used as a clinical tool for assessment of frailty prior to valve implantation.

Impact of Flow on Prosthesis-Patient Mismatch Following Transcatheter and Surgical Aortic Valve Replacement

BACKGROUND

Severe prosthesis-patient mismatch (PPM) is diagnosed by an indexed effective orifice area <0.65 cm²/m², which is derived from stroke volume index. We examined the impact of flow, determined by stroke volume index, on severe PPM following transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).

METHODS

We included SAVR patients from the PARTNER 2A trial (Placement of Aortic Transcatheter Valve 2A) and TAVR patients from the PARTNER 2 S3i (Placement of Aortic Transcatheter Valve 2 S3i) registry. The primary end point was the separate analysis of all-cause death, cardiac death, and rehospitalization at 5 years. Following TAVR and SAVR, we compared the primary end points between severe versus no-severe PPM in all patients, in low flow (LF), and in normal flow. Multivariable analysis was performed to determine variables associated with the end points.

RESULTS

Nine hundred fifty-four TAVR and 726 SAVR patients with PPM and flow data were included. Severe PPM following TAVR was significantly lower compared with SAVR in all patients (9% versus 28%, P<0.0001), in normal flow (5% versus 8%, P=0.04), and in LF (20% versus 42%, P<0.0001). Severe PPM was associated with rehospitalization following TAVR (odds ratio, 1.52 [95% CI, 1.01-2.29], P=0.0456) and SAVR (odds ratio, 1.51 [95% CI, 1.06-2.16], P=0.0237). Severe PPM in LF was independently associated with cardiac death following TAVR (odds ratio, 1.85 [95% CI, 1.06-3.23], P=0.0308). Following SAVR, severe PPM in LF and low ejection fraction was associated with increased cardiac death (35.26% versus 12.51%, P=0.01) and rehospitalization (37.59% versus 15.46%, P=0.006) compared with severe PPM in LF and preserved ejection fraction, respectively. Severe PPM in normal flow was not associated with clinical outcomes despite higher gradients and smaller valves compared with severe PPM in LF.

CONCLUSIONS

Severe PPM is more common following SAVR compared with TAVR. Regardless of the implanted valve size or gradient, severe PPM impacts mortality only in patients with LF following TAVR and LF and low ejection fraction following SAVR. Severe PPM in normal flow is not associated with poor outcomes. Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01314313 and NCT02687035.

Quantitative assessment of aortic regurgitation following transcatheter aortic valve replacement

Introduction: Transcatheter aortic valve replacement (TAVR) is expanding to lower risk and younger patients with severe symptomatic aortic valve disease. Despite clinical and technological improvements, post-procedural aortic regurgitation (AR) remains a limitation of TAVR, particularly when compared to surgical aortic valve replacement. Although several methods for AR quantification after TAVR are currently available, its exact graduation in everyday clinical practice remains challenging.Areas covered: This review describes the currently available evaluation methods of AR after TAVR, with a special emphasis on the quantitative assessment using videodensitometric angiography, echocardiography and cardiac magnetic resonance imaging.Expert opinion: In the majority of clinical scenarios, satisfactory evaluation of post-TAVR AR can be achieved with a combination of post-procedural angiography, hemodynamic indices and transthoracic echocardiography. Nevertheless, some TAVR patients show 'intermediate' forms of post-procedural AR, in which quantitative evaluation is mandatory for prognostic purposes and further decision-making. Notably, interpretation of quantitative measures early post-TAVR is challenging because of the lack of left ventricular enlargement. Video-densitometric angiography is an emerging method that appears to be clinically attractive for immediate post-TAVR assessment, but requires further validation in everyday clinical practice.

Strategies for Recovering an Embolized Percutaneous Device

PURPOSE OF REVIEW

Device embolization is a rare but potentially life-threatening complication of transcatheter structural heart interventions and may require prompt intervention. The present work aims to provide an overview of strategies for device retrievals in order to better guide the evaluation and management of device embolization.

RECENT FINDINGS

Although the evolution of transcatheter device therapies has had a tremendous impact on the management in structural heart disease, availability of various retrieval devices, knowledge in how to use them, and multidisciplinary collaboration are key for successful device retrieval. Understanding the reasons for embolization, strategies to avoid embolization, and the techniques for retrieval of devices used in structural heart disease should be appreciated by the treating physician.

Prosthesis-Patient Mismatch After Aortic Valve Replacement in the PARTNER 2 Trial and Registry

OBJECTIVES

This study aimed to compare incidence and impact of measured prosthesis-patient mismatch (PPM_M) versus predicted PPM (PPM_P) after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR).

BACKGROUND

TAVR studies have used measured effective orifice area indexed (EOAi) to body surface area (BSA) to define PPM, but most SAVR series have used predicted EOAi. This difference may contribute to discrepancies in incidence and outcomes of PPM between series.

METHODS

The study analyzed SAVR patients from the PARTNER (Placement of Aortic Transcatheter Valves) 2A trial and TAVR patients from the PARTNER 2 SAPIEN 3 Intermediate Risk registry. PPM was classified as moderate if EOAi ≤0.85 cm²/m² (≤0.70 if obese: body mass index ≥30 kg/m²) and severe if EOAi ≤0.65 cm²/m² (≤0.55 if obese). PPM_M was determined by the core lab-measured EOAi on 30-day echocardiogram. PPM_P was determined by 2 methods: 1) using normal EOA reference values previously reported for each valve model and size (PPM_P1; n = 929 SAVR, 1,069 TAVR) indexed to BSA; and 2) using normal reference EOA predicted from aortic annulus size measured by computed tomography (PPM_P2; n = 864 TAVR only) indexed to BSA. Primary endpoint was the composite of 5-year all-cause death and rehospitalization.

RESULTS

The incidence of moderate and severe PPM_P was much lower than PPM_M in both SAVR (PPM_P1: 28.4% and 1.2% vs. PPM_M: 31.0% and 23.6%) and TAVR (PPM_P1: 21.0% and 0.1% and PPM_P2: 17.0% and 0% vs. PPM_M: 27.9% and 5.7%). The incidence of severe PPM_M and severe PPM_P1 was lower in TAVR versus SAVR (P < 0.001). The presence of PPM by any method was associated with higher transprosthetic gradient. Severe PPM_P1 was independently associated with events in SAVR after adjustment for sex and Society of Thoracic Surgeons score (hazard ratio: 3.18;95% CI: 1.69-5.96; P < 0.001), whereas no association was observed between PPM by any method and outcomes in TAVR.

CONCLUSIONS

EOAi measured by echocardiography results in a higher incidence of PPM following SAVR or TAVR than PPM based on predicted EOAi. Severe PPM_P is rare (<1.5%), but is associated with increased all-cause death and rehospitalization after SAVR, whereas it is absent following TAVR.

Doppler Velocity Index Outcomes Following Surgical or Transcatheter Aortic Valve Replacement in the PARTNER Trials

OBJECTIVES

The aim of this study was to assess the association between Doppler velocity index (DVI) and 2-year outcomes for balloon-expandable SAPIEN 3 transcatheter aortic valve replacement (TAVR) and for surgical aortic valve replacement (SAVR).

BACKGROUND

DVI >0.35 is normal for a prosthetic valve, but recent studies suggest that DVI <0.50 is associated with poor outcomes following TAVR.

METHODS

Patients with severe aortic stenosis enrolled in the PARTNER (Placement of Aortic Transcatheter Valve) 2 (intermediate surgical risk) or PARTNER 3 (low surgical risk) trial undergoing TAVR (n = 1,450) or SAVR (n = 1,303) were included. Patients were divided into 3 DVI groups on the basis of core laboratory-assessed discharge or 30-day echocardiograms: DVI_LOW (≤0.35), DVI_INTERMEDIATE (>0.35 to ≤0.50), and DVI_HIGH (>0.50). Two-year outcomes were assessed.

RESULTS

Following TAVR, there were no differences among the 3 DVI groups in composite outcomes of death, stroke, or rehospitalization or in any individual components of 2-year outcomes (P > 0.70 for all). Following SAVR, there was no difference among DVI groups in the composite outcome (P = 0.27), but there was a significant association with rehospitalization (P = 0.02). Restricted cubic-spline analysis for combined outcomes showed an increased risk with post-SAVR DVI ≤0.35 but no relationship post-TAVR. DVI ≤0.35 was associated with increased 2-year composite outcome for SAVR (HR: 1.81; 95% CI: 1.29-2.54; P < 0.001), with no adverse outcomes for TAVR (P = 0.86).

CONCLUSIONS

In intermediate- and low-risk cohorts of the PARTNER trials, DVI ≤0.35 predicted worse 2-year outcomes following SAVR, driven primarily by rehospitalization, with no adverse outcomes associated with DVI following TAVR with the balloon-expandable SAPIEN 3 valve.

Impact of paravalvular regurgitation on the mid-term outcome after transcatheter and surgical aortic valve replacement

OBJECTIVES

The aim of this study was to evaluate the incidence and prognostic impact of paravalvular regurgitation (PVR) on the outcome after transcatheter (TAVR) and surgical aortic valve replacement (SAVR) for aortic stenosis.

METHODS

The nationwide FinnValve registry included data on 6463 consecutive patients who underwent TAVR (n = 2130) or SAVR (n = 4333) with a bioprosthesis for the treatment of aortic stenosis during 2008-2017. The impact of PVR at discharge after TAVR and SAVR on 4-year mortality was herein investigated.

RESULTS

The rate of mild PVR was 21.7% after TAVR and 5.2% after SAVR. The rate of moderate-to-severe PVR was 3.7% after TAVR and 0.7% after SAVR. After TAVR, 4-year survival was 69.0% in patients with none-to-trace PVR, 54.2% with mild PVR [adjusted hazard ratio (HR) 1.64, 95% confidence interval (CI) 1.35-1.99] and 48.9% with moderate-to-severe PVR (adjusted HR 1.61, 95% CI 1.10-2.35). Freedom from PVR-related reinterventions was 100% for none-to-mild PVR and 95.2% for moderate-to-severe PVR. After SAVR, mild PVR (4-year survival 78.9%; adjusted HR 1.29, 95% CI 0.93-1.78) and moderate-to-severe PVR (4-year survival 67.8%; adjusted HR 1.36, 95% CI 0.72-2.58) were associated with worse 4-year survival compared to none-to-trace PVR (4-year survival 83.7%), but the difference did not reach statistical significance in multivariable analysis. Freedom from PVR-related reinterventions was 99.5% for none-to-trace PVR patients, 97.9% for mild PVR patients and 77.0% for moderate-to-severe PVR patients.

CONCLUSIONS

This multicentre study showed that both mild and moderate-to-severe PVR were independent predictors of worse survival after TAVR. Mild and moderate-to-severe PVR are not frequent after SAVR, but tend to decrease survival also in these patients.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03385915.

Mortality in trials on transcatheter aortic valve implantation versus surgical aortic valve replacement: a pooled meta-analysis of Kaplan-Meier-derived individual patient data

OBJECTIVES

This meta-analysis of Kaplan-Meier-estimated individual patient data was designed to evaluate the effects of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) on the long-term all-cause mortality rate, to examine the potential time-varying effect and to model their hazard ratios (HRs) over time. Moreover, we sought to compare traditional meta-analytic tools and estimated individual patient data meta-analyses.

METHODS

Trials comparing TAVI versus SAVR were identified through Medline, Embase, Cochrane databases and specialist websites. The primary outcome was death from any cause at follow-up. Enhanced secondary analyses of survival curves were performed estimating individual patient time-to-event data from published Kaplan-Meier curves. Treatments were compared with the random effect Cox model in a landmark framework and fully parametric models.

RESULTS

We identified 6 eligible trials that included 6367 participants, randomly assigned to undergo TAVI (3252) or SAVR (3115). According to the landmark analysis, the incidence of death in the first year after implantation was significantly lower in the TAVI group [risk-profile stratified HR 0.85, 95% confidence interval (CI) 0.73-0.99; P = 0.04], whereas there was a reversal of the HR after 40 months (risk-profile stratified HR 1.31, 95% CI 1.01-1.68; P = 0.04) favouring SAVR over TAVI. This time-varying trend of HRs was also confirmed by a fully parametric time-to-event model. Traditional meta-analytic tools were shown to be biased because they did not intercept heterogeneity and the time-varying effect.

CONCLUSIONS

The mortality rates in trials of TAVI versus SAVR are affected by treatments with a time-varying effect. TAVI is related to better survival in the first months after implantation whereas, after 40 months, it is a risk factor for all-cause mortality.

Long-Term Prognostic Value of the Society of Thoracic Surgery Risk Score in Patients Undergoing Transcatheter Aortic Valve Implantation (From the OCEAN-TAVI Registry)

The Society of Thoracic Surgeons (STS) risk model, designed to predict operative mortality after cardiac surgery, is often used for the risk assessment of patients considered for transcatheter aortic valve implantation (TAVI). We investigated the long-term prognostic value of the STS score by utilizing the data of 2588 patients undergoing TAVI from the OCEAN (Optimized CathEter vAlvular iNtervention)-TAVI Japanese multicenter registry. The patients were divided into 3 groups according to their pre-procedural STS score as follows: low-risk (STS score <4%, n = 467 [18%]), intermediate-risk (4%≤ STS score <8%, n = 1200 [46.4%]), and high-risk (8%≤ STS score, n = 921 [35.6%]). Low-risk patients were younger and were more frequently male. The prevalence of most of the comorbidities were higher in high-risk patients, while active cancer was more frequent in low-risk patients (p <0.001).The cumulative 4-year all-cause mortality rates were higher in high-risk patients (49.0%) but comparable in low-risk (22.6%) and intermediate-risk patients (28.7%) (hazard ratio [HR] for intermediate-risk versus low-risk, 1.03; 95% confidence interval [CI], 0.77 to 1.37; p = 0.85; HR for high-risk versus low-risk, 2.27; 95% CI 1.72 to 2.99; p = <0.001). Similarly, the cumulative 4-year cardiovascular mortality rates were higher in high-risk patients (20.5%) but comparable in low-risk (9.9%) and intermediate-risk patients (10.3%) (HR for intermediate-risk versus low-risk, 1.10; 95% CI, 0.68 to 1.77; p = 0.69; HR for high-risk versus low-risk, 2.33; 95% CI 1.48 to 3.67; p = <0.001). After adjustment for several confounders, STS score ≥8% was independently associated with increased long-term mortality (HR, 1.35; 95% CI, 1.08 to 1.68). In conclusion, the risk stratification according to STS score demonstrated an increased risk of long-term mortality after TAVI in high-risk patients, albeit with comparable risks in intermediate- and low-risk patients.

Predictors of Early Stroke or Death in Patients Undergoing Transcatheter Aortic Valve Implantation

BACKGROUND/OBJECTIVE

While postoperative stroke is a known complication of Transcatheter Aortic Valve Implantation (TAVI), predictors of early stroke occurrence have not been specifically reviewed. The objective of this study was to estimate the predictors and incidence of stroke during the first 30 days post-TAVI.

METHODS

A cohort of 506 consecutive patients having undergone TAVI between January 2017 and June 2019 was extracted from a prospective database. Preoperative, intraoperative and postoperative characteristics were analyzed by univariate analysis followed by logistic regression to find predictors of the occurrence of stroke or death within the first 30 days after the procedure.

RESULTS

Incidence of stroke within 30 days post-TAVI was 4.9%, [CI 95% 3.3-7.2], i.e., 25 strokes. Four out of the 25 patients (16%) with a stroke died within 30 days post-TAVI. After logistic regression analysis, the predictors of early stroke related to TAVI were: CHA2Ds2VASc score ≥ 5 (odds ratio [OR] 2.62; 95% CI: 1.06-6.49; p = .037), supra-aortic access vs. femoral access (OR: 9.00, 95%CI: 2.95-27.44; p = .001) and introduction post-TAVI of a single vs. two or three antithrombotic agents (OR: 5.13; CI 95%: 1.99 to 13.19; p = .001). Over the 30-day period, bleeding occurred in 28 patients (5.5%), in 25 of whom, it was associated with femoral or iliac artery access injury. Anti-thrombotic regimen was not associated with bleeding; two patients out of 48 (4.1%) bled with a single anti-thrombotic regimen vs. 26 patients out of 458 (5.6%) with a dual or triple anti-thrombotic regimen (p = 0.94). The overall 30-day mortality rate was 3.9%, [95% CI 2.5-6.0]. Patients with a single post-TAVI antithrombotic agent (OR: 44.07 [CI 95% 13.45-144.39]; p < .0001) and patients with previous coronary artery bypass surgery or coronary artery stenting (OR: 6.16, [CI 95% 1.99-21.29]; p = .002) were at significantly higher risk of death within the 30-day period.

CONCLUSION

In this large-scale single-center retrospective study, a single post-TAVI antithrombotic regimen independently predicted occurrence of early stroke or death. Dual or triple antithrombotic regimen was not associated with a higher risk of bleeding and should be considered as an option in patients undergoing TAVI.

Balloon post-dilatation improves long-term valve performance after balloon-expandable valve implantation

BACKGROUND

The impact of balloon post-dilatation (BPD) on short- and long-term valve performance after Sapien 3 (S3) implantation is unknown. This study aimed to evaluate the impact of balloon post-dilatation (BPD) on short- and long-term valve performance after the implantation of S3.

METHODS

A total of 846 patients implanted with S3 from the OCEAN-TAVI registry were included in this study. The patients were divided into BPD and non-BPD groups. The clinical outcomes and valve functions were compared.

RESULTS

The BPD group included 173 (20.4%) patients and the non-BPD group comprised 673 (79.6%) patients. The prosthesis-patient mismatch (PPM) rates were significantly lower in the BPD group than in the non-BPD group before and after propensity score matching at in-hospital follow-up (before matching: 12 [7.1%] vs. 108 [16.3%], p = 0.002; after matching: 8 [6.3%] vs. 19 [14.8%], p = 0.027) and at 1-year follow-up (before matching: 14 [12.5%] vs. 112 [23.6%], p = 0.010; after matching: 9 [10.5%] vs. 19 [22.1%], p = 0.039). The rates of acute kidney injury, cardiac tamponade, and in-hospital cardiovascular death were significantly higher in the BPD group than in the non-BPD group (acute kidney injury: 22 [12.7%] vs. 33 [4.9%], p < 0.001; cardiac tamponade: 3 [1.7%] vs. 2 [0.3%], p = 0.028; in-hospital cardiovascular death: 4 [2.3%] vs. 3 [0.4%], p = 0.016). After matching, these clinical outcomes were similar between the BPD and non-BPD groups.

CONCLUSIONS

The BPD group demonstrated better short- and long-term valve performance. Caution is needed to avoid procedure-related complications in patients undergoing BPD.