A review of most relevant complications of transcatheter aortic valve implantation

Cardiovascular outcomes of emergent vs elective transcatheter aortic valve replacement in severe aortic stenosis: regression matched meta-analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has been highly increased as the recommended option for patients with a high surgical risk. This study aims to commit a systematic review and meta-analysis to assess the outcomes in severe aortic stenosis patients following emergency transcatheter aortic valve replacement (emergent TAVR) compared to elective TAVR or eBAV followed by elective TAVR.

METHODS

We conducted a systematic literature search of PubMed, Embase, Cochrane CENTRAL, CINAHL, Science Direct, and Google Scholar. We included nine studies in the latest analysis that reported the desired outcomes. Outcomes were classified into primary outcomes: 30-day all-cause mortality and 30-day readmission rate, and secondary outcomes, which were further divided into (a) peri-procedural outcomes, (b) vascular outcomes, and (c) renal outcomes. Statistical analysis was performed using Stata v.17 (College State, TX) software.

RESULTS

A total of 44,731 patients with severe aortic stenosis were included (emergent TAVR n = 4502; control n = 40045). 30-day mortality was significantly higher in the emergent TAVR group (OR: 2.62; 95% CI = 1.76-3.92; P < 0.01). Regarding post-procedural outcomes, the length of stay was significantly higher in the emergent TAVR group (Hedges's g: +4.73 days; 95% CI = +3.35 to +6.11; P < 0.01). With respect to vascular outcomes, they were similar in both groups. Regarding renal outcomes, both acute kidney injury (OR: 2.52; 95% CI = 1.59-4.00; P < 0.01) and use of renal replacement therapy (OR: 2.33; 95% CI = 1.87-2.91; P < 0.01) were significantly higher in emergent TAVR group as compared to the control group.

CONCLUSION

Our study demonstrated that despite increased 30-day mortality and worse renal outcomes, the post-procedural outcomes were similar in emergent and elective TAVR groups. The increased mortality and worse renal outcomes are likely due to hemodynamic instability in the emergent group. The similarity of post-procedural outcomes is evidence of the safety of TAVR even in emergent settings.

Safety and performance of the Vienna self-expandable transcatheter aortic valve system: 6-month results of the VIVA first-in-human feasibility study

Background

The novel Vienna TAVI system is repositionable and retrievable, already pre-mounted on the delivery system, eliminating the need for assembly and crimping of the device prior to valve implantation.

Aims

The purpose of this first-in-human feasibility study was to determine the safety, feasibility, clinical and hemodynamic performance of the Vienna TAVI system at 6-month follow-up. (ClinicalTrials.gov identifier NCT04861805).

Methods

This is a prospective, non-randomized, single-arm, single-center, first-stage FIH feasibility study, which is followed by a second-stage pivotal, multicenter, multinational study in symptomatic patients with severe aortic stenosis (SAS). The first-stage FIH study evaluated the safety and feasibility, clinical and hemodynamic performance of the device in 10 patients with SAS based on recommendations by the VARC-2.

Results

All patients were alive at 3-month follow-up. 1 non-cardiovascular mortality was reported 5 months after implantation. There were no new cerebrovascular events, life-threatening bleeding or conduction disturbances observed at 6-month follow-up. The mean AV gradient significantly decreased from 48.7 ± 10.8 to 7.32 ± 2.0 mmHg and mean AVA increased from 0.75 ± 0.18 to 2.16 ± 0.42 cm² (p < 0.00001). There was no incidence of moderate or severe total AR observed. In the QoL questionnaires, the patients reported a significant improvement from the baseline 12-KCCQ mean score 58 ± 15 to 76 ± 20. NYHA functional class improved in two patients, remained unchanged in one patient. There was an increase in mean 6-min-walk distance from baseline 285 ± 97 to 347 ± 57 m.

Conclusions

This study demonstrates that using Vienna TAVI system has favourable and sustained 6-month safety and performance outcomes in patients with symptomatic severe aortic stenosis.

Detrimental consequences after intimal disruption of subclavian artery during transcathether aortic valve implantation

BACKGROUND

TAVI via the left subclavian artery is considered a bail-out strategy in cases where a transfemoral approach is not feasible. However, since this route is only scarcely used, major complications can arise. We describe such an adverse course and present our proceeding.

CASE PRESENTATION

A 65-year-old man with severe aortic valve stenosis (AS) was referred for transcatheter aortic valve implantation (TAVI) via left subclavian artery. After uneventful deployment of the TAVI prosthesis, consequent valve assessment with transeosophageal echocardiography and angiography showed a highly mobile and tubular structure shifting within the valve. We went for a surgical extraction via sternotomy on cardiopulmonary bypass (CPB). A 6 cm longish intimal cylinder was hassle-free extracted. 4 days postoperatively the left sided radial pulse was missing. In a subsequent computed tomography angiography (CTA) scan a proximal dissection as well as an intimal flap, causing a subtotal stenosis of the left subclavian artery, was detected. Consecutively the intimal cylinder was removed using a Fogarty-balloon. Pre-discharge control revealed recurrence of peripheral radial pulse and an unimpeded function of the TAVI prosthesis. The patient presented no sequela at discharge.

CONCLUSION

Though TAVI is a well-advanced technique complications are not completely avertable. It is thus advisable to have patients discussed in the heart team encompassing all potentially involved specialties.

A European update on transcatheter aortic valve implantation (TAVI) in the COVID era

Minimally invasive approaches for aortic valve replacement are now at the forefront of pathological aortic valve treatment. New trials show comparability of these devices to existing therapies, not only in high-risk surgical cohorts but also in low-risk and intermediate-risk cohorts. This review provides vital clinical and anatomical background to aortic valvular disease treatment guidelines, while also providing an update on transcatheter aortic valve implantation (TAVI) devices in Europe, their interventional trials and associated complications.

30-Day and 1-Year Outcomes With HYDRA Self-Expanding Transcatheter Aortic Valve: The Hydra CE Study

OBJECTIVES

This study sought to evaluate the 30-day and 1-year safety and performance of the Hydra transcatheter aortic valve (THV) (in the treatment of symptomatic severe aortic stenosis in patients at high or extreme surgical risk.

BACKGROUND

The Hydra THV is a novel repositionable self-expanding system with supra-annular bovine pericardial leaflets.

METHODS

The Hydra CE study was a premarket, prospective, multicenter, single-arm study conducted across 18 study centers in Europe and Asia-Pacific countries. The primary endpoint was all-cause mortality at 30 days. All endpoints were adjudicated by an independent clinical events committee.

RESULTS

A total of 157 patients (79.2 ± 7.1 years of age, 58.6% female; Society of Thoracic Surgeons score 4.7 ± 3.4%) were enrolled. Successful implantation was achieved in 94.3% cases. At 30 days, there were 11 (7.0%) deaths, including 9 (5.7%) cardiovascular deaths, of which 5 (3.2%) were device related. At 1 year, there were 23 (14.6%) deaths, including 13 (8.3%) cardiovascular deaths. At 30 days, there were significant improvement of effective orifice area (from 0.7 ± 0.2 cm² to 1.9 ± 0.6 cm²) and mean aortic valve gradient (from 49.5 ± 18.5 mm Hg to 8.1 ± 3.7 mm Hg), which were sustained up to 1 year. Moderate or severe paravalvular leak was observed in 6.3% of patients at 30 days and 6.9% of patients at 1 year. The rate of new permanent pacemaker implantation was 11.7% at 30 days and 12.4% at 1 year.

CONCLUSIONS

The Hydra CE study demonstrated that transcatheter aortic valve replacement with Hydra THV offered favorable efficacy at 1 year, providing large effective orifice area and low transvalvular gradient as well as acceptable complication rates with regard to new permanent pacemaker and paravalvular leak. (A Clinical Evaluation of the HYDRA Self Expanding Transcatheter Aortic Valve; NCT02434263).

Comparing Single- and Dual Antiplatelet Therapies Following Transcatheter Aortic Valve Implantation

BACKGROUND

Transcatheter aortic valve implantation has been an established treatment in patients with symptomatic severe aortic stenosis. However, the postoperative antiplatelet regimen after transcatheter aortic valve implantation was not established certainly. The aim of this meta-analysis is to compare the safety and efficacy of single- (SAPT) and dual-antiplatelet therapies (DAPT) in patients undergoing transcatheter aortic valve implantation.

METHODS

Eligible randomized controlled trials and cohort studies published before February 2021 were retrieved from PubMed, Embase, and the Cochrane Library. We calculated odds ratios with 95% confidence intervals.

RESULTS

Nine articles, involving 19,277 patients, met the selection criteria. In the short-term outcome, compared with SAPT, DAPT was associated with a significantly higher rate of bleeding (odds ratios, 95% confidence intervals: 3.00, 1.67-5.38) and showed no significant differences in thrombotic events (odds ratios, 95% confidence intervals: 1.25, 0.74-2.11) and all-cause mortality (odds ratios, 95% confidence intervals: 0.84; 0.42-1.69). In the long-term outcome, DAPT was associated with a significantly higher bleeding rate (odds ratios, 95% confidence intervals: 1.85, 1.24-2.78) and showed no differences in thrombotic events (odds ratios, 95% confidence intervals: 1.13, 0.86-1.48) and all-cause mortality (odds ratios, 95% confidence intervals: 1.12, 0.95-1.32). Our trial sequential analysis confirmed DAPT didn't confer any benefit for reducing all-cause mortality and thrombotic events, and carried a higher risk of bleeding than SAPT.

CONCLUSIONS

SAPT should be a sufficient antiplatelet strategy in post- transcatheter aortic valve implantation patients without indications for oral anticoagulation medication, especially in the long-term follow-up period.

How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement

PURPOSE OF REVIEW

In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications.

RECENT FINDINGS

Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.

Transcatheter Aortic Valve Replacement in Rheumatic Aortic Stenosis: A Comprehensive Review

Rheumatic heart disease (RHD) mainly affects people in developing, low-income countries. However, due to globalization and migration, developed countries are now seeing more cases of RHD. In RHD patients who develop severe symptomatic aortic stenosis, surgical aortic valve replacement remains the treatment of choice. In the past decade, there has been an extension of transcatheter aortic valve replacement (TAVR) to intermediate-risk and lower-risk patients with aortic stenosis. This review suggests the possible utility of TAVR for the treatment of rheumatic aortic stenosis. Rheumatic aortic stenosis has been excluded from major TAVR studies due to the predominantly noncalcific pathology of the rheumatic aortic valve. However, there have been case reports and case series showing successful implantation of the valve even in patients with and without significant leaflet calcification. In this review article, we summarize the latest evidence of severe rheumatic aortic stenosis treated with TAVR and discuss the procedure's impact on patient care, safety, and efficacy.

Sutureless and Transcatheter Aortic Valve Replacement: When Rivals Become Allies

In recent years, sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve replacement (TAVR) have emerged as viable alternatives to standard surgical aortic valve replacement (AVR) in higher risk patients. We report 7 cases in which SU-AVR and TAVR were used as bailout procedures for each other. Between June 2011 and August 2018, 626 patients underwent SU-AVR with the Perceval S prosthesis, and 588 patients underwent TAVR at the Montreal Heart Institute. Herein, we report the cases of 7 patients who underwent both procedures within a short time frame: 3 patients who underwent SU-AVR with a Perceval prosthesis after a failed TAVR procedure, 3 patients who underwent TAVR after degeneration of a surgically implanted Perceval sutureless prosthesis, and 1 patient who was scheduled for multiple percutaneous interventions-including TAVR, right coronary angioplasty, atrial fibrillation ablation with left atrial appendage occlusion-who suffered a periprocedural complication requiring an emergent surgery, during which a Perceval sutureless prosthesis was deployed. All patients were discharged home alive. Two patients suffered a complete heart block requiring permanent pacemaker implantation. We demonstrate that SU-AVR with the Perceval S prosthesis and TAVR are complementary procedures within the therapeutic armamentarium to treat aortic valve disease in higher risk patients. Specifically, valve-in-valve TAVR is an attractive option in the setting of Perceval prosthesis degeneration, whereas SU-AVR is a useful bailout option in the context of periprocedural failure of a TAVR.

Regional differences in aortic valve replacements: Atlantic Canadian experience

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is evolving rapidly and is increasingly being adopted in the treatment of aortic valve disease. The goal of this study was to examine regional differences in surgical aortic valve replacement (SAVR) and TAVI across Atlantic Canada.

METHODS

We identified all patients who underwent SAVR or TAVI between Jan. 1, 2010, and Dec. 31, 2014, in New Brunswick, Nova Scotia and Newfoundland and Labrador. Data obtained included patient demographic characteristics and surgical procedure details. We performed univariate descriptive analyses and calculated crude and age- and sex-adjusted incidence rates.

RESULTS

A total of 3042 patients underwent SAVR or TAVI during the study period, 1491 in Nova Scotia, 1042 in New Brunswick and 509 in Newfoundland and Labrador. Patient demographic characteristics were similar across regions. A much higher proportion of patients in Newfoundland and Labrador (43.6%) than in Nova Scotia (4.2%) or New Brunswick (13.6%) received a mechanical versus a bioprosthetic valve. Rates of TAVI increased over the study period, with New Brunswick adopting their program before Nova Scotia (144 v. 74 procedures). Adjusted rates of all AVR procedures remained stable in Nova Scotia (40-50 per 100 000 people). Adjusted rates were lower in New Brunswick and Newfoundland and Labrador than in Nova Scotia; they increased slowly in New Brunswick over the study period.

CONCLUSION

Despite geographical proximity and similar patient demographic characteristics, there existed regional differences in the management of aortic valve disease within Atlantic Canada. Further study is required to determine whether the observed differences in age- and sex-adjusted rates of AVR may be explained by geographical disease-related differences, varying practice patterns or barriers in access to care.

Cardiac Tamponade and Complete Heart Block During Transcatheter Aortic Valve Implantation: A Simulation Scenario for Anesthesia Providers

Introduction

This simulation on cardiac tamponade and complete heart block in the context of severe aortic stenosis presents the learner with a rare (cardiac tamponade) and a common (complete heart block) complication in the intraoperative setting of transfemoral aortic valve implantation in a high-fidelity, low-risk simulation environment. Based on an amalgam of index cases, the simulation was developed to address a recognized area of need for cardiothoracic anesthesia scenarios in the simulation curriculum of our home institution.

Methods

The simulation case file covered the case narrative, learning objectives, a summary of critical actions performed, and supplemental figures needed to complete the educational activity. A high-fidelity patient simulator, an anesthesia machine, monitors, and a computer capable of displaying standard computer slide presentation software and movie files provided the optimal environment for simulation.

Results

Fifteen anesthesia residents experienced the simulation over the 2016-2017 and 2017-2018 academic years. The trainees who experienced this simulation improved their understanding of tamponade hemodynamic pathophysiology and recognition of hemodynamically unstable bradycardia.

Discussion

This case has been an effective addition to the repertoire of simulation scenarios at the University of Iowa and has been incorporated into the general curriculum of simulation cases for mid-training junior and senior anesthesia residents.

Impact of gender on outcomes after transcatheter aortic valve implantation

Backgound

The influence of gender on clinical outcomes following transcatheter aortic valve implantation (TAVI) was considerably discrepant in previous studies. We aimed to investigate the impact of gender in our registry.

Methods

The study is a retrospective observational analysis of a prospectively designed cohort (546 consecutive patients treated at the University Hospital Zurich who were enrolled in Swiss TAVI Cohort from May 2008 to April 2014). The Study took place in University Heart Centre at University Hospital Zurich, Switzerland.

Results

Both genders were equally represented with 51.5 % (n = 281) of the populations being females, who were significantly older and had a more pronounced history of hypertension (P < 0.001). Males on the other hand showed a higher incidence of diabetes (P = 0.004), coronary artery disease (P < 0.001), chronic obstructive pulmonary disease (P < 0.001) and renal failure requiring renal replacement therapy (P = 0.018). Patients were followed up for a median of 391 days with a 100% complete follow-up at one year. The primary outcome (all-cause mortality) occurred in 6.8% (n = 37) and 15% (n = 82) of patients at 30 days and one year, respectively. The 30-day all-cause mortality outcome did not significantly differ between females (7.5%) and males (6.0%) (P = 0.619), but one year all-cause mortality occurred significantly more in males than in females (18.7% vs. 11.7%, P < 0.037).

Conclusion

After TAVI implantation for severe aortic stenosis, males have a less favorable long-term (one year) mortality outcome than females.

Factors associated with early cardiac complications following transcatheter aortic valve implantation with transapical approach

Purpose

To estimate the incidence of postprocedural early cardiac complications among patients undergoing transcatheter aortic valve implantation, through transapical approach (TA-TAVI), and to identify factors independently associated with the occurrence of them.

Patients and methods

A retrospective cohort study of 90 patients, who had undergone TA-TAVI in a tertiary hospital of Liverpool, UK, during a 5-year period (September 2008–October 2013), was conducted. Data on patient demographics, periprocedural characteristics and cardiac complications presented within 30-day post TA-TAVI were collected, retrospectively, using the hospital’s electronic database.

Results

The overall 30-day incidence of cardiac complications was estimated at 18.9% (n=17/90). The rate of new onset of atrial fibrillation (AF), atrioventricular block requiring permanent pacemaker implantation, shockable cardiac arrest rhythm and cardiac tamponade was 11.1%, 3.3%, 2.2% and 2.2%, respectively. Bivariate analysis found that absence of preoperative AF (p=0.01), receiving of oral inotropes preprocedurally (p=0.01), intravenous inotropic support postprocedurally (p=0.01) and requirement for postprocedural tracheal intubation (p=0.001) were the main factors associated with increased probability for patient cardiac morbidity.

Conclusion

It seems that patients with absence of AF and oral inotropic support preprocedurally and those with post TA-TAVI mechanical ventilatory and intravenous inotropic support have greater probability to develop cardiac complications. This knowledge allows the early identification of high-risk patients and supports clinicians to apply both preventive and therapeutic interventions for the optimum patient management and care. In addition, administrators could allocate the health care system resources effectively.

Analysis of cardiovascular mortality, bleeding, vascular and cerebrovascular events in patients with atrial fibrillation vs. sinus rhythm undergoing transfemoral Transcatheter Aortic Valve Implantation (TAVR)

Background

Transcatheter aortic valve replacement (TAVR) has been demonstrated to be an established therapy for high-risk, inoperable patients with severe symptomatic aortic valve stenosis. For patients with moderate surgical risk, TAVR is equivalent to conventional aortic valve surgery. However, atrial fibrillation (AF) is also present in many of these patients, thus requiring post-implantation oral anticoagulation therapy in addition to the inhibition of thrombocyte aggregation, which poses the risk of bleeding complications. The aim of our work was to investigate the influence of AF on mortality and the occurrence of bleeding, vascular and cerebrovascular complications related to TAVR according to the VARC-2 criteria.

Methods

Two hundred eighty-three patients who underwent TAVR between March 2010 and April 2016 were retrospectively examined. In total, 257 patients who underwent transfemoral access were included in this study. The mean patient age was 81 ± 6 years, 54.1% of the patients were women, and 42.4% had pre-interventional AF.

Results

Compared to patients with sinus rhythm (SR, n = 148), patients with AF (n = 109) had an almost three-fold higher incidence of major vascular complications (AF 14.7% vs. SR 5.4%, p = 0.016) and life-threatening bleeding (AF 11.9% vs. SR 4.1%, p = 0.028) during the first 30 post-procedural days. However, the rate of cerebrovascular complications (AF 3.7% vs. SR 2.7%, p = 0.726) did not significantly differ between the two groups. Overall mortality was significantly higher in patients with AF during the first month (AF 8.3% vs. SR 2.0%, p = 0.032) and the first year (AF 28.4% vs. SR 15.3%; p = 0.020) following TAVR.

Conclusion

Patients with AF had significantly more severe bleeding complications after TAVR, which were significantly related to mortality. Future prospective randomized studies must clarify the optimal anticoagulation therapy for patients with AF after TAVR.

Trial registration

DRKS00011798 on DRKS (Date 17.03.2017).

Acute kidney injury post-transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a treatment option in high-risk patients with severe aortic stenosis who are not surgical candidates. In light of emerging evidence, it is being increasingly performed even in intermediate-risk patients in recent years. Patients who develop acute kidney injury (AKI) following TAVR are known to have worse outcomes. The objective of this concise review was to identify the prevalence and the impact of AKI following TAVR on patient outcomes by including the most recent literature in our search. After a thorough search on MEDLINE, Google Scholar, and PubMed, we included all literature relevant to AKI following TAVR. We found that AKI was caused by a variety of reasons, such as hemodynamic instability during rapid pacing, blood transfusion, periprocedural embolization, and use of contrast medium, to name a few. In patients who developed AKI following TAVR, 30-day and 1-year mortality were increased. Further, in these patients, length and cost of hospital stay were increased as well. Preventive measures such as optimal periprocedural hydration, careful contrast use, and techniques to prevent embolization during device implantation have been tried with limited success. Given that TAVR is expected to be increasingly performed, this review aimed to summarize the rapidly expanding currently available literature in an effort to reduce procedural complications and thereby improve patient outcomes.

Permanent Pacing After Transcatheter Aortic Valve Implantation: Incidence, Predictors and Evolution of Left Ventricular Function

Background

Transcatheter aortic valve implantation (TAVI) is a well-established procedure; however, atrioventricular block requiring permanent pacemaker implantation (PPI) is a common complication.

Objectives

To determine the incidence, predictors and clinical outcomes of PPI after TAVI, focusing on how PPI affects left ventricular ejection fraction (LVEF) after TAVI.

Methods

The Brazilian Multicenter TAVI Registry included 819 patients submitted to TAVI due to severe aortic stenosis from 22 centers from January/2008 to January/2015. After exclusions, the predictors of PPI were assessed in 670 patients by use of multivariate regression. Analysis of the ROC curve was used to measure the ability of the predictors; p < 0.05 was the significance level adopted.

Results

Within 30 days from TAVI, 135 patients (20.1%) required PPI. Those patients were older (82.5 vs. 81.1 years; p = 0.047) and mainly of the male sex (59.3% vs 45%; p = 0.003). Hospital length of stay was longer in patients submitted to PPI (mean = 15.7 ± 25.7 vs. 11.8 ± 22.9 days; p < 0.001), but PPI affected neither all-cause death (26.7% vs. 25.6%; p = 0.80) nor cardiovascular death (14.1% vs. 14.8%; p = 0.84). By use of multivariate analysis, the previous presence of right bundle-branch block (RBBB) (OR, 6.19; 3.56-10.75; p ≤ 0.001), the use of CoreValve^® prosthesis (OR, 3.16; 1.74-5.72; p ≤ 0.001) and baseline transaortic gradient > 50 mm Hg (OR, 1.86; 1.08-3.2; p = 0.025) were predictors of PPI. The estimated risk of PPI ranged from 4%, when none of those predictors was present, to 63%, in the presence of all of them. The model showed good ability to predict the need for PPI: 0.69 (95%CI: 0.64 - 0.74) in the ROC curve. The substudy of 287 echocardiograms during the 1-year follow-up showed worse LVEF course in patients submitted to PPI (p = 0.01).

Conclusion

BRD prévio, gradiente aórtico médio > 50 mmHg e CoreValve® são preditores independentes de implante de MPD pós-TAVI. Ocorreu implante de MPD em aproximadamente 20% dos casos de TAVI, o que prolongou a internação hospitalar, mas não afetou a mortalidade. O implante de MPD afetou negativamente a FEVE pós-TAVI.

Outcomes of Aortic Valve Replacement According to Surgical Approach in Intermediate and Low Risk Patients: A Propensity Score Analysis

BACKGROUND

Previous trials have shown that, among high-risk patients with aortic stenosis, survival rates are similar for transcatheter aortic-valve implantation (TAVI) and surgical aortic valve replacement. The study aimed to compare the outcomes of aortic valve replacement according to the adopted surgical approach in intermediate and low risk patients.

METHODS

This is a retrospective, observational, cohort study of prospectively collected data from 421 patients undergoing isolated aortic valve replacement between 2011 and 2015. A multinomial logit propensity score model based on preoperative risk factors was used to match patients 1:1:1 between conventional replacement (CAVR), minimally invasive (MIAVR) and TAVI groups, resulting in 50 matched three cohorts.

RESULTS

After multinomial logit propensity score, the three groups were comparable in terms of preoperative characteristics. Mean age and Logistic EuroSCORE I of CAVR, MIAVR and TAVI groups were (84.2±5.1 vs. 82.3±4.8 vs. 85.6±4.9 years; p=0.002) and (11.4±3.6% vs. 8.3±3.4% vs. 15.8±5.4%; p<0.001) respectively. Overall mortality rates were similar for the three patient cohorts at one year. There were no significant differences related to stroke to 30 days. In the TAVI cohort, pacemaker implantation for new-onset total atrioventricular block became necessary in 30% of patients (p<0.001) and 16% of patients had some degree of paravalvular aortic regurgitation, which was more than mild (p<0.001). Total length of stay was shorter in the TAVI group when compared with surgical groups (11.5±5.3 vs. 10.1±6.9 vs 8.5±3.7 days; p=0.023). After discharge, the survival rate follow-up (average follow up: 46.7 months) was 70%, 84% and 72% for three cohorts (log Rank x²=2.40, p=0.3).

CONCLUSIONS

In our experience, the three aortic valve replacement approaches offer very good results. Differences in the rate of complications were found between groups. Depending on patient's characteristics the Heart-Team group must offer the best surgical approach for each patient.

A New Experimental Device for Transapical Access of the Aortic and Mitral Valves as well as the Aorta in its Various Segments

Objective

To present the results of a new experimental device developed to facilitate the transapical access in endovascular treatment of structural heart diseases. It aims to reduce the risk of bleeding and complications in this type of access and demonstrate the device as a safe, fast and effective alternative.

Methods

CorPoint is composed of three parts: introducer, base with coiled spring, and closing capsule. By rotating movements, the spring is introduced into the myocardium and progressively approaches the base to the surface of the heart. Guidewires and catheters are inserted through the hollow central part and, at the end of the procedure, the capsule is screwed over the base, therefore stopping any bleeding.

Results

The device was implanted in 15 pigs, weighing 60 kg each, through an anterolateral thoracotomy, while catheters were introduced and guided by fluoroscopy. All animals had minimal bleeding; introducers with diameter up to 22 Fr were used and various catheters and guidewires were easily handled. After finishing the procedure, the closing capsule was attached and no bleeding was observed at the site.

Conclusion

This new device has proved effective, fast and secure for the transapical access. This shows great potential for use, especially by ensuring an easier and direct access to the mitral and aortic valves; the shortest distance to be traveled by catheters; access to the ascending and descending aorta; decreased bleeding complications; decreased surgical time; and the possibility of allowing the technique to evolve and become totally percutaneous.

Increased mortality from complications of pulmonary hypertension in patients undergoing transcatheter aortic valve replacement

Aortic stenosis (AS) leads to pulmonary hypertension (PH) and right ventricle (RV) failure. Our goal was to describe mortality related to postoperative complications in PH patients undergoing transcatheter aortic valve replacement (TAVR). Ninety-three TAVR patients were analyzed (controls, sPAP < 50 mmHg; cases, sPAP ≥ 50 mmHg). Significant findings in cases included increased mortality (365 days), post-TAVR atrioventricular block (AVB) and acute kidney injury (AKI), and increased mean length of stay (LOS). This novel study highlights complications of PH as independent risk factors for death and significant morbidity post TAVR. Optimization of preoperative volume status and RV afterload reduction, while addressing AVB and AKI, may play a vital role in reducing mortality and LOS.

Correlation between structural changes and acute thrombogenicity in transcatheter pericardium valves after crimping and balloon deployment

INTRODUCTION

Transcathether heart valve replacement has gained considerable acceptance during the last decades. It is now part of the armamentarium for aortic valve replacement. The procedure proved to be highly efficient. However the issues of the blood compatibility and tissue durability were not raised and the adverse events were probably under-reported, according to observations of thrombosis after deployment.

MATERIAL AND METHOD

Bovine pericardium leaflets were sewn inside a 26mm diameter stainless steel stent to manufacture these valves (one control and two experimental). The correlation between the trauma and the acute thombogenicity of bovine pericardium leaflets, after crimping and ballooning, was investigated via an in vitro blood flow with labeled platelets. These leaflets were processed for histology: scanning electron microscopy, light microscopy, and transmission electron microscopy.

RESULTS

The control specimens showed a regular pericardium structure with some blood cells deposited on the collagen fibrous surface (inflow) and scarce blood cells deposited on the serous surface (outflow). After crimping and ballooning, the structure of the pericardium was severely injured, eventually with delaminations and ruptures. The blood cell uptake was considerably increased compared to the control.

CONCLUSION

It would therefore be appropriate to pay more attention to the design of the valves. Specifically, the incorporation of a buffer tissue or fabric between the pericardium and the metallic stent is suggested. The issue of ballooning deserves detailed and in depth investigation regarding the lifetime of the device.

On the Mechanics of Transcatheter Aortic Valve Replacement

Transcatheter aortic valves (TAVs) represent the latest advances in prosthetic heart valve technology. TAVs are truly transformational as they bring the benefit of heart valve replacement to patients that would otherwise not be operated on. Nevertheless, like any new device technology, the high expectations are dampened with growing concerns arising from frequent complications that develop in patients, indicating that the technology is far from being mature. Some of the most common complications that plague current TAV devices include malpositioning, crimp-induced leaflet damage, paravalvular leak, thrombosis, conduction abnormalities and prosthesis-patient mismatch. In this article, we provide an in-depth review of the current state-of-the-art pertaining the mechanics of TAVs while highlighting various studies guiding clinicians, regulatory agencies, and next-generation device designers.

Conduction disturbances after transcatheter aortic valve implantation procedures - predictors and management

Transcatheter aortic valve implantation (TAVI) has become a safe and efficient alternative to cardiac surgery in patients with severe aortic stenosis. In many countries the number of performed TAVI procedures equals the number of surgical implantations. Indications for TAVI are becoming more liberal, allowing a wider spectrum of patients to benefit from the advantages of transcatheter therapy. Due to its invasive nature, TAVI is associated with some complications such as conduction disturbances. Although these disturbances are usually not lethal, they have a great influence on patients’ state and long term-survival. The most relevant and common are His’ bundle branch blocks, atrioventricular blocks, and need for permanent pacemaker implantation. With the frequency at 10% to even 50%, conduction abnormalities are among the most important TAVI-related adverse events. Risk factors for conduction disturbances include age, anatomy of the heart, periprocedural factors, type of implanted valve, and comorbidities. Severity of occurring complications varies; therefore selection of a proper treatment approach is required. Considered as the most effective management, permanent pacemaker implantation turned out to negatively influence both recovery and survival. Moreover, there is no expert consensus on use of resynchronization therapy after TAVI. In this paper, the authors present a comprehensive analysis of the most common conduction disturbances accompanying TAVI, factors related to their occurrence, and treatment approach.

Prosthetic valve endocarditis with valvular obstruction after transcatheter aortic valve replacement

Patients with severe aortic stenosis who are at high risk for open-heart surgery might be candidates for transcatheter aortic valve replacement (TAVR). To our knowledge, this is the first report of Streptococcus viridans endocarditis that caused prosthetic valve obstruction after TAVR. A 77-year-old man who had undergone TAVR 17 months earlier was admitted because of evidence of prosthetic valve endocarditis. A transthoracic echocardiogram revealed a substantial increase in the transvalvular peak gradient and mean gradient in comparison with an echocardiogram of 7 months earlier. A transesophageal echocardiogram showed a 1.5-cm vegetation obstructing the valve. Blood cultures yielded penicillin-sensitive S. viridans. The patient was hemodynamically stable and was initially treated with vancomycin because of his previous penicillin allergy. Subsequent therapy with levofloxacin, oral penicillin (after a negative penicillin skin test), and intravenous penicillin eliminated the symptoms of the infection. Transcatheter aortic valve replacement is a relatively new procedure, and sequelae are still being discovered. We recommend that physicians consider obstructive endocarditis as one of these.

Post-mortem computed tomography and post-mortem computed tomography angiography following transcatheter aortic valve implantation†

OBJECTIVES

At present, transcatheter aortic valve implantation (TAVI) is widely used. As with any interventional treatment, however, TAVI may also be accompanied by complications and may result in periprocedural mortality. This study aims to evaluate such complications and causes of death after TAVI.

METHODS

The study included 32 deceased (59.4% female, n = 19, median age: 82 years) patients with TAVI, since 2008, in whom post-mortem computed tomography (PMCT) and PMCT angiography were performed with the intention of identifying complications.

RESULTS

Altogether, we registered bleeding (28.1%, 9/32), perforation and rupture (25%, 8/32), cerebral infarction (18.8%, 6/32), injury of the conduction system (3.1%, 1/32), insufficiency of the aortic (12.5%, 4/32) and the mitral valve (9.4%, 3/32) and of valve-in-valve procedures (9.4%, 3/32). Furthermore, there were findings due to cardiopulmonary resuscitation and intensive care. PMCT and PMCT angiography has advantages over autopsy. The demonstration of bleeding vessels, ruptures, the position of the implanted aortic valve and its effects on the mitral valve and its suspensions were more easily accessible by computed tomography-imaging display than by customary autopsy photo-documentation.

CONCLUSIONS

After TAVI, PMCT and PMCT angiography successfully demonstrated the complications leading to death. PMCT and PMCT angiography contribute to the post-mortem analysis of causes of periprocedural death.

The current state and future directions of transcatheter aortic valve implantation

Currently, surgical aortic valve replacement (SAVR) remains the standard of care for most patients with symptomatic severe aortic stenosis (AS). However, transcatheter aortic valve implantation (TAVI) has emerged as an alternative option for patients with symptomatic AS who have a prohibitive risk profile for SAVR.