Life beyond 5 Years after TAVI: Patients' Perceived Health Status and Long-Term Outcome after Transcatheter Aortic Valve Implantation

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.

Measurement of health-related quality of life post aortic valve replacement via minimally invasive incisions

Background

Minimally invasive aortic surgery is growing in popularity among surgeons. Although many clinical reports have proven both the safety and efficacy from a surgical point of view, there are few data regarding its impact on patients’ quality of life and whether there is a difference between ministernotomy and minithoracotomy from the patient perspective.

Methods

This prospective, questionnaire-based, nonrandomized study included 189 patients who underwent aortic valve replacement via a minimally invasive incision between May 2014 and December 2020 and completed at least 1 year of follow-up. The study uses the RAND SF 36-Item Health Survey 1.0 to assess and compare health-related quality of life between ministernotomy and minithoracotomy.

Results

There was a statistically significant improvement in the minithoracotomy group with regard to physical functioning, role limitation due to a physical problem, and social functioning (79.69 ± 20.72, 75.28 ± 26.52, 87.91 ± 16.98) compared to the ministernotomy group (70.31 ± 22.88, 58.59 ± 31.17, 66.15 ± 27.32) with p values (0.0036, 0.0001, < 0.0001), respectively.

Conclusions

Both minimally invasive aortic valve incisions positively impacted patient quality of life. The minithoracotomy incision showed significant improvements in physical capacity and successful patient re-engagement in daily physical and social activities. This, in turn, positively improved their general health status compared to the 1-year preoperative status.

Trial registration: This study was approved by the Research Ethics Committee (REC) at the Faculty of Medicine, Ain Shams University, under the number code (FWA 000017585, FAMSU R 91 /2021).

Characterization of Turbulent Flow Behind a Transcatheter Aortic Valve in Different Implantation Positions

The development of turbulence after transcatheter aortic valve (TAV) implantation may have detrimental effects on the long-term performance and durability of the valves. The characterization of turbulent flow generated after TAV implantation can provide fundamental insights to enhance implantation techniques. A self-expandable TAV was tested in a pulse replicator and the three-dimensional flow field was extracted by means of tomographic particle image velocimetry. The valve was fixed inside a silicone phantom mimicking the aortic root and the flow field was studied for two different supra-annular axial positions at peak systole. Fluctuating velocities and turbulent kinetic energy were compared between the two implantations. Velocity spectra were derived at different spatial positions in the turbulent wakes to characterize the turbulent flow. The valve presented similar overall flow topology but approximately 8% higher turbulent intensity in the lower implantation. In this configuration, axial views of the valve revealed smaller opening area and more corrugated leaflets during systole, as well as more accentuated pinwheeling during diastole. The difference arose from a lower degree of expansion of the TAV's stent inside the aortic lumen. These results suggest that the degree of expansion of the TAV in-situ is related to the onset of turbulence and that a smaller and less regular opening area might introduce flow instabilities that could be detrimental for the long-term performance of the valve. The present study highlights how implantation mismatches may affect the structure and intensity of the turbulent flow in the aortic root.

OS-LALM-OGM Algorithm-Based Computed Tomography Image for Characteristics and Comorbidities of Patients before Transcatheter Aortic Valve Implantation

Based on the ordered subsets (OS), a linear augmentation Lagrangian method (OS-LALM) was constructed, which was then combined with the optimized gradient method (OGM) to construct the OS-LALM-OGM, so as to discuss application of the computed tomography (CT) images based on OS-LALM-OGM in evaluation of clinical manifestations and complications of patients before transcatheter aortic valve implantation (TAVI). The OS-LALM-OGM was compared with the filtered back projection (FBP) and OS-LALM. In addition, it was applied to evaluate the conditions of 128 patients before TAVI. It was found that the peak signal-to-noise ratio (PSNR) of OS-LALM-OGM was greater than that of the FBP and OS-LALM when the number of iterations was 5, 20, and 40, while the root mean square error (RMSD) was the opposite (P < 0.05). The proportion of dyspnea was the highest, 38.28%, followed by angina (19.53%) and fainting (21.09%). The long diameter of the annulus and the average inner diameter of the annulus measured by the CT image based on the OS-LALM-OGM algorithm were greatly larger than the inner diameter of the aortic annulus measured by the CT based on the FBP algorithm (P < 0.05); the evaluation sensitivity (95.24%) and specificity (85.85%) of CT based on the OS-LALM-OGM algorithm were obviously greater than those of X-ray, which were 84.43% and 76.77%, respectively (P < 0.05). In short, the OS-LALM-OGM proposed had a relatively excellent effect on CT image reconstruction. The CT image based on the OS-LALM-OGM algorithm showed a better evaluation performance for patients before TAVI than the traditional FBP algorithm, showing higher sensitivity and specificity.

All-cause readmission after transcatheter aortic valve replacement in a community hospital - Long term follow-up: Readmissions after aortic valve replacement

BACKGROUND

Post-procedure readmissions are associated with lower quality of life and increased economic burden. The study aimed to identify predictors for long-term all-cause readmissions in patients who underwent transcatheter aortic valve replacement (TAVR) in a community hospital.

METHODS

A Historical cohort study of all adults who underwent TAVR at Cape-Cod hospital between June 2015 and December 2017 was performed and data on readmissions was collected up-to May 2020 (median follow up of 3.3 years). Pre-procedure, procedure and in-hospital post-procedure parameters were collected. Readmission rate was evaluated, and univariate and multivariable analyses were applied to identify predictors for readmission.

RESULTS

The study included 262 patients (mean age 83.7±7.9 years, 59.9% males). The median Society of Thoracic Surgeons (STS) probability of mortality (PROM) score was 4.9 (IQR, 3.1-7.9). Overall, 120 patients were readmitted. Ten percent were readmitted within 1-month, 20.8% within 3-months, 32.0% within 6-months and 44.5% within 1-year. New readmissions after 1-year were rare. STS PROM 5% or above (HR 1.50, p=0.039), pre-procedure anemia (HR 1.63, p=0.034), severely decreased pre-procedure renal function (HR 1.93, p=0.040) and procedural complication (HR 1.65, p=0.013) were independent predictors for all-cause readmission.

CONCLUSIONS

Elevated procedural risk, anemia, renal dysfunction and procedural complication are important predictors for readmission. Pre-procedure and ongoing treatment of the patient's background diseases and completion of treatment for complications prior to discharge may contribute to a reduction in the rate of readmissions.

Assessment of postoperative nutritional status and physical function between open surgical aortic valve replacement and transcatheter aortic valve implantation in elderly patients

Background and aims : Severe aortic stenosis (AS) has been normally treated with surgical aortic valve replacement (AVR) whereas recently, transcatheter aortic valve implantation (TAVI) has been introduced as a minimally invasive operation for patients with high surgical risk and frailty. In this study, we have evaluated postoperative physical function and nutrition intake in the patients following AVR and TAVI. Methods : This prospective observational study involved 9 patients with surgical aortic valve replacement (AVR) and 7 patients with transcatheter aortic valve implantation (TAVI). Body composition was measured one day prior surgery, postoperative day (POD) 1, POD 3, POD 5 and POD 7. Hand grip strength, calf circumference and gait speed were measured one day before surgery and on the day of discharge. Results : Skeletal muscle was significantly decreased in AVR patients at postoperative day 3 and 7, while there was no change in TAVI patients. Patients with TAVI showed higher dietary intake after surgery compared to patients with AVR, and they maintained hand grip strength and calf circumference at discharge. Conclusions : In elderly patients with AS, TAVI can improve post-operative recovery maintaining nutritional status and physical function even. J. Med. Invest. 67 : 139-144, February, 2020.