Transcatheter Aortic Valve Replacement in Intermediate- and Low-Risk Patients

Screening for Occult Transthyretin Amyloidosis in Patients with Severe Aortic Stenosis and Amyloid Red Flags

AIMS

The optimal strategy to identify transthyretin-type cardiac amyloidosis (ATTR-CA) in patients with aortic stenosis (AS) is still unclear. This study aimed to investigate if targeted screening for ATTR-CA in patients with severe AS and amyloid red flags is associated with higher detection rates.

METHODS

The study prospectively enrolled patients ≥65 years with severe AS. Patients who fulfilled ≥1 major (carpal tunnel syndrome (CTS), ruptured biceps tendon, spinal stenosis, N-terminal pro B-type natriuretic peptide ≥1000 pg/mL, cardiac troponin >99th percentile) or ≥2 minor criteria (diastolic dysfunction ≥2 grade/lateral e' <10 cm/s, atrial fibrillation, atrioventricular conduction disease/pacemaker) received bone scintigraphy and biochemical analysis for light chain amyloidosis. Hypertensive patients (>140/90 mmHg) and those with interventricular septal thickness (IVSd) ≤13 mm were excluded.

RESULTS

Overall, 264 patients were screened, of whom 85 were included in the analysis. Tracer uptake Perugini grade ≥1 was detected in nine patients (11%). An endomyocardial biopsy was additionally performed in four of nine patients, yielding a prevalence of 7% (n = 6). All patients with dual AS-ATTR were male. Syncope was more commonly reported in AS-ATTR patients (50% vs. 6%, p = 0.010), who also tended to have more severe hypertrophy (IVSd of 18 vs. 16 mm, p = 0.075). Pericardial effusion and CTS were more common in patients with dual pathology (67% vs. 8%, p < 0.001, and 83% vs. 24%, p = 0.003, respectively).

CONCLUSION

Targeted screening for ATTR-CA in patients with AS and amyloid red flags does not yield higher detection rates than those reported previously in all comers with AS.

Comparative Analysis of TAVR (Transcatheter Aortic Valve Replacement) and Surgical Valve Replacement for Low-Risk Patients

"Aortic stenosis" (AS) refers to a cardiac condition in which the aortic valve narrows, creating an obstruction that hinders the flow of blood from the left ventricle to the aorta. This contraction of the arteries influences normal blood circulation, leading to elevated pressure within the left ventricle and potentially culminating in heart failure. The management of AS typically involves two primary treatments, i.e. "surgical aortic valve replacement" (SAVR) and "transcatheter aortic valve replacement" (TAVR). In both cases, the goal is to replace a dysfunctional aortic valve with a functional substitute. Presently, TAVR has gained much preference over SAVR in clinical practice. However, there is a dearth of comprehensive research directly comparing the real-world outcomes of TAVR and SAVR. In recent years, TAVR has emerged as an attractive alternative to SAVR, yet studies that provide a detailed comparison of their real-world solutions are limited. This review article assesses the mortality of patients who underwent TAVR vis-a-vis patients who underwent SAVR.

Comparison of Transfemoral versus Transsubclavian/Transaxillary access for transcatheter aortic valve replacement: A systematic review and meta-analysis

Femoral access is the gold standard for transcatheter aortic valve replacement (TAVR). Safe alternative access, that represents about 15 % of TAVR cases, remains important for patients without adequate transfemoral access. We aimed to perform a systematic review and meta-analysis of studies comparing transfemoral (TF) access versus transsubclavian or transaxillary (TSc/TAx) access in patients undergoing TAVR. We searched PubMed, Cochrane CENTRAL Register, EMBASE, Web of Science, Google Scholar and ClinicalTrials.gov (inception through May 24, 2022) for studies comparing (TF) to (TSc/TAx) access for TAVR. A total of 21 studies with 75,995 unique patients who underwent TAVR (73,203 transfemoral and 2,792 TSc/TAx) were included in the analysis. There was no difference in the risk of in-hospital and 30-day all-cause mortality between the two groups (RR 0.64, 95 % CI 0.36-1.13, P = 0.12) and (RR 0.95, 95 % CI 0.64-1.41, P = 0.81), while 1-year mortality was significantly lower in the TF TAVR group (RR 0.79, 95 % CI 0.67-0.93, P = 0.005). No significant differences in major bleeding (RR 0.82, 95 % CI 0.65-1.03, P = 0.09), major vascular complications (RR 1.14, 95 % CI 0.75-1.72, P = 0.53), and stroke (RR 0.66, 95 % CI 0.42-1.02, P = 0.06) were observed. In patients undergoing TAVR, TF access is associated with significantly lower 1-year mortality compared to TSc/TAx access without differences in major bleeding, major vascular complications and stroke. While TF is the preferred approach for TAVR, TSc/TAx is a safe alternative approach. Future studies should confirm these findings, preferably in a randomized setting.

Infective Endocarditis Complicated With Septic Embolic Stroke After Transcatheter Aortic Valve Implantation: A Case Report

Transcatheter aortic valve implantation (TAVI) is a relatively novel procedure developed for aortic stenosis (AS) management in patients with moderate to high surgical risk, especially the elderly with multiple comorbidities. Infective endocarditis following transcatheter aortic valve implantation (post-TAVI-IE) is an uncommon complication that contributes to very high morbidity and mortality. Further complications from post-TAVI-IE include ischemic stroke from septic emboli. Here, we report a case of an 82-year-old man with severe symptomatic AS who underwent TAVI, presenting with fever and alteration of consciousness, which was diagnosed as post-TAVI-IE per Duke criteria complicated by acute hemiparesis from septic emboli stroke. He was treated successfully conservatively using antibiotics. We have reviewed the options of treatment and outcomes for post-TAVI-IE.

Comparison of the results of transcatheter aortic valve implantation in patients with bicuspid and tricuspid aortic valve

Introduction

Indications for transcatheter aortic valve implantation (TAVI) are constantly expanding, including younger patients. Bicuspid aortic valves (BAV) often occur in this group. In order to achieve optimal treatment results in younger patients, it is necessary to develop an effective method for selecting the size of implanted valves.

Aim

To compare the results of TAVI with use of a self-expanding prosthesis in patients with a BAV and a tricuspid aortic valve (TAV) with valve selection based on annular sizing.

Material and methods

The diagnosis of BAV and TAV and measurements (annular sizing) were based on multi-slice computed tomography scans. Eighty-three patients received a self-expanding CoreValve or Evolut R prosthesis. In group I (BAV) there were 21 (25.3%) patients and in group II (TAV) there were 62 (74.7%) patients.

Results

The groups did not differ in terms of baseline clinical characteristics. Device success was achieved in 16 (76.2%) and 55 (88.7%) (p = NS) in group I and II respectively. Composite endpoints: early safety occurred in 5 (23.8%) and 11 (17.7%) patients (p =NS) in group I and II respectively; clinical efficacy occurred in 10 (47.6%) and 28 (45.2%) patients (p = NS) in group I and II respectively. 30-day mortality was 4.8% vs 9.7%, 1-year mortality was 28.6% vs 17.7% (p = NS) in group I and II respectively.

Conclusions

TAVI in patients with severe aortic stenosis and BAV is as effective as in patients with TAV using self-expanding prostheses if the valve selection is based on annular sizing.

Procedural sedation and analgesia for percutaneous high-tech cardiac procedures

The interest in percutaneous high-tech cardiac procedures has increased in recent years together with its safety and efficacy. In fragile patients, procedural sedation and analgesia are used to perform most of the procedures. General anesthesia remains the technique of choice during the team learning curve and might be required in selected patients or in emergent situations. Despite the high costs of percutaneous high-tech cardiac procedures, the decrease in length of hospital stays, rate of intensive care admission and complications, balance the increase in devices costs. In fragile patients who undergo percutaneous high tech cardiac procedures, the primary role of the anesthesiologist is to prevent the need for postprocedural intensive care unit and complications rate. Starting from the experience of a large university third level hospital we identified the eight most commonly performed contemporary percutaneous high tech cardiac procedures (ventricular tachycardia and atrial fibrillation ablation, protected percutaneous coronary intervention, transcatheter aortic valve implantation, MitraClip® (Abbott Laboratories; Abbott Park, IL, USA), percutaneous patent foramen ovale closure, left atrial appendage closure, and dysfunctional lead extraction), discuss the role of procedural sedation and analgesia in this setting, and explore future perspectives.

Coronary revascularization after surgical aortic valve replacement

Objective

It remains unclear how often coronary revascularization is necessary after aortic valve interventions, either by surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement. However, these data are relevant for treatment and prosthesis choice. The authors sought to analyze the incidence and characteristics of coronary revascularization after SAVR during follow-up.

Methods

Of 2256 patients undergoing isolated SAVR between 1987 and 2015, 420 patients (mean age 56.9 ± 15.5 years, 66.9% male) were followed at the Erasmus Medical Center. Incidence, predictors, and characteristics of coronary revascularization were analyzed. Cumulative incidence of revascularization was assessed using a competing risk approach.

Results

Mean follow-up after SAVR was 17.2 years (total of 4541 patient-years). A total of 24 patients underwent 28 procedures of revascularization. The cumulative incidence of revascularization after SAVR was 0.5%, 2.2%, 4.1%, and 6.9% at 1, 5, 10, and 20 years, respectively. The linearized rate of revascularization was 6.2 per 1000 patient-years. Percutaneous coronary intervention was the most common revascularization method (64%; N = 18/28). Revascularization before SAVR (N = 36/420; of whom 27 percutaneous coronary intervention) was an independent predictor of revascularization during follow-up (hazard ratio, 6.6; 95% confidence interval, 2.6-17.1; P < .001).

Conclusions

After SAVR, the rate of coronary revascularization was 6.9% (N = 24/420) at 20-year follow-up. Patients were at particular risk if they had undergone previous revascularization before SAVR. These data may furthermore be relevant to the transcatheter aortic valve replacement population.

Propensity score weighting under limited overlap and model misspecification

Propensity score weighting methods are often used in non-randomized studies to adjust for confounding and assess treatment effects. The most popular among them, the inverse probability weighting, assigns weights that are proportional to the inverse of the conditional probability of a specific treatment assignment, given observed covariates. A key requirement for inverse probability weighting estimation is the positivity assumption, i.e. the propensity score must be bounded away from 0 and 1. In practice, violations of the positivity assumption often manifest by the presence of limited overlap in the propensity score distributions between treatment groups. When these practical violations occur, a small number of highly influential inverse probability weights may lead to unstable inverse probability weighting estimators, with biased estimates and large variances. To mitigate these issues, a number of alternative methods have been proposed, including inverse probability weighting trimming, overlap weights, matching weights, and entropy weights. Because overlap weights, matching weights, and entropy weights target the population for whom there is equipoise (and with adequate overlap) and their estimands depend on the true propensity score, a common criticism is that these estimators may be more sensitive to misspecifications of the propensity score model. In this paper, we conduct extensive simulation studies to compare the performances of inverse probability weighting and inverse probability weighting trimming against those of overlap weights, matching weights, and entropy weights under limited overlap and misspecified propensity score models. Across the wide range of scenarios we considered, overlap weights, matching weights, and entropy weights consistently outperform inverse probability weighting in terms of bias, root mean squared error, and coverage probability.

Gender differences in aortic valve replacement: is surgical aortic valve replacement riskier and transcatheter aortic valve replacement safer in women than in men?

Aortic stenosis (AS) is a progressive and degenerative disease that necessitates valve replacement through either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). Various studies have shown that, unlike for TAVR, SAVR is associated with an elevated risk for women as compared to men. The aim of this review is to better understand the risks and their possible causes, associated with the use of both TAVR and SAVR in female patients. Our systematic review included studies published between 2012 and 2020, identified through specific searches of PubMed. Compatibility of publications, determined by the use of pre-defined inclusion/exclusion criteria, resulted in 15 articles being used in our review. Overall, more men than women undergo SAVR, but our findings confirmed that SAVR is associated with worse outcomes in women in the short-term. Reasons for a higher 30-day mortality post-SAVR in women include an increased age, higher in-hospital mortality and, possibly baseline comorbidities and anatomical differences. There was no difference observed in 30-day mortality between men and women undergoing TAVR. Female patients appear to have a better longer-term survival post-TAVR than their male counterparts. Understanding the reasons why women have worse outcomes post-SAVR is essential for ensuring appropriate treatment selection for patients with AS, as well as for achieving the best possible long-term and safety outcomes for these patients.

Radiation Dose Reduction in Preprocedural CT Imaging for TAVI/TAVR Using a Novel 3-Phase Protocol: A Single Institution's Experience

PURPOSE

 To retrospectively investigate the effectiveness of a novel 3-phase protocol for computed tomography (CT) before transcatheter aortic valve implantation/transcatheter aortic valve replacement (TAVI/TAVR) in terms of radiation dose and image quality.

MATERIALS AND METHODS

 A total of 107 nonrandomized patients (81 ± 7.4 years) scheduled for TAVI/TAVR underwent preprocedural CT on an 80-row CT scanner. 55 patients underwent a combined ECG-synchronized spiral scan of the chest and non-ECG-synchronized spiral scan of the abdomen/pelvis as recommended by the Society of Cardiovascular Computed Tomography (SCCT). 52 patients underwent an updated 3-phase variable helical pitch (vHP3) protocol combining a non-ECG-synchronized spiral scan of the upper thoracic aperture, followed by a prospective ECG-synchronized spiral scan of the heart, and a non-ECG-synchronized abdominal/pelvic spiral scan. The radiation dose was determined from an automatically generated protocol based on the CT dose index (CTDI). Objective image quality in terms of vessel attenuation and image noise was measured, and the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Subjective image quality was evaluated using a 4-point scale and compared for interrater agreement using Cohen's weighted kappa coefficient (κw). All data were compared and statistically analyzed.

RESULTS

 Use of the novel 3-phase vHP3 protocol reduced the dose-length product (DLP) from 1256.58 ± 619.05 mGy*cm to 790.90 ± 238.15 mGy*cm, reducing the effective dose (E) from 21.36 ± 10.52 mSv to 13.44 ± 4.05 mSv and size-specific dose estimates (SSDE) from 20.85 ± 7.29 mGy to 13.84 ± 2.94 mGy (p < 0.001). There were no significant differences in objective and subjective image quality between the two protocols and between the two readers.

CONCLUSION

 The novel 3-phase vHP3 protocol significantly reduces the radiation dose of preprocedural TAVI/TAVR CT without a loss of image quality.

KEY POINTS

  · The use of a novel 3-phase protocol for preprocedural TAVI/TAVR CT reduces radiation dose by 37 % compared to a combined ECG-synchronized and non-ECG-synchronized spiral CT protocol.. · Objective image quality remains unaffected as image noise, SNR, and CNR did not differ significantly between the two protocols. The average attenuation of the aortic root and abdominal aorta exceeded 450 HU in both protocols.. · The average subjective image quality ratings were good to excellent for both protocols with almost perfect to substantial interrater agreement..

CITATION FORMAT

· Shnayien S, Bressem KK, Beetz NL et al. Radiation Dose Reduction in Preprocedural CT Imaging for TAVI/TAVR Using a Novel 3-Phase Protocol: A Single Institution's Experience. Fortschr Röntgenstr 2020; 192: 1174 - 1182.

Coronary Artery Disease Assessed by Computed Tomography-Based Leaman Score in Patients With Low-Risk Transcatheter Aortic Valve Implantation

We aimed to evaluate the burden of coronary artery disease (CAD) using the computed tomography (CT) Leaman score in low-risk transcatheter aortic valve implantation (TAVI) patients. The extent of CAD in low-risk patients with aortic stenosis who are candidates for TAVI has not been accurately quantified. The CT Leaman score was developed to quantify coronary CT angiography (CCTA) atherosclerotic burden and has been validated to evaluate the extent of CAD. CT Leaman score >5 has been associated with an increase in major adverse cardiac events over long-term follow-up. The study population included patients enrolled in the Low Risk TAVI trial who underwent CCTA before the procedure. For the CT Leaman score, we used 3 sets of weighting factors: (1) location of coronary plaques, (2) type of plaque, and (3) degree of stenosis. A total of 200 patients were enrolled in the Low Risk TAVI trial. Excluded were 31 patients who had no analyzable CCTA imaging. For the remaining 169 patients, the mean CT Leaman score was 6.27 ± 0.27, of whom 102 (60.4%) had CT Leaman score >5. Nearly all analyzed patients (97%) had coronary plaques. Furthermore, 33 patients (19.5%) had potentially obstructive coronary plaques (>50% stenosis by CCTA) in proximal segments. Most low-risk TAVI patients have significant CAD burden by CCTA. It should be a priority for future TAVI devices to guarantee unimpeded access to the coronary arteries for selective angiography and interventions.

Episode Payments for Transcatheter and Surgical Aortic Valve Replacement

BACKGROUND

Aortic stenosis is the most common valvular heart disease in the United States. Transcatheter aortic valve replacement (TAVR) is increasingly being adopted as an alternative to surgical aortic valve replacement (SAVR). In an era of value-based payment reform, our objective was to better understand the economic impact of the use of TAVR and SAVR in the United States.

METHODS AND RESULTS

We performed a retrospective cohort study of Medicare beneficiaries who underwent TAVR or SAVR between 2012 and 2015. Using claims from a 20% sample of national fee-for-service Medicare beneficiaries, we calculated episode payments for patients who underwent aortic valve replacement from 90 days before aortic valve replacement through 90 days after hospital discharge. Among 18 804 eligible patients, 6455 underwent TAVR (34.3%), and 12 349 underwent SAVR (65.7%). After adjustment for patient characteristics, episode payments for TAVR were ≈7% lower than for SAVR (TAVR, $55 545 [95% CI, $54 643-56 446] versus $59 467 [95% CI, $58 723-60 211]; P<0.001). Patients with TAVR had higher preprocedural payments, but lower payments during and after the index hospitalization for the procedure. Episode payments increased with increasing comorbidity score for patients undergoing TAVR or SAVR (rate ratio, 1.16 [95% CI, 1.15-1.17]; P<0.001); however, this association was stronger for SAVR (rate ratio, 1.18 [95% CI, 1.17-1.19]) than for TAVR (rate ratio, 1.11 [95% CI, 1.11-1.12]; P<0.001 for interaction). Thus, differences in episode payments between TAVR and SAVR were greatest for the sickest patients but much less in healthier patients.

CONCLUSIONS

TAVR is associated with lower episode payments than SAVR. However, episode payments for TAVR are less influenced by patient comorbidity. Therefore, as TAVR is increasingly used in patients with better baseline health status, the economic advantages of TAVR relative to SAVR may diminish.

Outcome of Transcatheter Aortic Valve Implantation in Patients with Peripheral Vascular Disease

Peripheral vascular disease (PVD) is common in patients referred for transcatheter aortic valve implantation (TAVI). We sought to investigate the impact of PVD on patients who underwent TAVI. Using data from the National Inpatient Sample database 2011 and 2014, we identified patients who had undergone TAVI. We studied the clinical characteristics and procedural outcomes in patients with PVD who underwent TAVI compared with those patients without PVD using propensity score matching score matching. Results: A total of 42,215 patients underwent TAVI; of which 1,388 patients were matched using propensity score matched scores to 694 in each (PVD vs no PVD) patients. The population had a mean age of 81 years old and 55.8% were of female gender. African-Americans constituted 4.3%. PVD patients who underwent TAVI were found to have higher rates of vascular complications (11.8% vs 5.9 % p <0.001) compared with non-PVD patients and tended to have higher mortality (5.5% vs 3.6%, p = 0.121) and post-TAVI bleeding (13.5% vs 12% p = 0.143). In conclusion, PVD patients have higher in-hospital mortality and higher incidence of in-hospital overall complications compared with patients who have no PVD.

Contemporary nursing care in transcatheter aortic valve replacement

The purpose of this article is to inform nurses of the latest trend in the care of patients with aortic stenosis using transcatheter aortic valve replacement and pertinent knowledge regarding the care of these patients.