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Nuis RJ, van den Dorpel M, Adrichem R, Daemen J, Van Mieghem N. Conduction Abnormalities after Transcatheter Aortic Valve Implantation: Incidence, Impact and Management Using CT Data Interpretation. Interv Cardiol 2024; 19:e12. [PMID: 39221063 PMCID: PMC11363062 DOI: 10.15420/icr.2024.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/09/2024] [Indexed: 09/04/2024] Open
Abstract
The demonstrated safety and effectiveness of transcatheter aortic valve implantation (TAVI) among low surgical risk patients opened the road to its application in younger low-risk patients. However, the occurrence of conduction abnormalities and need for permanent pacemaker implantation remains a frequent problem associated with adverse outcomes. The clinical implications may become greater when TAVI shifts towards younger populations, highlighting the need for comprehensive strategies to address this issue. Beyond currently available clinical and electrocardiographic predictors, patient-specific anatomical assessment of the aortic root using multi-sliced CT (MSCT) imaging can refine risk stratification. Moreover, leveraging MSCT data for computational 3D simulations to predict device-anatomy interactions may help guide procedural strategy to mitigate conduction abnormalities. The aims of this review are to summarise the incidence and clinical impact of new left bundle branch block and permanent pacemaker implantation post-TAVI using contemporary transcatheter heart valves; and highlight the value of MSCT data interpretation to improve the management of this complication.
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Affiliation(s)
- Rutger-Jan Nuis
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Mark van den Dorpel
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Rik Adrichem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Nicolas Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center Rotterdam, the Netherlands
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2
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Webb JG, Millar K. Editorial: Decreasing pacemaker implantation rates with Evolut supra-annular transcatheter aortic valves. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00584-0. [PMID: 39054173 DOI: 10.1016/j.carrev.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/12/2024] [Indexed: 07/27/2024]
Affiliation(s)
- John G Webb
- From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, BC, Canada.
| | - Kevin Millar
- From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, BC, Canada
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Zhang Y, Wang M, Zhang E, Wu Y. Artificial Intelligence in the Screening, Diagnosis, and Management of Aortic Stenosis. Rev Cardiovasc Med 2024; 25:31. [PMID: 39077660 PMCID: PMC11262349 DOI: 10.31083/j.rcm2501031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/30/2023] [Accepted: 09/13/2023] [Indexed: 07/31/2024] Open
Abstract
The integration of artificial intelligence (AI) into clinical management of aortic stenosis (AS) has redefined our approach to the assessment and management of this heterogenous valvular heart disease (VHD). While the large-scale early detection of valvular conditions is limited by socioeconomic constraints, AI offers a cost-effective alternative solution for screening by utilizing conventional tools, including electrocardiograms and community-level auscultations, thereby facilitating early detection, prevention, and treatment of AS. Furthermore, AI sheds light on the varied nature of AS, once considered a uniform condition, allowing for more nuanced, data-driven risk assessments and treatment plans. This presents an opportunity to re-evaluate the complexity of AS and to refine treatment using data-driven risk stratification beyond traditional guidelines. AI can be used to support treatment decisions including device selection, procedural techniques, and follow-up surveillance of transcatheter aortic valve replacement (TAVR) in a reproducible manner. While recognizing notable AI achievements, it is important to remember that AI applications in AS still require collaboration with human expertise due to potential limitations such as its susceptibility to bias, and the critical nature of healthcare. This synergy underpins our optimistic view of AI's promising role in the AS clinical pathway.
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Affiliation(s)
- Yuxuan Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease,
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, 100037 Beijing, China
- Center for Structural Heart Diseases, State Key Laboratory of
Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular
Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College,
100037 Beijing, China
| | - Moyang Wang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease,
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, 100037 Beijing, China
- Center for Structural Heart Diseases, State Key Laboratory of
Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular
Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College,
100037 Beijing, China
| | - Erli Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease,
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, 100037 Beijing, China
- Center for Structural Heart Diseases, State Key Laboratory of
Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular
Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College,
100037 Beijing, China
| | - Yongjian Wu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease,
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, 100037 Beijing, China
- Center for Structural Heart Diseases, State Key Laboratory of
Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular
Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College,
100037 Beijing, China
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Park S, Kang DY, Ahn JM, Kim DH, Park DW, Park SJ, Kang JW, Yang DH, Lee SA, Koo HJ. Impact of new-onset arrhythmia on cardiac reverse remodeling following transcatheter aortic valve replacement: computed tomography-derived left ventricular and atrial strains. Eur Radiol 2023; 33:8454-8463. [PMID: 37368107 DOI: 10.1007/s00330-023-09836-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/03/2023] [Accepted: 04/10/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Patients who undergo transcatheter aortic valve replacement (TAVR) are at risk for new-onset arrhythmia (NOA) that may require permanent pacemaker (PPM) implantation, resulting in decreased cardiac function. We aimed to investigate the factors that are associated with NOA after TAVR and to compare pre- and post-TAVR cardiac functions between patients with and without NOA using CT-derived strain analyses. METHODS We included consecutive patients who underwent pre- and post-TAVR cardiac CT scans six months after TAVR. New-onset left bundle branch block, atrioventricular block, and atrial fibrillation/flutter lasting over 30 days after the procedure and/or the need for PPM diagnosed within 1 year after TAVR were regarded as NOA. Implant depth and left heart function and strains were analyzed using multi-phase CT images and compared between patients with and without NOA. RESULTS Of 211 patients (41.7% men; median 81 years), 52 (24.6%) presented with NOA after TAVR, and 24 (11.4%) implanted PPM. Implant depth was significantly deeper in the NOA group than in the non-NOA group (- 6.7 ± 2.4 vs. - 5.6 ± 2.6 mm; p = 0.009). Left ventricular global longitudinal strain (LV GLS) and left atrial (LA) reservoir strain were significantly improved only in the non-NOA group (LV GLS, - 15.5 ± 4.0 to - 17.3 ± 2.9%; p < 0.001; LA reservoir strain, 22.3 ± 8.9 to 26.5 ± 7.6%; p < 0.001). The mean percent change of the LV GLS and LA reservoir strains was evident in the non-NOA group (p = 0.019 and p = 0.035, respectively). CONCLUSIONS A quarter of patients presented with NOA after TAVR. Deep implant depth on post-TAVR CT scans was associated with NOA. Patients with NOA after TAVR had impaired LV reserve remodeling assessed by CT-derived strains. CLINICAL RELEVANCE STATEMENT New-onset arrhythmia (NOA) following transcatheter aortic valve replacement (TAVR) impairs cardiac reverse remodeling. CT-derived strain analysis reveals that patients with NOA do not show improvement in left heart function and strains, highlighting the importance of managing NOA for optimal outcomes. KEY POINTS • New-onset arrhythmia following transcatheter aortic valve replacement (TAVR) is a concern that interferes with cardiac reverse remodeling. • Comparison of pre-and post-TAVR CT-derived left heart strain provides insight into the impaired cardiac reverse remodeling in patients with new-onset arrhythmia following TAVR. • The expected reverse remodeling was not observed in patients with new-onset arrhythmia following TAVR, given that CT-derived left heart function and strains did not improve.
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Affiliation(s)
- Sohee Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Do-Yoon Kang
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jung-Min Ahn
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dae-Hee Kim
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Duk-Woo Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seung-Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Joon-Won Kang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seung-Ah Lee
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Anderson RH, Spicer DE, Sánchez-Quintana D, Macias Y, Kapadia S, Tretter JT. Relationship between the aortic root and the atrioventricular conduction axis. Heart 2023; 109:1811-1818. [PMID: 37400231 DOI: 10.1136/heartjnl-2023-322716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/10/2023] [Indexed: 07/05/2023] Open
Abstract
Damage to the atrioventricular conduction axis continues to be a problem subsequent to transcatheter implantation of aortic valvar prostheses. Accurate knowledge of the precise relationships of the conduction axis relative to the aortic root could greatly reduce the risk of such problems. Current diagrams highlighting these relationships rightly focus on the membranous septum. The current depictions, however, overlook a potentially important relationship between the superior fascicle of the left bundle branch and the nadir of the semilunar hinge of the right coronary leaflet of the aortic valve. Recent histological investigations demonstrate, in many instances, a very close relationship between the left bundle branch and the right coronary aortic leaflet. The findings also highlight two additional variable features, which can be revealed by clinical imaging. The first of these is the extent of an inferoseptal recess of the left ventricular outflow tract. The second is the extent of rotation of the aortic root within the base of the left ventricle. Much more of the conduction axis is within the confines of the circumference of the outflow tract when the root is rotated in counterclockwise fashion as assessed from the perspective of the imager, with this finding itself associated with a much narrower inferoseptal recess. A clear understanding of the marked variability within the aortic root is key to avoiding future problems with atrioventricular conduction.
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Affiliation(s)
- Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | | | - Yolanda Macias
- Department of Medical and Surgical Therapeutics, University of Extremadura, Badajoz, Spain
| | - Samir Kapadia
- Cardiovascular Medicine Department, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Justin T Tretter
- Cardiovascular Medicine Department, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
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Campens L, Wang X, Montarello NJ, He J, Kofoed KF, Chen M, Sondergaard L, De Backer O. Anatomical mapping of the membranous septum in tricuspid and bicuspid aortic valves by cardiac computed tomography. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:1557-1559. [PMID: 37149839 DOI: 10.1007/s10554-023-02850-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/10/2023] [Indexed: 05/08/2023]
Abstract
A higher incidence of conduction disturbances and permanent pacemaker implantation (PPI) has been observed after transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valves (BAVs) as compared to those with tricuspid aortic valves (TAVs). This study aimed to provide an anatomical explanation for this observation, supported by an in-depth anatomical mapping of the membranous septum (MS) in a large cohort of BAVs and TAVs using cardiac computed tomography (CT). A total of 300 cardiac CT scans were analysed, revealing a significantly shorter sub-annular length of the MS in BAVs at all measuring points compared to TAVs (p < 0.001). In the current BAV cohort, the MS was found to be at its shortest at the RCC site, measuring less than 1 mm in depth. In addition, the MS was located more anteriorly towards the RCC in BAVs, where the transcatheter aortic valve tends to be implanted deeper, and we observed a trend towards a higher PPI rate in BAVs. Future studies should investigate whether anatomical mapping of the MS in patients undergoing TAVI could be a useful tool for decision-making and potentially mitigate the risk of conduction disturbances.
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Affiliation(s)
- Laurence Campens
- The Heart Centre - Rigshospitalet, Copenhagen University Hospital, Inge Lehmannsvej 7, 2100, Copenhagen, Denmark
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Xi Wang
- The Heart Centre - Rigshospitalet, Copenhagen University Hospital, Inge Lehmannsvej 7, 2100, Copenhagen, Denmark
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Nicholas J Montarello
- The Heart Centre - Rigshospitalet, Copenhagen University Hospital, Inge Lehmannsvej 7, 2100, Copenhagen, Denmark
| | - Jingjing He
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Klaus Fuglsang Kofoed
- The Heart Centre - Rigshospitalet, Copenhagen University Hospital, Inge Lehmannsvej 7, 2100, Copenhagen, Denmark
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lars Sondergaard
- The Heart Centre - Rigshospitalet, Copenhagen University Hospital, Inge Lehmannsvej 7, 2100, Copenhagen, Denmark
| | - Ole De Backer
- The Heart Centre - Rigshospitalet, Copenhagen University Hospital, Inge Lehmannsvej 7, 2100, Copenhagen, Denmark.
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Tretter JT, Burbano-Vera NH, Najm HK. Multi-modality imaging evaluation and pre-surgical planning for aortic valve-sparing operations in patients with aortic root aneurysm. Ann Cardiothorac Surg 2023; 12:295-317. [PMID: 37554720 PMCID: PMC10405341 DOI: 10.21037/acs-2023-avs2-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/30/2023] [Indexed: 08/10/2023]
Abstract
Cardiac computed tomography (CT) and magnetic resonance (CMR) supplement echocardiography in the evaluation of those with aortic root and ascending aortic dilation, determining timing for intervention, guiding pre-surgical planning and post-operative surveillance. The dynamic, three-dimensional complexity of the aortic root and how it relates to the base of the left ventricle must be understood in any surgical approach addressing the aneurysmal aortic root. With improved imaging technology and the importance for proper patient counseling, it is no longer acceptable to enter the operating theater without a detailed blue print of what the problem is, and how best to address it. In addition, reliance on surgical expertise alone for intraoperative evaluation and decision making could be suboptimal due to the unloaded condition of the aortic root and the variance of experience of the surgeons to successfully repair the aortic valve. This is exemplified by the selective surgeons and centers who have the ability to tackle these aortic valve and root pathologies, compared to mitral valve repair techniques that have been codified and are generalizable. This review discusses a multimodality imaging approach in the patient with aortic root aneurysm, focusing on the precision added with pre-surgical CT assessment to guide aortic-valve sparing operations. This precision is afforded with a detailed understanding of the anatomy of the aortic root and underlying support, and its accurate evaluation by standard two- and three-dimensional imaging. Furthermore, we describe the evolving ability to predict the location of ventricular components of the atrioventricular conduction axis with further clinical imaging to personalize surgical strategies.
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Affiliation(s)
- Justin T. Tretter
- Valve Procedural Planning Center, Department of Pediatric Cardiology and Division of Pediatric Cardiac Surgery, Cleveland Clinic Children’s, and The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nelson H. Burbano-Vera
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hani K. Najm
- Valve Procedural Planning Center, Department of Pediatric Cardiology and Division of Pediatric Cardiac Surgery, Cleveland Clinic Children’s, and The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Mori S, Aksoy O, Do DH, Dave RH, Shivkumar K. Transcatheter Aortic Valve Replacement Guided by Preprocedural Simulation of Fluoroscopic Location of the Membranous Septum. JACC Case Rep 2023; 16:101888. [PMID: 37396330 PMCID: PMC10313484 DOI: 10.1016/j.jaccas.2023.101888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/15/2023] [Accepted: 03/01/2023] [Indexed: 07/04/2023]
Abstract
We show the virtual simulation of the fluoroscopic location of the membranous septum using preprocedural cardiac computed tomographic data sets. Recognizing the risk distance before the procedure can help individualize implantation strategy to reduce the risk of atrioventricular conduction axis damage during transcatheter aortic valve replacement. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Olcay Aksoy
- UCLA Cardiovascular Interventional Programs, David Geffen School of Medicine at UCLA and UCLA Health System, Los Angeles, California, USA
| | - Duc H. Do
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ravi H. Dave
- UCLA Cardiovascular Interventional Programs, David Geffen School of Medicine at UCLA and UCLA Health System, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- UCLA Cardiovascular Interventional Programs, David Geffen School of Medicine at UCLA and UCLA Health System, Los Angeles, California, USA
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Sá MP, Van den Eynde J, Jacquemyn X, Erten O, Rodriguez R, Goldman S, Coady PM, Gnall E, Gray WA, Jarrett H, Abramson SV, Clavel MA, Pibarot P, Ramlawi B. Computed tomography-derived membranous septum length as predictor of conduction abnormalities and permanent pacemaker implantation after TAVI: A meta-analysis of observational studies. Catheter Cardiovasc Interv 2023; 101:1203-1213. [PMID: 37070459 DOI: 10.1002/ccd.30666] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/13/2023] [Accepted: 04/08/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) is associated with higher risk of mortality and rehospitalization for heart failure. Efforts to prevent conduction abnormalities (CA) requiring PPI after TAVI should be made. The membranous septum (MS) length and its interaction with implantation depth (ID-ΔMSID) could provide useful information about the risk of CA/PPI following TAVI. OBJECTIVES To identify MS length and ΔMSID as predictors of CA/PPI following TAVI. METHODS Study-level meta-analysis of studies published by September 30, 2022. RESULTS Eighteen studies met our eligibility including 5740 patients. Shorter MS length was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: odds ratio [OR] 1.60, 95% confidence interval [CI] 1.28-1.99, p < 0.001). Similarly, lower ΔMSID was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: OR 1.75, 95% CI 1.32-2.31, p < 0.001). Meta-regression analyses revealed a statistically significant modulation of the effect of shorter MS length and lower ΔMSID on the outcome (CA/PPI) by balloon postdilatation (positive regression coefficients with p < 0.001); with increasing use of balloon postdilatation, the effect of shorter MS length and lower ΔMSID on the outcome increased. MS length and ΔMSID demonstrated excellent discriminative abilities, with diagnostic ORs equaling 9.49 (95% CI 4.73-19.06), and 7.19 (95% CI 3.31-15.60), respectively. CONCLUSION Considering that short MS length and low ΔMSID are associated with higher risk of CA and PPI, we should include measurement of MS length in the pre-TAVI planning with MDCT and try to establish optimal ID values before the procedure to avoid CA/PPI.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | | | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Ozgun Erten
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Roberto Rodriguez
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Scott Goldman
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Paul M Coady
- Department of Interventional Cardiology, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Eric Gnall
- Department of Interventional Cardiology, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - William A Gray
- Department of Interventional Cardiology, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Harish Jarrett
- Department of Cardiovascular Imaging, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Sandra V Abramson
- Department of Cardiovascular Imaging, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Marie-Annick Clavel
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Philippe Pibarot
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Basel Ramlawi
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
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10
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Tretter JT, Spicer DE, Macías Y, Talbott C, Kasten JL, Sánchez-Quintana D, Kapadia SR, Anderson RH. Vulnerability of the ventricular conduction axis during transcatheter aortic valvar implantation: A translational pathologic study. Clin Anat 2023. [PMID: 36864653 DOI: 10.1002/ca.24032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/01/2023] [Indexed: 03/04/2023]
Abstract
The ventricular components of the conduction axis remain vulnerable following transcatheter aortic valvar replacement. We aimed to describe features which may be used accurately by interventionalists to predict the precise location of the conduction axis, hoping better to avoid conduction disturbances. We scanned eight normal adult heart specimens by 3T magnetic resonance, using the images to simulate histological sections in order accurately to place the conduction axis back within the heart. We then used histology, tested in two pediatric hearts, to prepare sections, validated by the magnetic resonance images, to reveal the key relationships between the conduction axis and the aortic root. The axis was shown to have a close relationship to the nadir of the right coronary leaflet, in particular when the aortic root was rotated in counterclockwise fashion. The axis was more vulnerable in the setting of a narrow inferoseptal recess, when the inferior margin of the membranous septum was above the plane of the virtual basal ring, and when minimal myocardium was supporting the right coronary sinus. The features identified in our study are in keeping with the original description provided by Tawara, but at variance with more recent accounts. They suggest that the vulnerability of the axis during transcatheter valvar replacement can potentially be inferred on the basis of knowledge of the position of the aortic root within the ventricular base. If validated by clinical studies, our findings may better permit avoidance of new-onset left bundle branch block following transcatheter aortic valvar replacement.
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Affiliation(s)
- Justin T Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's, and Cardiovascular Medicine Department, The Heart, Vascular, & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Yolanda Macías
- Department of Medical and Surgical Therapeutics, Faculty of Veterinary, University of Extremadura, Cáceres, Spain
| | - Cheryl Talbott
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer L Kasten
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Damián Sánchez-Quintana
- Department of Human Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Samir R Kapadia
- Cardiovascular Medicine Department, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
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Sammour YM, Lak H, Chahine J, Abushouk A, Chawla S, Kadri A, Alkhalaileh F, Kumar S, Ghimire B, Svensson L, Popovic Z, Tarakji K, Wazni O, Reed GW, Yun J, Puri R, Krishnaswamy A, Kapadia SR. Clinical and echocardiographic outcomes with new-onset left bundle branch block after SAPIEN-3 transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2023; 101:187-196. [PMID: 36378620 DOI: 10.1002/ccd.30488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/13/2022] [Accepted: 10/30/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND New-onset left bundle branch block (LBBB) can develop after transcatheter aortic valve replacement (TAVR) resulting in worse outcomes. AIMS Describe clinical and echocardiographic outcomes with new-onset LBBB after TAVR. METHODS We included consecutive patients who underwent transfemoral-TAVR with SAPIEN-3 (S3) valve between April 2015 and December 2018. Exclusion criteria included pre-existing LBBB, right BBB, left anterior hemiblock, left posterior hemiblock, wide QRS ≥ 120ms, prior permanent pacemaker (PPM), and nontransfemoral access. RESULTS Among 612 patients, 11.4% developed new-onset LBBB upon discharge. The length of stay was longer with new-onset LBBB compared with no LBBB [3 (2-5) days versus 2 (1-3) days; p < 0.001]. New-onset LBBB was associated with higher rates of 30-day PPM requirement (18.6% vs. 5.4%; p < 0.001) and 1-year heart failure hospitalizations (10.7% vs. 4.4%; p = 0.033). There was no difference in 3-year mortality between both groups (30.9% vs. 30.6%; p = 0.829). Further, new-onset LBBB was associated with lower left ventricular ejection fraction (LVEF) at both 30 days (55.9 ± 11.4% vs. 59.3 ± 9%; p = 0.026) and 1 year (55 ± 12% vs. 60.1 ± 8.9%; p = 0.002). These changes were still present when we stratified patients according to baseline LVEF (≥50% or <50%). New-onset LBBBs were associated with a higher 1-year LV end-diastolic volume index (51.4 ± 18.6 vs. 46.4 ± 15.1 ml/m2 ; p = 0.036), and LV end-systolic volume index (23.2 ± 14.1 vs. 18.9 ± 9.7 ml/m2 ; p = 0.009). Compared with resolved new-onset LBBB, persistent new-onset LBBB was associated with worse LVEF and higher PPM at 1 year. CONCLUSIONS New-onset LBBB after S3 TAVR was associated with higher PPM requirement, worse LVEF, higher LV volumes, and increased heart failure hospitalizations, with no difference in mortality.
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Affiliation(s)
- Yasser M Sammour
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hassan Lak
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Johnny Chahine
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Abdelrahman Abushouk
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sanchit Chawla
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amer Kadri
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Feras Alkhalaileh
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sachin Kumar
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Bindesh Ghimire
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Lars Svensson
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Zoran Popovic
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Khaldoun Tarakji
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Oussama Wazni
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Grant W Reed
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - James Yun
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Russo G, Tang GHL, Sangiorgi G, Pedicino D, Enriquez-Sarano M, Maisano F, Taramasso M. Lifetime Management of Aortic Stenosis: Transcatheter Versus Surgical Treatment for Young and Low-Risk Patients. Circ Cardiovasc Interv 2022; 15:915-927. [PMID: 36378737 DOI: 10.1161/circinterventions.122.012388] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transcatheter aortic valve replacement is now indicated across all risk categories of patients with symptomatic severe aortic stenosis and has been proposed as first line option for the majority of patients >74 years old. However, median age of patients enrolled in the transcatheter aortic valve replacement low-risk trials is 74 years and transcatheter aortic valve replacement has never been systematically investigated in young low risk patients. Although the long-term data in surgical aortic valve replacement in young patients (age <75) are well known, such data remain lacking in transcatheter aortic valve replacement. In the absence of clear guideline recommendations in patients with challenging anatomies (eg, hostile calcium, bicuspid), it is important to know the potential advantages and disadvantages of each treatment and to consider how they might integrate with each other in the lifetime management of such patients. In this review, we discuss current outstanding issues on the management of severe aortic stenosis from a lifetime management perspective, particularly in terms of initial intervention and future reinterventions.
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Affiliation(s)
- Giulio Russo
- Department of Biomedicine and Prevention, Policlinico Tor Vergata, Rome (G.R., G.S.)
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York (G.H.L.T.)
| | - Giuseppe Sangiorgi
- Department of Biomedicine and Prevention, Policlinico Tor Vergata, Rome (G.R., G.S.)
| | - Daniela Pedicino
- Fondazione Policlinico Universitario A Gemelli IRCSS, Roma, Italia (D.P.).,Università Cattolica del Sacro Cuore, Roma, Italia (D.P.)
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