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Flores-Umanzor E, Cepas-Guillén P, Ruberti A, Regueiro A, Sanchis L, Gabani R, Rodés-Cabau J, Vidal B, Freixa X. Paravalvular leak closure after TAVI with plugs: A literature review with a specific focus on arterio-arterial loop. Catheter Cardiovasc Interv 2024. [PMID: 38984656 DOI: 10.1002/ccd.31145] [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: 03/28/2024] [Revised: 06/17/2024] [Accepted: 06/26/2024] [Indexed: 07/11/2024]
Abstract
More than mild paravalvular leak (PVL) following transcatheter aortic valve implantation (TAVI) is associated with a twofold increase in all-cause mortality, heart failure hospitalizations, and the need for reintervention. Successfully addressing PVL in TAVIs is more challenging than in surgical valves. The arterial-arterial (A-A) rail technique emerges as a valuable strategy for post-TAVI PVL closure, enhancing success rates by enabling the effective use of lower-profile vascular plug devices. When standard approach is ineffective, generating an A-A loop for post-TAVI PVL closure is probably the most recommended strategy to ensure procedural success.
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Affiliation(s)
- Eduardo Flores-Umanzor
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Pedro Cepas-Guillén
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Andrea Ruberti
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ander Regueiro
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Laura Sanchis
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Rami Gabani
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Josep Rodés-Cabau
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Barbara Vidal
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Xavier Freixa
- Department of Cardiology, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Amat-Santos IJ, Fernández-Cordón C. The Tootsie Roll Technique for Paravalvular Leak Closure: A New Candy in the Catheterization Laboratory. JACC Cardiovasc Interv 2024; 17:645-647. [PMID: 38244003 DOI: 10.1016/j.jcin.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Ignacio J Amat-Santos
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Spain; Centro de investigación biomédica en red - Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.
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Ueyama HA, Greenbaum AB, Xie JX, Shekiladze N, Gleason PT, Byku I, Devireddy CM, Hanzel GS, Block PC, Babaliaros VC. Transcatheter Paravalvular Leak Closure With Covered Stent Tract and Vascular Plug: Tootsie Roll Technique. JACC Cardiovasc Interv 2024; 17:635-644. [PMID: 38244000 DOI: 10.1016/j.jcin.2023.11.034] [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: 09/14/2023] [Revised: 11/06/2023] [Accepted: 11/17/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Transcatheter closure of transcatheter heart valve (THV)-related paravalvular leak (PVL) is associated with a high failure rate with available devices due to the complex interaction of THV and aortic/mitral annulus. OBJECTIVES This study reports on novel transcatheter techniques to treat PVL after THV. METHODS The authors describe consecutive patients who underwent PVL closure after transcatheter aortic valve replacement (TAVR) or transcatheter mitral valve replacement (TMVR). A covered self-expanding stent (Viabahn) was deployed in the defect to create a seal between the THV and annulus. A vascular plug (Amplatzer Vascular Plug 2 [AVP2] or AVP4) was then deployed inside the covered stent to obliterate PVL. RESULTS Eight patients with THV-related PVL were treated using this method (aortic [3 SAPIEN, 1 Evolut], mitral [2 SAPIEN-in-MAC (mitral annular calcification), 2 M3 TMVR). Various combinations of stents and plugs were used (5 mm × 2.5 cm Viabahn + 6 mm AVP4 [n = 2], 8 mm × 2.5 cm Viabahn + 10 mm AVP2 [n = 5], and 10 mm × 5.0 cm Viabahn + 12 mm AVP2 [n = 1]). All had technical success with immediate elimination of target PVL, without in-hospital complications. None had signs of postprocedure hemolysis. All patients were discharged alive (median 3.5 days [Q1-Q3: 1.0-4.8 days]). No residual PVL was seen at discharge, except for 1 patient with mild regurgitation due to another untreated PVL location. One patient died before 30 days due to complication of valve-in-MAC TMVR. In remaining patients, none had recurrence of PVL at 30 days. Symptoms decreased to NYHA functional class I/II in 6 patients. NYHA functional class III symptoms remained in 1 patient with mitral regurgitation awaiting subsequent valve replacement procedure. CONCLUSIONS The technique of sequential deployment of a covered stent and vascular plug may effectively treat THV-related PVL.
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Affiliation(s)
- Hiroki A Ueyama
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Adam B Greenbaum
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Joe X Xie
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Nikoloz Shekiladze
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Patrick T Gleason
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Isida Byku
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Chandan M Devireddy
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - George S Hanzel
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Peter C Block
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Vasilis C Babaliaros
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA.
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Oikonomou G, Apostolos A, Drakopoulou M, Simopoulou C, Karmpalioti M, Toskas P, Stathogiannis K, Xanthopoulou M, Ktenopoulos N, Latsios G, Synetos A, Tsioufis C, Toutouzas K. Long-Term Outcomes of Aortic Stenosis Patients with Different Flow/Gradient Patterns Undergoing Transcatheter Aortic Valve Implantation. J Clin Med 2024; 13:1200. [PMID: 38592019 PMCID: PMC10932005 DOI: 10.3390/jcm13051200] [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: 01/29/2024] [Revised: 02/11/2024] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Few data exist on the comparative long-term outcomes of severe aortic stenosis (AS) patients with different flow-gradient patterns undergoing transcatheter aortic valve implantation (TAVI). This study sought to evaluate the impact of the pre-TAVI flow-gradient pattern on long-term clinical outcomes after TAVI and assess changes in the left ventricular ejection fraction (LVEF) of different subtypes of AS patients following TAVI. Methods: Consecutive patients with severe AS undergoing TAVI in our institution were screened and prospectively enrolled. Patients were divided into four subgroups according to pre-TAVI flow/gradient pattern: (i) low flow-low gradient (LF-LG): stroke volume indexed (SVi) ≤ 35 mL/m2 and mean gradient (MG) < 40 mmHg); (ii) normal flow-low gradient (NF-LG): SVi > 35 mL/m2 and MG < 40 mmHg; (iii) low flow-high gradient (LF-HG): Svi 35 mL/m2 and MG ≥ 40 mmHg and (iv) normal flow-high gradient (NF-HG): SVi > 35 mL/m2 and MG ≥ 40 mmHg. Transthoracic echocardiography was repeated at 1-year follow-up. Clinical follow-up was obtained at 12 months, and yearly thereafter until 5-year follow-up was complete for all patients. Results: A total of 272 patients with complete echocardiographic and clinical follow-up were included in our analysis. Their mean age was 80 ± 7 years and the majority of patients (N = 138, 50.8%) were women. 62 patients (22.8% of the study population) were distributed in the LF-LG group, 98 patients (36%) were LF-HG patients, 95 patients (34.9%) were NF-HG, and 17 patients (6.3%) were NF-LG. There was a greater prevalence of comorbidities among LF-LG AS patients. One-year all-cause mortality differed significantly between the four subgroups of AS patients (log-rank p: 0.022) and was more prevalent among LF-LG patients (25.8%) compared to LF-HG (11.3%), NF-HG (6.3%) and NF-LG patients (18.8%). At 5-year follow-up, global mortality remained persistently higher among LF-LG patients (64.5%) compared to LF-HG (47.9%), NF-HG (42.9%), and NF-LG patients (58.8%) (log-rank p: 0.029). At multivariable Cox hazard regression analysis, baseline SVi (HR: 0.951, 95% C.I.; 0.918-0.984), the presence of at least moderate tricuspid regurgitation at baseline (HR: 3.091, 95% C.I: 1.645-5.809) and at least moderate paravalvular leak (PVL) post-TAVI (HR: 1.456, 95% C.I.: 1.106-1.792) were significant independent predictors of late global mortality. LF-LG patients and LF-HG patients exhibited a significant increase in LVEF at 1-year follow-up. A lower LVEF (p < 0.001) and a lower Svi (p < 0.001) at baseline were associated with LVEF improvement at 1-year. Conclusions: Patients with LF-LG AS have acceptable 1-year outcomes with significant improvement in LVEF at 1-year follow-up, but exhibit exceedingly high 5-year mortality following TAVI. The presence of low transvalvular flow and at least moderate tricuspid regurgitation at baseline and significant paravalvular leak post-TAVI were associated with poorer long-term outcomes in the entire cohort of AS patients. The presence of a low LVEF or a low SVi predicts LVEF improvement at 1-year.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” General Hospital of Athens, 11527 Athens, Greece; (G.O.); (A.A.); (M.D.); (C.S.); (M.K.); (P.T.); (K.S.); (M.X.); (N.K.); (G.L.); (A.S.); (C.T.)
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Harari E, Landes U. Post-Transcatheter Aortic Valve Implantation paravalvular leak: multiple aetiologies and no panacea. Eur Heart J 2023; 44:4811-4812. [PMID: 37897337 DOI: 10.1093/eurheartj/ehad696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/30/2023] Open
Affiliation(s)
- Emanuel Harari
- Department of Cardiology, Assuta Ashdod University Hospital, Ben-Gurion University, Ashdod, Israel
| | - Uri Landes
- Department of Cardiology, Edith Wolfson Medical Center, Ha-Lokhamim St 62, Holon 5822012, Israel and Tel-Aviv University, Tel Aviv 6997801, Israel
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Flores-Umanzor E, Cepas-Guillen P, Freixa X. Enhancing success rate in transcatheter closure of paravalvular leaks post-TAVI with vascular plug technology. Eur Heart J 2023; 44:4810. [PMID: 37897360 DOI: 10.1093/eurheartj/ehad688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/30/2023] Open
Affiliation(s)
- Eduardo Flores-Umanzor
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Villaroel Street 170, Barcelona 08036, Spain
| | - Pedro Cepas-Guillen
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Villaroel Street 170, Barcelona 08036, Spain
| | - Xavier Freixa
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Villaroel Street 170, Barcelona 08036, Spain
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Pollari F, Hitzl W, Rottmann M, Vogt F, Ledwon M, Langhammer C, Eckner D, Jessl J, Bertsch T, Pauschinger M, Fischlein T. A Machine Learning Model for the Accurate Prediction of 1-Year Survival in TAVI Patients: A Retrospective Observational Cohort Study. J Clin Med 2023; 12:5481. [PMID: 37685547 PMCID: PMC10488486 DOI: 10.3390/jcm12175481] [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: 07/11/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND predicting the 1-year survival of patients undergoing transcatheter aortic valve implantation (TAVI) is indispensable for managing safe early discharge strategies and resource optimization. METHODS Routinely acquired data (134 variables) were used from 629 patients, who underwent transfemoral TAVI from 2012 up to 2018. Support vector machines, neuronal networks, random forests, nearest neighbour and Bayes models were used with new, previously unseen patients to predict 1-year mortality in TAVI patients. A genetic variable selection algorithm identified a set of predictor variables with high predictive power. RESULTS Univariate analyses revealed 19 variables (clinical, laboratory, echocardiographic, computed tomographic and ECG) that significantly influence 1-year survival. Before applying the reject option, the model performances in terms of negative predictive value (NPV) and positive predictive value (PPV) were similar between all models. After applying the reject option, the random forest model identified a subcohort showing a negative predictive value of 96% (positive predictive value = 92%, accuracy = 96%). CONCLUSIONS Our model can predict the 1-year survival with very high negative and sufficiently high positive predictive value, with very high accuracy. The "reject option" allows a high performance and harmonic integration of machine learning in the clinical decision process.
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Affiliation(s)
- Francesco Pollari
- Cardiac Surgery, Cardiovascular Center, Paracelsus Medical University-Klinikum Nuremberg, 90471 Nuremberg, Germany; (M.R.); (F.V.); (M.L.); (T.F.)
| | - Wolfgang Hitzl
- Research and Innovation Management (RIM), Team Biostatistics and Publication of Clinical Trial Studies, Paracelsus Medical University, 5020 Salzburg, Austria;
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Magnus Rottmann
- Cardiac Surgery, Cardiovascular Center, Paracelsus Medical University-Klinikum Nuremberg, 90471 Nuremberg, Germany; (M.R.); (F.V.); (M.L.); (T.F.)
| | - Ferdinand Vogt
- Cardiac Surgery, Cardiovascular Center, Paracelsus Medical University-Klinikum Nuremberg, 90471 Nuremberg, Germany; (M.R.); (F.V.); (M.L.); (T.F.)
| | - Miroslaw Ledwon
- Cardiac Surgery, Cardiovascular Center, Paracelsus Medical University-Klinikum Nuremberg, 90471 Nuremberg, Germany; (M.R.); (F.V.); (M.L.); (T.F.)
| | - Christian Langhammer
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, 90471 Nuremberg, Germany; (C.L.); (T.B.)
| | - Dennis Eckner
- Cardiology, Cardiovascular Center, Paracelsus Medical University-Klinikum Nuremberg, 90419 Nuremberg, Germany; (D.E.); (J.J.); (M.P.)
| | - Jürgen Jessl
- Cardiology, Cardiovascular Center, Paracelsus Medical University-Klinikum Nuremberg, 90419 Nuremberg, Germany; (D.E.); (J.J.); (M.P.)
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, 90471 Nuremberg, Germany; (C.L.); (T.B.)
| | - Matthias Pauschinger
- Cardiology, Cardiovascular Center, Paracelsus Medical University-Klinikum Nuremberg, 90419 Nuremberg, Germany; (D.E.); (J.J.); (M.P.)
| | - Theodor Fischlein
- Cardiac Surgery, Cardiovascular Center, Paracelsus Medical University-Klinikum Nuremberg, 90471 Nuremberg, Germany; (M.R.); (F.V.); (M.L.); (T.F.)
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