The safety and efficacy of a modified Wrapping technique for the treatment of ascending aortic dilatation

Background

Current data are unclear in terms of the simultaneous treatment of Ascending Aorta Aneurysms (AAD) with a coexisting surgical pathology requiring open heart surgery (OHS), since replacement of the ascending aorta in all of those AAD patients may increase morbidity and mortality in respect with longer time in extracorporeal circulation. To overcome the aforementioned complications in patients with ADD and a concomitant indication for OHS, we have applied a less invasive technique, in contrast to the conventional method of replacement of the ascending aorta with a supracoronary synthetic tubular graft interposition

Purpose

We tested the safety and the efficacy of the Wrapping Ascending Aorta Dilatation (WAAD) technique that is based on the wrapping of the dilated ascending aorta with a synthetic graft from the sinotubular junction to the origin of innominate artery.

Methods

We retrospectively studied 254 patients who underwent ascending aorta surgery from 2000 to 2020 at Euroclinic Hospital of Athens Greece, from the same senior Cardiac Surgeon. Patients with an AAD with a diameter of 40–45mm in combination with a coexisting cardiac surgical pathology requiring OHS were treated with the wrapping technique, while patients with AAD diameter more than 45mm were treated with replacement. The WAAD technique was applied during patient's rewarming period using a longitudinally opened synthetic tubular Dacron graft around the AAD, without increasing the patient's time on extracorporeal circulation. The mean follow-up interval was 12.2±4.5 years.

Results

Two hundred and three patients (80%) were treated with OHS with replacement of the ascending aorta. Fifty one patients (20%) had an AAD with a diameter of 40–45mm (mean diameter 43±3.3mm) in combination with a coexisting cardiac surgical pathology requiring OHS and were treated with the WAAD technique. due to concomitant aortic valve surgery in 34 patients (67%), coronary artery bypass Graft in 10 patients (19.6%) and mitral valve surgery in 7 (14%). One of the patients who underwent mitral valve surgery exhibited AAD as well as dilation of the common pulmonary trunk extending to the right pulmonary artery and had both treated with the wrapping technique. During follow up no AAD recurrence or any other event concerning the ascending aorta or pulmonary artery were observed.

Conclusion

In patients with AAD undergoing OHS for a different cardiac pathology, WAAD is safe and effective and may be beneficial for patients with AAD with an aortic diameter of 40–45mm. Further randomized control studies are needed to confirm our results.

Funding Acknowledgement

Type of funding sources: None.

The wrapping technique as an alternative method for the treatment of ascending aortic dilatation

Background

The natural history of Ascending Aorta Dilatations (AAD) is unpredictable because acute dissections and ruptures have been observed even at aortic diameter sizes as small as 40s mm. Current data are unclear in terms of the simultaneous treatment of Ascending Aorta Aneurysms (AAD) with a coexisting surgical pathology requiring open heart surgery (OHS). To overcome the aforementioned complications in patients with ADD and a concomitant indication for OHS, we have applied a less invasive technique, in contrast to the conventional method of replacement of the ascending aorta with a supracoronary synthetic tubular graft interposition.

Purpose

The safety and efficacy of the Wrapping Ascending Aorta Dilatation (WAAD) technique that is based on the wrapping of the dilated ascending aorta with a synthetic graft from the sinotubular junction to the origin of innominate artery.

Methods

We studied 254 patients who underwent ascending aorta surgery from 2000 to 2020 at a Euroclinic Hospital Greece, from the same senior Cardiac Surgeon. Patients with an AAD with a diameter of 40–45mm in combination with a coexisting cardiac surgical pathology requiring OHS were treated with the wrapping technique, while patients with AAD diameter more than 45mm were treated with replacement. The WAAD technique was applied during patient's rewarming period using a longitudinally opened synthetic tubular Dacron graft around the AAD, without increasing the patient's time on extracorporeal circulation. The mean follow-up interval was 12.2±4.5 years.

Results

Two hundred and three patients (80%) were treated with OHS with replacement of the ascending aorta. Fifty one patients (20%) had an AAD with a diameter of 40–45mm (mean diameter 43±3.3mm) in combination with a coexisting cardiac surgical pathology requiring OHS and were treated with the WAAD technique. due to concomitant aortic valve surgery in 34 patients (67%), coronary artery bypass Graft in 10 patients (19.6%) and mitral valve surgery in 7 (14%). One of the patients who underwent mitral valve surgery exhibited AAD as well as dilation of the common pulmonary trunk extending to the right pulmonary artery and had both treated with the wrapping technique. During follow up no AAD recurrence or any other event concerning the ascending aorta or pulmonary artery were observed.

Conclusion

In patients with AAD undergoing OHS for a different cardiac pathology, WAAD is safe and effective and may be beneficial for patients with AAD with an aortic diameter of 40–45mm. Further randomized control studies are needed to confirm our results.

Funding Acknowledgement

Type of funding sources: None.

TAVI for low-flow, low-gradient severe aortic stenosis: impact on outcome

Background

Several factors have been identified as predictors of events after transcatheter aortic valve implantation (TAVI) but the impact of transaortic flow (F) and mean transaortic gradient (MG) upon outcomes is controversial. This study aimed to clarify the prognostic role of low FL and low MG after TAVI.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2], referred for TAVR at our institution were consecutively enrolled. Given the aim of this analysis, patients were divided according to F and MG into four groups: 1) LF-LG Patients with low flow (SVi <35ml/m2) and low mean gradient (MG <40mmHg), 2) NF-LG Patients with normal flow (SVi ≥35ml/m2) and low mean gradient (MG <40mmHg), 3) LF-HG Patients with low flow (SVi <35ml/m2) and high mean gradient (MG ≥40mmHg) and 4) NF-HG patients with normal flow (SVi ≥35ml/m2) and high mean gradient (MG ≥40mmHg). Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analyzed. One-year outcomes were compared between the 4 groups of patients. Primary clinical endpoint was all-cause mortality at long term follow up, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

In total 255 patients undergoing TAVI at our institution were included in our study: 35 (13.7%) patients with LF-LG, 17 (6.7%) with NF-LG, 108 (42.4%) with LF-HG and 95 (37.3%) with NF-HG. There was a statistically significant difference in gender distribution between the groups with most females being represented in the NF-HG group (64.2%) vs the LF-LG (31.4%), the NF-LG (47.1%) or the LF-HG group (50.9%) (p=0.008). Moreover, LF-LG patients were younger than NF-LG, LF-HG or NF-HG patients (ANOVA, p=0.037). There was a greater prevalence of prior myocardial infarction (MI) in the LF-LG group (34.5%) vs 20% in the NF-LG, 16.1% in the LF-HG and 20.2% in the NF-HG group (p=0.005). At 1 year follow up there were no statistically significant differences in major vascular complication, major bleeding complication or permanent pacemaker implantation rates between the groups, (all p>0.05). At a median follow up of 36 months IQR (17, 56) all-cause mortality was significantly higher in the LF-LG group as opposed to the NF-LG, LF-HG and NF-HG groups (77.41% vs 60% vs 55.67% vs 46.15% respectively, p=0.005). These results were confirmed by multivariate logistic regression analysis, as the combination of low flow and low mean gradient emerged as the strongest long term all cause mortality predictor (HR: 5.39, 95% confidence intervals: 1.72–16.83; p=0.004)

Conclusion

Combination of low flow and low mean transaortic gradient portends a worse prognosis after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Impact of significant preprocedural mitral regurgitation on mortality after transcatheter aortic valve implantation

Background

Mitral regurgitation (MR) is commonly encountered in patients with severe aortic stenosis scheduled for transcatheter aortic valve implantation (TAVI). The presence of significant pre-procedural MR, however, has not been accounted in pivotal trials of TAVI and data regarding its independent impact on outcome are contradictory.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were stratified into two groups according to MR severity: ≤ grade 1 were defined as non-significant and ≥ grade 2 as significant. Change in MR was determined by comparison between baseline and 30-day echocardiogram. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

A total of 331 consecutive patients were enrolled in the study: 247 (74.6%) had non-significant MR and 84 (25.4%) patients had significant MR at baseline. Patients with significant pre-procedural MR had lower baseline ejection fraction (47.7±10.4% versus 51.2±8.4%, p=0.002), higher pulmonary artery systolic pressure (52±14.3mmHg versus 42.5±11.1mmHg, p<0.0001) and higher rates of moderate or severe tricuspid regurgitation (TR) (50% versus 19.4%) compared to patients with non-significant MR. Of all patients, mitral regurgitation improved in 9.5%, remained the same in 83.9%, and worsened in 6.6% 30 days after TAVR. In a multivariable analysis, pre-procedural TR severity was predictor of improved mitral regurgitation [OR 3.003,(95% CI 1.216–7.417, p=0.017)].

The primary clinical end point occurred in 44.7% of all patients during a follow-up period of 36.6.±25.9 months. Patients with significant pre-procedural MR had significantly higher rates of all-cause mortality compared to patients with non-significant (54.7% and 41.3%, respectively; log rank p=0.015). Performing a multivariable analysis demonstrated that preprocedural MR severity could independently predict cumulative mortality [OR 0.480, (95% CI 0.247–0.932, p=0.03)].

Conclusion

Significant pre-procedural MR is common in patients undergoing TAVI and is associated with increased all-cause mortality. TAVI is associated with a significant improvement in MR, especially in severe types. These data provide new insights in the crucial role of mitral regurgitation in the risk assessment of TAVI candidates.

Funding Acknowledgement

Type of funding sources: None.

Effect of concomitant atrioventricular valve regurgitation on the outcome after transcatheter aortic-valve implantation

Background

Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or more. The impact of coexistent tricuspid regurgitation (TR) remains to be determined.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA)≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were divided into 4 groups according to MR and TR severity pre-procedurally: no/mild MR and TR, moderate/severe MR, moderate/severe TR, moderate/severe MR and TR. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

A total of 244 consecutive patients were enrolled in the study: 148 (60.7%) patients no/mild MR and TR, 32 (13.1%) moderate/severe MR, 35 (14.3%) moderate/severe TR, 29 (11.9%) moderate/severe MR and TR pre-procedurally. There was significant difference in pre-procedural pulmonary artery systolic pressure (PASP) among groups (no/mild MR and TR: 40.8±10 mmHg, moderate/severe MR: 46.6±11.2 mmHg, moderate/severe TR: 49.9±13mmHg, moderate/severe MR and TR: 59.8±15.2mmHg, p<0.0001). The Kaplan–Meier curves for 2 year mortality showed that the severity of TR was associated with poor survival. Interestingly, patients with moderate/severe MR and TR had the worse survival (no/mild MR and TR (91.2%), moderate/severe MR (78.1%), moderate/severe TR (62.9%), moderate/severe MR and TR (62.1%), p<0.0001).

Conclusion

The presence of concomitant moderate or severe mitral and tricuspid valve regurgitation was associated with the higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.

Funding Acknowledgement

Type of funding sources: None.

Novel computed-tomography derived prognostic markers in patients undergoing TAVI with a self-expanding valve

Introduction

Transcatheter aortic valve implantation is the treatment of choice in a consistently expanding group of patients with severe aortic valve stenosis. Tricuspid and mitral annular dilatation with consequent valvular regurgitation are associated with adverse outcome. Computed tomography angiography (CTA) is routinely performed for preprocedural evaluation of vascular access and prosthesis sizing.

Purpose

To evaluate the impact of mitral and tricuspid annular dimensions in preprocedural CTA on prognosis of patients undergoing TAVI with a self-expanding valve.

Methods

CTAs of consecutive patients undergoing TAVI in a single high-volume center between 2016 and 2019 were retrospectively evaluated. Maximal septolateral tricuspid annular diameters (TAD) and mitral annular diameters (MAD) were obtained and measured from properly angulated three dimensional CTA datasets. Moreover, maximal pulmonary artery diameter perpendicular to the long axis was measured in every patient. Patients were followed up by clinical visits or telephone contacts. As clinical events were defined all-cause mortality, stroke and heart failure hospitalization.

Results

In total 123 patients were included in the study. The mean follow-up duration was 875±383 days and 21 clinical events were recorded. There was a moderate but statistical significant correlation between TAD and both pulmonary artery diameter (r=0.39, p<0.001) and pulmonary artery systolic pressure by echocardiography (r=0.23, p=0.015). In univariate logistic regression analysis pulmonary artery diameter and TAD were both associated with heart failure hospitalization (p=0.03 and 0.02 respectively). In addition, MAD was associated with total events (OR: 0.43, 95% CI 0.19–0.99, p=0.048). The relationship of MAD with events remained significant after adjustment for sex, age and tricuspid annular dimensions (OR: 0.28, 95% CI 0.1–0.79, p=0.02).

Conclusions

TAD and MAD were associated with heart failure rehospitalization and clinical events respectively in patients undergoing TAVI with a self-expanding valve. Further larger prospective studies are warranted to evaluate the prognostic value of these CTA markers.

Funding Acknowledgement

Type of funding sources: None.

Percutaneous access versus surgical cutdown in TAVI: vascular and bleeding complications

Background

Access options for transcatheter aortic valve implantation (TAVI) are vital, since use of large sheaths may lead to access-related complications and bleeding.

Purpose

To determine the access-related vascular and bleeding complications of patients undergoing transfemoral TAVI.

Methods

Consecutive patients scheduled for transfemoral TAVI were retrospectively grouped according to vascular access [percutaneous access (p-TAVI) and surgical cutdown (sc-TAVI)]. Primary end points were vascular and bleeding complications, based on the VARC-II criteria.

Results

Totally, 187 patients were included in the analysis (p-TAVI: 124 patients; sc-TAVI: 63 patients). Mean procedure time was shorter in the p-TAVI group compared to the sc-TAVI group (45.65±6.17 min versus 64.05±15.73 min, p<0.001). Contrast use was lower in the p-TAVI group compared to the sc-TAVI group (81.18±15.96 ml versus 106.75±25.67 ml, p<0.001), which resulted in higher rates of acute kidney injury in the sc-TAVI group (13% versus 1%, p=0.01). Vascular access complications occurred numerically but not statistically more often in the p-TAVI group compared to the sc-TAVI group (11% versus 5% for minor complications and 6% versus 3% for major complications respectively, p=0.10). Patients in the p-TAVI group had the same minor and major bleeding complications compared to the sc-TAVI group (11% versus 8% for minor, 10% versus 6% for major bleeding complications respectively, p=0.49), but no life-threatening bleeding (0% versus 1.5%).

Conclusions

Transfemoral access options in TAVI (surgical cutdown or percutaneous) have similar efficacy and should be offered in TAVI patients if and when appropriate.

Funding Acknowledgement

Type of funding sources: None.

Impact of severe mitral annular calcification on paravalvular leak after transcatheter aortic valve implantation

Aims

Paravalvular leak (PVL) remains a frequent complication after transcatheter aortic valve implantation (TAVI) and seems to affect short- and long-term survival.

Purpose

The aim of this study was: 1) to identify anatomical predictors of PVL after TAVI and 2) assess the impact of PVL on cumulative survival.

Methods and results

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analyzed. Patients were stratified into two groups according to the presence of PVL after TAVI and were followed up postoperatively with clinical and echocardiographic assessment. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium 2. In total, 291 patients were included (male: 50.2%, mean age: 80±7.6 years) in our study. Of these, 165 (56,8%) presented at least mild PVL after TAVI (mild: 85,5%, moderate: 13.3% and severe: 1.2%). The median follow-up period was 27.3 [min. 0, max 113 months. Two patients with severe PVL were excluded from the analysis. In the follow up period, there was no significant difference regarding all-cause mortality between patients with and those without PVL after TAVI, independently from the degree of PVL (log rank: 0.991 - Figure 1). Severe aortic annulus calcification, the presence of a bicuspid aortic valve and aortic root angulation, as assessed by computed tomography (CT), were found to associate with PVL after TAVI in univariate analysis. In the multivariate analysis, severe aortic annulus calcification was found to be the only independent predictor of mild or moderate PVL after TAVI [Exp(B): 1.540, 95% Confidence Interval: 1.067–2.224, B=0.432, p=0.021].

Conclusion

The presence of mild or moderate PVL after TAVI was not found to affect cumulative survival in the 27 months of follow up period. Severe annulus calcification assessed by CT-scan, was found to be the only independent predictor of PVL after TAVI.

Funding Acknowledgement

Type of funding sources: None.

The effect of permanent pacemaker implantation following transcatheter aortic valve implantation upon survival

Purpose

Transcatheter aortic valve implantation (TAVI) is often followed by conduction abnormalities, leading to a permanent pacemaker implantation (PPI). Data regarding the clinical impact of PPI following TAVI is yet to be established.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analyzed. Patients were stratified into two groups according to the need for PPI after TAVI and were followed up postoperatively with clinical and echocardiographic assessment. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium 2.

Results

In total, 292 patients were included (male: 50.2%, mean age: 80±7.6 years) in our study. Of these, 109 (37.5%) underwent PPI simultaneously or shortly after TAVI. The median follow-up period was 27.3 In this period, all-cause mortality showed no significant difference between patients with and those without PPI after TAVI (log-rank p=0.756), even after excluding patients with a pre-existing pacemaker from the analysis. Subgroup analysis also showed no difference in survival between patients with low ejection fraction (<50%) and those with preserved (≥50%) receiving a permanent pacemaker after TAVR (log-rank p=0.269). Taking into consideration factors that were found to associate to PPI in univariate analysis (pre TAVI - ejection fraction, pulmonary artery systolic pressure and New York Heart Association functional class) in a multivariate model, pre TAVI pulmonary artery systolic pressure was found to be an independent predictor of peri-procedural PPI [Exp(B): 0.977, 95% Confidence Interval: 0.957–0.998, B=−0.023, p=0.029]. Pre-TAVI conduction abnormalities and the degree of aortic annulus calcification, as assessed by computed-tomography, were not found to predict PPI after TAVI.

Conclusion

PPI following TAVI was not associated with survival at 27 months of follow-up, independently from the pre TAVI ejection fraction.

Figure 1

Funding Acknowledgement

Type of funding source: None

One-year echocardiographic outcomes of transcatheter aortic valve implantation with or without predilatation of the aortic valve: insights from the multicenter, randomized DIRECT trial

Introduction

Transcatheter aortic valve implantation (TAVI) has become the standard of care for high-risk and inoperable surgical patients and a valid alternative in intermediate-risk patients with severe aortic stenosis.The DIRECT trial (Predilatation in Transcatheter Aortic Valve Implantation Trial) was a multicenter, randomized, clinical trial designed to evaluate the safety and efficacy of TAVI with or without balloon aortic valvuloplasty (BAV) in patients with symptomatic, severe aortic valve stenosis.

Purpose

To compare the one year echocardiographic findings among patients, who underwent TAVI using a self-expanding valve with or without BAV.

Methods

A total of 171 patients with severe aortic stenosis were randomly assigned at 4 tertiary centers to undergo TAVI with the use of self-expanding prostheses with (pre-BAV) or without pre-dilatation (no-BAV). Follow up transthoracic echocardiography was performed 1 year after TAVI.

Results

Of 171 patients, 86 patients were randomized to pre-BAV group and 85 to no-BAV group. One year echocardiographic follow up was available in 146 patients. In one year follow up there was no significant difference between pre-BAV and no-BAV group in aortic valve area (1.84±0.39cm2 vs. 1.85±0.44cm2, p=0.79), peak aortic valve gradient (15.95±9.97 mmHg vs. 14.51±6.60 mmHg, p=0.35), mean aortic valve gradient (8.37±5.01 mmHg vs. 7.99±4.04 mmHg, p=0.64), aortic valve peak velocity (1.90±0.51 m/s vs. 1.80±0.42m/s, p=0.24), ejection fraction (54.19±8.36% vs. 53.19±9.58%, p=0.52) and pulmonary artery systolic pressure (41.86±14.34 mmHg vs. 40.71±12.40 mmHg, p=0.64). The incidence of moderate or severe paravalvular regurgitation (PVL) in 1 year follow up was 6.2% without significant difference between the 2 study groups (5.7% in the no-BAV group vs. 6.6% in the pre-BAV group, p=0.83).

Conclusions

Direct transcatheter aortic valve implantation has no impact on one-year prosthesis function and PVL in patients undergoing TAVI with self-expanding valve

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic

Echocardiographic assessment of functional changes of prosthetic valve after transcatheter aortic valve implantation in one year follow up: insights from the multicenter, randomized DIRECT trial

Introduction

The DIRECT trial (Predilatation in Transcatheter Aortic Valve Implantation (TAVI) Trial) was a multicenter, randomized, clinical trial designed to evaluate the safety and efficacy of TAVI with or without balloon aortic valvuloplasty (BAV) in patients with symptomatic, severe aortic valve stenosis.

Purpose

To investigate by echocardiography the functional changes of self-expanding prosthetic valves during the first year after TAVI with or without BAV.

Methods

One hundred seventy one consecutive patients with severe aortic stenosis were enrolled at 4 centers and randomized to TAVI using self-expanding prostheses with (pre-BAV) or without pre-dilatation (no-BAV). Transthoracic echocardiography was obtained at baseline, 30 days and 1 year after TAVI.

Results

Of 171 patients, 86 patients were randomized to pre-BAV group and 85 to no-BAV group. Over the one year, 7 (4%) patients died and in 18 (10%) there was no available paired 30 day/1 year echo. At baseline echocardiography the peak and mean aortic valve gradient and the aortic valve area (AVA) in no-BAV group were 77.31±22.56 mmHg, 47.23±14.98 mmHg and 0.69±0.16cm2 and in pre-BAV group 81.97±23.17 mmHg, 49.39±14.78 mmHg and 0.65±0.15cm2 respectively. One year after TAVI, patients in no-BAV and pre-BAV group showed stable peak and mean aortic valve gradients similar to those at 30 days (from 16.36±7.88 to 14.51±6.6 mmHg vs. 17.17±8.88 to 15.95±9.97 mmHg and from 8.87±4.23 to 7.99±4.04 mmHg vs. 9.39±4.79 to 8.38±5.02 mmHg respectively, P<0.001 vs. baseline). The AVA was similarly stable in one year follow up in no-BAV group (from 1.85±0.43cm2 to 1.85±0.44cm2, P<0.001 vs. baseline) and in pre-BAV group (from 1.86±0.49cm2 to 1.84±0.39cm2, P<0.001 vs. baseline). The incidence of moderate or severe paravalvular regurgitation remained unchanged in both groups (from 4.7% to 5.7% in no-BAV group and from 5.8% to 6.6% in pre-BAV group).

Conclusions

In both pre-BAV and no-BAV groups the improvement in hemodynamics of self-expanding prosthetic valves remained durable during the one year echocardiographic follow up assessment.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): MEDTRONIC

No impact of direct implantation of a self-expanding valve on one-year clinical outcomes. Insights from the multicenter, randomized DIRECT trial

Introduction

The DIRECT trial (Predilatation in Transcatheter Aortic Valve Implantation Trial) evaluated in a randomized fashion the safety and efficacy of direct (without balloon pre-dilatation) implantation of a self-expanding valve in all comers undergoing TAVI.

Purpose

To investigate the impact of direct implantation of a self-expanding valve on one-year clinical outcomes.

Methods

DIRECT trial randomized consecutive patients with severe aortic stenosis at 4 tertiary centers to undergo TAVI with the use of self-expanding prostheses with (pre-BAV) or without pre-dilatation (no-BAV). The primary endpoint was device success according to the VARC-2 criteria. Secondary endpoints included periprocedural mortality and stroke, new permanent pacemaker implantation and vascular complications.

All cause death, cardiac death, stroke and heart failure hospitalizations were recorded at one year and compared between the two groups using Kaplan-Meier plots.

Results

In total 171 patients were randomized in 4 centers. In the intention to treat analysis 86 patients were randomized to the pre-BAV group and 85 patients to the no-BAV TAVI group.

The device success according to the VARC-2 criteria was non-inferior in the no-BAV group compared to the pre-BAV group (65/85 - 76.5% for no-BAV versus 64/86 – 74.4% for pre-BAV, mean difference = 2.1%, 90% CI: −8.9 to 13). In the no-BAV group 25 (29.4%) patients underwent post balloon dilatation and in the pre-BAV group 13 patients (15.1%) (p=0.03).

At one year 4 deaths were recorded in pre-BAV group (4.7%) and 3 deaths in no-BAV group (3.5%). There was no difference in Kaplan-Meier plots between the two groups in all-cause mortality (log-rank p=0.72, figure). Similarly, there was no difference in one-year incidence of stroke (1 in pre-BAV and 2 in no-BAV group, log-rank p=0.55), cardiac death (log-rank p=0.66), non-cardiac death (log-rank p=0.98) and heart failure hospitalizations (1 in pre-BAV versus 3 in no-BAV group, log-rank p=0.31). Lastly, there was no difference in the incidence of permanent pacemaker implantation between the two groups at one year (27/67 in no-BAV group versus 20/69 in pre-BAV group, log-rank p=0.24)

Conclusions

Direct transcatheter aortic valve implantation is non-inferior to the procedure with pre-dilatation in self-expanding valve. Despite the overall low rate of events, direct procedure has no impact on clinical outcomes at one year.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic

Thin cap fibroatheroma and plaque rupture is associated with carotid thermal heterogeneity in patients presenting with acute myocardial infarction

 

Microwave radiometry (MWR) has been applied successfully in the evaluation of carotid atherosclerosis, measuring reliably temperature heterogeneity of atherosclerotic plaques. Recent studies have shown an association between increased carotid temperature heterogeneity (ΔT) detected by MWR and cardiovascular events. Vulnerable plaques of the coronary arteries, share common characteristics such as the thin cap fibrous cap, that make the prone to rupture in the presence of stimulus such as shear stress or inflammation. Optical coherence tomography (OCT) is an imaging method, by which the fibrous cap and the presence of plaque rupture can be accurately in vivo visualized.

Purpose

To evaluate the impact of carotid temperature heterogeneity on the culprit plaque morphology on patients presenting with acute myocardial infarction.

Method

A total of 37 patients undergoing percutaneous coronary intervention (PCI) for an acute myocardial infarction who had an identifiable de novo culprit lesion in a native coronary artery, were enrolled in this study. All patients underwent PCI and Optical Coherence Study (OCT) within 12 hours since symptom onset. The OCT study was performed according to the standard techniques and acquired images were analyzed by 2 independent investigators., After the completion of the PCI all patients underwent MWR of both carotid arteries and ΔT was defined as maximal temperature detected along each carotid artery minus minimum.

Results

Thirty four patients with acute myocardial infarction 21 with STEMI (61.76%) and 13 (38.23%) with NSTEMI were included in the study. Thin cap fibroatheroma (TCFA) was present in 31 patients (91.1%), while all ruptured plaques had a TCFA compared to 11 TCFA (78.57%) observed in plaques that had no rupture (p=0.03). HsCRP was significantly increased in ruptured plaques compared to non ruptured ones (14.41±4.02 versus 9.9±2.5, p<0.005). Mean ΔT was significantly increased in ruptured plaques compared to no ruptured ones (1.01±0.31 versus 0.51±0.14°C, p<0.005), as well as in plaques with TCFA compared to those without a TCFA (0.82±0.37 versus 0.60±0.05°C, p=0.001). In the multivariate analysis DM, hsCRP, and ΔT were entered from which DM (OR 4.12; 95% CI 0.77–22.07; P=0.07) and ΔTau ((OR for 0.1°C increase 1.43; 95% CI 1.03–1.98; P=0.03) remained in the final model, with ΔT being the only variable independently associated with the presence of TCFA. Similarly regarding plaque rupture, STEMI, hsCRP, and ΔT were entered in the multivariate analysis from which hsCRP (OR 1.51; 95% CI 0.99–2.28; P=0.051) and ΔTau ((OR for 0.1°C increase 3.40; 95% CI 1.29–8.96; P=0.013) remained in the final model, with ΔT being the only variable independently associated with the presence of rupture.

Conclusions

Carotid thermal heterogeneity is associated with TCFA and plaque rupture in patients with acute myocardial infarction.

Funding Acknowledgement

Type of funding source: None

Carotid artery temperature reduction with statin therapy in patients with familial hyperlipidemia syndromes

Background

Familial hypercholesterolemia (FH) syndromes constitute an important risk factor for premature atherosclerosis. Microwave radiometry (MWR) assess non-invasively carotid artery temperatures reflecting inflammation. Recent data support that statin therapy, that constitutes the cornerstone for the treatment of FH, reduces systemic inflammation.

Purpose

To investigate the impact of statin therapy either with simvastatin or with combination simvastatin plus ezetimibe on carotid artery temperatures.

Methods

Consecutive patients with diagnosis of either heterozygous hypercholesterolemia (hFH) or combined hyperlipidemia (FCH) not under statin therapy for at least 6 months were included in the study. FH pts were assigned to either simvastatin 40 mg or simvastatin 40 mg plus ezetimibe 10mg according to the discretion of the physician. FH patients who refused statin therapy were used as control group for the assessment of statins effect. In all subjects, common carotid intima-media thickness (ccIMT) was measured in the last 2 cm of the far wall of both common carotids close to the carotid bifurcation and ΔT (maximum-minimum) temperature measurements were performed across each carotid during MWR evaluation. Examinations were performed at baseline and after 6 months. Blood's lipid profile was also obtained in all patients.

Results

In total 115 patients were included in the study. Of them 40 patients received simvastatin (19 hFH and 11 FCH), 41 simvastatin + ezetimibe (31hFH and 10 FCH) and 34 (21 hFH and 13 FCH) no statin. There was no difference at baseline in ccIMT and ΔT measurements between hFH and FCH patients (0.10±0.03 vs 0.10±0.02, p=0.74 and 0.88±0.38 vs 0.84±0.32, p=0.52, respectively). Patients who refused statin therapy did not show any reduction in ccIMT and ΔT measurements between baseline and follow up (ccIMT: 0.10±0.02 vs 0.09±0.02, p=0.06 and ΔT: 0.72±0.26 vs 0.70±0.26). In contrast, there was a significant reduction in ccIMT and ΔT for patients under both simvastatin (0.10±0.03 vs 0.09±0.01, p=0.004 for ccIMT and 0.83±0.34 vs 0.63±0.24, p=0.04 for ΔT) and simvastatin + ezetimibe therapy (0.11±0.03 vs 0.09±0.02, p<0.001 and 1.00±0.38 vs 0.69±0.23, p<0.001 for ΔT). Patients under combination therapy reduced more significantly their carotid artery temperatures compared to patients under simvastatin monotherapy or patients without statin (−0.31±0.46 vs −0.2±0.40 vs −0.01±0.37, ANOVA p=0.04, Figure 1).

Conclusions

Both simvastatin and simvastatin + ezetimibe therapy among the beneficial effect on IMT, reduced carotid wall inflammation in FH pts.

Figure 1

Funding Acknowledgement

Type of funding source: None

Coronary plaque rupture is associated with carotid thermal heterogeneity in patients presenting with acute myocardial infarction

Introduction

Vulnerable plaques of the coronary arteries, share common characteristics such as the thin cap fibrous cap, that make the prone to rupture in the presence of stimulus such as shear stress or inflammation. Optical coherence tomography (OCT) is an imaging method, by which the fibrous cap and the presence of plaque rupture can be accurately in vivo visualized. Recent studies have shown an association between increased carotid temperature heterogeneity (ΔT) detected by microwave radiometry (MWR) and cardiovascular events.

Purpose

To evaluate the impact of carotid temperature heterogeneity on the culprit plaque morphology on patients presenting with acute myocardial infarction.

Method

A total of 37 patients undergoing percutaneous coronary intervention (PCI) for an acute myocardial infarction who had an identifiable de novo culprit lesion in a native coronary artery, were enrolled in this study. All patients underwent PCI and Optical Coherence Study (OCT) within 12 hours since symptom onset. The culprit lesion of the angiogram was clearly identified by a combination of ECG, wall motion abnormalities seen in cardiac ultrasound, and coronary angiogram. The OCT study was performed using the LightLab OCT wire, and acquired images were analyzed by 2 independent investigators using previously validated criteria for OCT plaque characterization. After the completion of the PCI all patients underwent MWR of both carotid arteries and ΔT was defined as maximal temperature detected along each carotid artery minus minimum.

Results

Thirty four patients with acute myocardial infarction 21 with STEMI (61.76%) and 13 (38.23%) with NSTEMI were included in the study. STEMI patients had more ruptured plaques compared to NSTEMI patients (71.41 versus 38.46%, p=0.053). Thin cap fibroatheroma (TCFA) was present in 31 patients (91.1%), while all ruptured plaques had a TCFA compared to 11 TCFA (78.57%) observed in plaques that had no rupture (p=0.03). HsCRP was significantly increased in ruptured plaques compared to non ruptured ones (14.41±4.02 versus 9.9±2,5, p<0.005). Mean ΔT was significantly increased in ruptured plaques compared to no ruptured ones (1.01±0.31 versus 0.51±0.14°C, p<0.005), as well as in plaques with TCFA compared to those without a TCFA (0.82±0.37 versus 0.60±0.05°C, p=0.001). In the multivariate analysis, STEMI, hsCRP, and ΔT were entered from which hsCRP (OR 1.51; 95% CI 0.99–2.28; P=0.051) and ΔT ((OR for 0.1°C increase 3.40; 95% CI 1.29–8.96; P=0.013) remained in the final model, with ΔT being the only variable independently associated with the presence of rupture.

Conclusions

Carotid thermal heterogeneity is associated with the presence of plaque rupture in patients with acute myocardial infarction. Further studies are needed in order to assess the possible prognostic impact of carotid ΔT on such population.

Funding Acknowledgement

Type of funding source: None

Percutaneous coronary intervention with everolimus-eluting stents versus coronary artery bypass surgery in patients with stable angina and an isolated proximal left anterior descending artery disease

Background/Introduction

Revascularization of the proximal segment of left anterior descending artery (pLAD) demonstrates an additional prognostic significance in survival for patients with multivessel disease. It is also indicated for symptomatic relief in patients with stable angina who are receiving optimal medical treatment in the presence of limiting angina or angina equivalent. Both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are still commonly needed as therapeutic options for pLAD disease.

Moreover, Everolimus-eluting stents (EES) have demonstrated superiority in safety and efficacy among other types of second or new generation drug-eluting stents.

Purpose

We aim to evaluate the long-term outcomes of PCI with EES compared to CABG surgery with left internal mammary artery, in patients with stable angina and an isolated single vessel pLAD disease.

Methods

The sample consisted of 824 patients with isolated pLAD and chronic stable angina; 445 participants were included in the EES-PCI group, and 379 were included in the CABG group. The study's primary endpoint was the occurrence of major adverse cardiac events (MACEs), namely, cardiac death, myocardial infarction (MI) not attributed to a non-target vessel and target lesion revascularization as a composite index. Secondary endpoints were Patient-Related Outcome (PRO; a composite index of all-cause mortality, any MI related to any coronary artery, any revascularization conducted to any coronary artery), individual components of MACEs, recurrence of stable or unstable angina or a nonfatal arrhythmia and disease progression of other lesions. For the comparisons between the two groups, chi-square tests and Fisher's exact tests, were used, as appropriate.

Results

During the 4.6 years of follow-up period, no statistically significant difference was observed between the two study groups in respect to the primary endpoint MACE (8.1% versus 7.4%, p=0.71). Concerning secondary endpoints, repeat revascularization (3.6% versus 2.9%, p=0.58), cardiac death (2.9% versus 3.2%, p=0.84), MI (1.6% versus 1.3%, p=0.76) and PRO (16.9% versus 17.7%, p=0.76) did not significantly differ between the two groups. Recurrence of angina was more frequent in the EES-PCI group (14.9% versus 8.4%, p=0.005) even though higher Class of angina was found less common in EES patients than in CABG patients (p<0.001). Patients treated with EES-PCI had lower rates of onset of arrhythmias compared to those treated with CABG (6.3% versus 11.9%, p=0.005). Finally, revascularization in other than target lesion was more frequent in the stent than in the surgery arm (6.3% versus 3.2%, p=0.04); as a consequence, higher rates of revascularization in any vessel was recorded in the PCI group than the CABG one (9.9% versus 5.8%, p=0.03).

Conclusion

PCI with EES seem to have similar long-term clinical outcomes compared with CABG in patients with isolated pLAD disease.

Funding Acknowledgement

Type of funding source: None

Long-term outcomes after transcatheter aortic valve implantation. An analysis of 5-year survival and beyond

Background

Transcatheter aortic valve implantation (TAVI) has seen an unprecedented rise in the past decade and has become the gold-standard therapy for inoperable, high- and intermediate-risk patients with aortic valve stenosis.

Purpose

To investigate the long-term clinical outcomes (5-year survival and beyond) of patients undergoing TAVI.

Methods

Consecutive patients who underwent TAVI with a self-expanding valve between 2012 - 2015 were included in the study. Patients with bicuspid valves and valve-in-valve procedures were excluded. Clinical follow-up was performed at specified time intervals (30-day post TAVI and yearly thereafter). The primary endpoint of this study was to evaluate survival rates in the long-term (≥5 years). Secondary endpoints were echocardiographic findings and clinical status at 5 years. All endpoints were considered as per the VARC-2 criteria and the latest consensus documents.

Results

In total, 267 patients were included in the study. Complete follow-up was complete in 189 (70%) patients. The mean age at implantation was 80.71±6.81 years, 129 (48%) were female, mean logistic EuroSCORE was 24.28±8.64% and 73% of patients were at NYHA Class III. The median follow-up was 4.0±1.5 years.

Before the procedure, ejection fraction (EF) was 49.92±9.37%, mean gradient was 48.83±14.68mmHg, pulmonary artery systolic pressure (PASP) was 44.31±12.72mmHg and aortic valve area was 0.98±5.02cm2.

All patients received the self-expanding valve (mean valve size was 27.60±2.12mm), with the majority of them undergoing transfemoral TAVI (71%). Predilation was performed in 77% of the population and post TAVI dilation was performed in 20%.

Compared to pre TAVI values, EF was higher at 50.66±9.37% (p=0.041), mean gradient was lower at 9.41±4.65mmHg (p<0.001), PASP was lower at 41.55±9.93mmHg (p=0.005) and aortic valve area was higher at 1.69±0.81cm2 (p<0.001) post TAVI.

At the end of the fifth year, 160 (60%) patients were alive. Mean survival post TAVI was 32 months (median: 32.2 months, range: 0–91.2 months) and the majority of deaths were non-cardiac in nature (78%). Also, 43% patients of patients were at NYHA Class I, 50% were at NYHA Class II and 7% were at NYHA Class III. At multivariate analysis, sole independent predictor of death at 5 years was baseline PASP levels (OR 1.027, 95% CI: 1–1.054, p=0.049).

Conclusion

Transcatheter aortic valve implantation offers a viable solution for aortic stenosis patients and long-term results beyond 5 years are reassuring. Further studies are necessary in order to shed a light for very long-term outcomes.

Funding Acknowledgement

Type of funding source: None

Prognostic implication of electrocardiographic left ventricular strain in patients undergoing Transcatheter Aortic Valve Implantation

Background

Electrocardiographic (ECG) strain has been linked to excess cardiovascular morbidity and mortality in asymptomatic patients with aortic stenosis.

Purpose

We aim to determine the differential impact of baseline ECG-strain on long-term mortality after transcatheter aortic valve implantation (TAVI).

Methods

Patients with severe and symptomatic aortic stenosis (effective orifice area [EOA]≤1cm2), who were scheduled for TAVI with a self-expanding valve between May 2015 and May 2018 were consecutively enrolled. Left ventricular strain was defined as the presence of ≥1mm convex ST-segment depression with asymmetrical T-wave inversion in leads V5 to V6 on baseline ECG. Patients were excluded, if they had bundle branch block or a permanent pacemaker at baseline. Baseline parameters were compared, and multivariate Cox proportional hazard regression models were generated to assess outcome difference. The primary clinical endpoint was cumulative mortality defined according to the criteria proposed by the Valve Academic Research Consortium-2.

Results

Of the 171 patients screened, 56 patients were excluded due to left bundle branch block or paced rhythm. In the 115 included patients (mean age: 81.4±7), 36 patients (31.3%) had strain pattern on pre-TAVI ECG. There were no differences in baseline characteristics between the two groups. During a median follow-up of 2.32 years (IQR 1.62 to 3), 11 patients (9.6%) reached the primary clinical endpoint. Patients in the strain group had higher incidence of all-cause mortality compared to patients without left ventricular strain (25% vs 2.5%, χ2=14.4, p<0.001). Kaplan-Meier survival analysis showed a significantly decreased cumulative probability of survival at 3 years in patients with LV-strain compared with patients without LV-strain (log-rank p=0.002, Figure 1). In the multivariate analysis, left ventricular strain [Exp(B): 8.952, 95% Confidence Interval (CI): 1.215–65.938, B=2.192, p=0.031] and QRS duration [Exp(B): 1.058, 95% CI: 1.022–1.095, B=0.056, p<0.001] were found to be independent predictors of all-cause mortality after TAVI.

Conclusion

Baseline ECG left ventricular strain was an independent predictor of long-term mortality post TAVI. Systematic strain measurements might aid in risk-stratifying patients scheduled for TAVI.

Figure 1

Funding Acknowledgement

Type of funding source: None

P2802Second-generation drug-eluting stents versus coronary artery bypass surgery in patients with stable angina and an isolated lesion in the proximal left anterior descending artery

Background/Introduction

Both coronary artery bypass grafting surgery (CABG) and percutaneous coronary intervention (PCI), especially with the use of new-generation drug-eluting stents (DES), remain the most common therapeutic options of coronary artery disease, especially when the proximal segment of left anterior descending artery (pLAD) is involved. There are only a small number of studies comparing these approaches in patients with isolated lesions in LAD.

Purpose

We aim to compare the long-term outcomes of PCI with second-generation DES versus CABG surgery with left internal mammary artery, in patients with stable angina and an isolated single vessel pLAD disease.

Methods

The study population consisted of 1010 consecutive patients with stable angina and an isolated pLAD that were treated either with PCI with second generation (zotarolimus or everolimus) DES (631 patients) or with CABG surgery (379 patients). The primary endpoint was the occurrence of any major adverse cardiac event (MACE) namely cardiac death, non-fatal myocardial infarction and target lesion revascularization (using either percutaneous or surgical technique) as a composite index. Other evaluated main clinical outcomes were the components of MACE, patient-related outcome (PRO-a composite index of all-cause mortality, any myocardial infarction, any revascularization), recurrence of stable angina and arrhythmias occurrence.

Results

Lower rates of in-hospital complications (0.3% versus 12.1%, p<0.001) and shorter hospitalization [median, 1 (interquartile-range: 1–4) versus 8 (interquartile-range: 7–11), p<0.001] were recorded in the PCI group compared with the surgery arm. During the follow-up period (mean, 4.6±2.5 years), no statistical difference was observed in respect to MACE between the two study groups (10.1% versus 7.4%, p=0.14). Higher rates of repeat revascularization were detected in patients treated with PCI than those treated with CABG (5.5% versus 2.9%, p=0.05). Concerning other secondary endpoints, cardiac death (2.9% versus 3.2%, p=0.78), myocardial infarction (1.7% versus 1.3%, p=0.60), and PRO (18.9% versus 17.7%, p=0.64) did not differ in a statistically significant manner between the two techniques. Recurrence of stable angina was significantly increased in PCI (15.6% versus 8.4%, p=0.001), whereas arrhythmias occurrence was most common in the surgery group (6.3% versus 11.9%, p=0.002).

Conclusion

PCI with second-generation DES seem to have similar long-term clinical outcomes compared with CABG in patients with isolated LAD disease, highlighting the excellent long-term outcomes of both therapeutic approaches

Monitoring calcific aortic valve disease: the role of biomarkers

Calcific aortic valve disease is a common disease in the elderly associated with significant morbidity and mortality. It was once described as a passive degenerative process during which serum calcium attaches to the valve surface and binds to the leaflet. However, during the last decade mounting evidence demonstrated that this disease has an active biologic process with numerous signaling pathways. The histological hallmarks seem to be inflammation, oxidized lipids-also detectable in aortic valve lesions-and a remodeling of the extracellular matrix leading to bone formation. Over the years, growing evidence has indicated the risk factors for calcific aortic stenosis including lipids, hypertension, male gender, renal failure, and diabetes. Additional monitoring tools, such as molecular imaging, could improve risk stratification, while assessment of severity and prognosis of patients with chronic aortic regurgitation, is desirable. Also, several studies have investigated the role of biomarkers regarding their utility in the screening of calcific aortic valve disease and their putative clinical value, though their role still remains undetermined.

Left atrial appendage exclusion system for stroke prevention in atrial fibrillation: a percutaneous device delivery approach

Atrial fibrillation (AF) is a well-known predisposing factor for stroke. Most of the thrombi responsible for these ischemic events originate in the left atrial appendage. Left atrium appendage (LAA) occlusion is a potential alternative to warfarin in patients with atrial fibrillation who have contraindications to anticoagulation. The Percutaneous LAA Transcatheter Occlusion (PLAATO System, ev3 Inc., Plymouth, Minnesota) and the WATCHMAN LAA system (Atritech Inc., Plymouth, Minnesota), are currently the two devices specifically designed for LAA occlusion. Although available data are still limited, LAA occlusion is technically feasible, with good intermediate results, but its long-term safety and ability to reduce stroke incidence remains unproven. Randomized studies will clarify the usefulness of the LAA occlusion devices as an alternative treatment strategy to long-term anticoagulation.