Clinical impact of cerebral protection during transcatheter aortic valve implantation

BACKGROUND

Embolization of debris can complicate transcatheter aortic valve implantation (TAVI) causing stroke. Cerebral embolism protection (CEP) devices can divert or trap debris.

PURPOSE

To evaluate the efficacy of CEP during TAVI vs the standard procedure.

DATA SOURCES

PubMed, SCOPUS and DOAJ 1/01/2014-04/12/2023.

STUDY SELECTION

Randomized and observational studies comparing CEP versus standard TAVI, according to PRISMA.

PRIMARY OUTCOME

stroke.

SECONDARY OUTCOMES

death, bleeding, vascular access complications, acute kidney injury and infarct area.

DATA EXTRACTION

Two investigators independently assessed study quality and extracted data.

DATA SYNTHESIS

Twenty-six articles were included (540.247 patients). The primary endpoint was significantly lower (RR = 0.800 95%CI:0.682-0.940; p = 0.007) with CEP. Similarly, death rates were significantly lower with CEP (RR = 0.610 95%CI:0.482-0.771; p < 0.001). No difference was found for bleeding (RR = 1.053 95%CI:0.793-1.398; p = 0.721), vascular complications (RR = 0.937 95%CI:0.820-1.070; p = 0.334) or AKI (RR = 0.982 95%CI:0.754-1.279; p = 0.891).

CONCLUSIONS

Use of CEP during TAVI is associated with improved outcomes. Future studies will identify patients who benefit most from CEP.

Commissural alignment during TAVR reduces the risk of overlap to coronary ostia

BACKGROUND

Transcatheter aortic valve replacement (TAVR) showed safety and efficacy in patients with severe aortic stenosis. Commissural alignment (CA) during TAVR has the potential to reduce the impact of the prostheses on accessibility of coronary arteries, as misalignment of the neocommissures could cause partial overlap with coronary ostia. Therefore, the aim of this study was to investigate the impact of CA on coronary overlap rates.

METHODS

We examined the techniques of CA and their impact on coronary access. Eligible studies were searched for on Pubmed, SCOPUS and DOAJ and selected using PRISMA guidelines. The primary endpoint was the incidence of a severe coronary overlap or failed coronary re-access. Results of the analysis are expressed as Risk Ratio (RR) with 95% CI.

RESULTS

Four studies were included in this analysis. In these, 681 patients underwent TAVR with CA and 210 underwent TAVR without CA. We examined Evolut valves and Acurate Neo valves. The primary endpoint occurred in 138 patients undergoing TAVR with CA and in 154 patients without CA (RR = 0.279; 95% CI 0.201-0.386; p < 0.001). Neither prosthesis-related, nor patient-related factors had a significant interaction with the measured effect.

CONCLUSIONS

Commissural alignment was associated with significantly lower rates of commissure-to-coronary ostia overlap and failure of coronary access. Consequently, a modified insertion technique could reduce coronary overlap and coronary occlusion, particularly in supra-annular valves. Therefore, controlled orientation of prostheses by CA during TAVR could favour coronary access, especially in younger patients that could require coronary re-access after TAVR.

909 TIMING AND DETERMINANTS OF PERMANENT PACEMAKER IMPLANTATION AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT: IS THE NEW GENERATION BETTER?

Background

conduction disturbances requiring permanent pacemaker (PPM) implantation are among the most common adverse events in patients undergoing transcatheter aortic valve replacement (TAVR). The introduction in clinical practice of a new generation of TAVR devices has contributed to a significant reduction in procedural complications. However, limited data is available regarding the usual timing of PPM implantation after TAVR with the latest available valves. Therefore, in this analysis, we aimed to investigate the incidence, risk factors, and timing of new permanent pacemakers after TAVR, with respect to the type of valve implanted.

Methods

Patients who underwent TAVR at our Institution from September 2008 to June 2022 were included in this analysis. Patients with previous PPM/ICD implantation or receiving only balloon angioplasty were excluded, as well as cases with procedural unsuccess. The independent association between baseline clinical and procedural variables and the occurrence of PPM implantation was investigated with cross-sectional logistic regression analysis.

Results

A total of 497 patients were included in the study, with a mean age of 80.4±5.6 years old; 59% were females, 37.2% of patients had diabetes, 60.2% had dyslipidemia, and 25.8% had chronic kidney disease. The mean left ventricular ejection fraction (LVEF) was 52.1%, and the mean Euroscore II was 7.7±5.1. The new generation of self-expandable valves was used in 280 (56.3%) patients, while the new generation of balloon-expandable devices was implanted in 118 (23.7%). After TAVR, 109 (21.3%) patients underwent PPM/ICD implantation after a mean time of 4.1±3.1 days. After adjustment, self-expandable devices, larger valve sizes (29 or 34 mm), and diabetes were significantly associated with PPM/ICD implantation. Of note, the new generation of valve devices was associated with a lower risk of PPM/ICD implantation.

Conclusion

The necessity for a permanent pacemaker is a well-known possible adverse effect after TAVR. In this analysis, we confirm the previous evidence of an increasing risk of PPM implantation with self-expandable compared to balloon-expandable devices. Interestingly, the new valve generation was associated with a lower risk of conduction disturbances requiring PPM implantation. Further analyses and investigations will be needed to assess the impact of developing interventional techniques and advanced technologies on the occurrence of conduction disturbances.

1068 THE IMPACT OF COMMISSURAL ALIGNMENT ON CORONARY ARTERY ACCESS: A META ANALYSIS

Background

The use of TAVR has been spreading out globally due to its favorable safety profile and the excellent efficacy data from randomized controlled trials. With the growing number of treated patients, the attention is rising around specific issues, such as the treatment of intercurrent coronary artery disease. Commissural alignment of transcatheter heart valves (THV) has the potential to reduce the impact of the prosthesis on accessibility of coronary ostia, as misalignment of the neo-commissures could be responsible for partial overlap with coronary artery ostia. However, no definitive evidence is available, despite multiple trials have addressed this issue.

Methods

The aim of this meta-analysis was to investigate the impact of the commissural alignment on coronary filling. We examined the techniques of commissural alignment and their impact on coronary access and coronary overlap. Eligible studies were searched for on Pubmed and SCOPUS and selected using the PRISMA guidelines. The primary endpoint is a composite of severe coronary overlap and failure of transcatheter coronary access. Odds Ratio were used as the metric for comparison between the groups. A random effects meta-analysis was selected as the calculation model.

Results

Six studies with a total of 1213 patients were included in this analysis. Of these patients, 757 patients underwent TAVR with commissural alignment and 456 underwent TAVR without commissural alignment. The composite endpoint of coronary overlap and failure of coronary access occurred in 118 patients undergoing TAVR with commissural alignment and in 124 patients without commissural alignment (OR=0.20, 95% CI 0.08-0.48; p= 0.0003).

Conclusions

Commissural alignment was associated with significantly lower rates of commissure-to-coronary-ostia overlap and failure of coronary access. Therefore, a modified insertion technique could reduce coronary overlap and coronary occlusion, particularly in supra-annular valves. Commissural alignment performed during TAVR could therefore have an important role in coronary re-access and re-intervention especially in younger patients.

1066 THE USEFULNESS OF CEREBRAL PROTECTION DURING TAVR: A METANALYSIS

Introduction

although transcatheter aortic valve replacement (TAVR) represents a milestone in the treatment of degenerative aortic stenosis, stroke remains an important complication compared to surgical aortic valve replacement (SAVR). Multiple magnetic resonance imaging (MRI) studies demonstrated a substantial rate of new cerebral ischemic lesions after TAVR. In order to avoid debris passage into the circulation and to prevent procedure-related embolic stroke, cerebral embolic protection (CEP) devices were developed. However, their safety and efficacy remain controversial. Very recently, new studies provided additional evidence on this topic.

Aim

to assess the entire body of evidence from randomized controlled studies about neurological outcomes after TAVR.

Materials and Methods

a systematic meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched MEDLINE, Scopus, and Google Scholar for randomized controlled studies. The following keywords were used for the search: “transcatheter aortic valve implantation” or “stroke prevention” or “embolic protection” and “cerebral protection”. Study groups were defined as a the “CEP group” and the “control group”. Non-randomized studies reporting outcomes with cerebral embolic protection (CEP) during TAVR were excluded to reduce the selection and confounding bias of observational pilot studies. The primary outcome was post-procedural stroke. Secondary outcomes included total lesion volume on MRI and new ischemic lesions on MRI.

Results

nine trials including 4077 patients were eligible for analysis and included to the meta-analysis. Of those, 2203 patients were randomized to cerebral embolic protection and 1874 patients to control group. Despite the rate of post-procedural stroke was higher in the CEP arm (2.27%) compared to the control arm (2.87%, p&lt;0.001), the use of cerebral embolic protection was not associated with a significantly lower risk of stroke (OR=0.82, 95% CI 0.59-1.15; p=0.255). Cumulative meta-analysis revealed a trend towards a lower impact on stroke prevention with more recent trials.

Conclusions

use of cerebral embolic protection devices during TAVR is a safe procedure. However, the current outline of results from all randomized controlled trials available does not support its routine use, as no significant reduction of stroke risk was evident. The use of these devices might be considered in selected high-risk patients, such as in the setting of heavy calcified cusps or atherosclerotic aortic lesions.

1050 ULTRASOUND GUIDED CANNULATION OF FEMORAL ARTERY IN PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT

Background

Vascular access complications are a significant source of morbidity and mortality after transcatheter aortic valve replacement (TAVR). Ultrasound-guided cannulation (UGC) of central veins or arteries is a widely used approach for patients undergoing invasive procedures. Whether UGC significantly decreases the risk of vascular access complications also for large-bore access procedures, such as TAVR, lacks evidence

Objectives

in this study, we aimed to evaluate the benefits of routine use of UGC in patients undergoing TAVR.

Methods

Data were retrospectively collected from two high-volume TAVR centers from September 2009 to March 2022. UGC was performed using a two-dimensional ultrasound short-axis views, while manual palpation, fluoroscopy, or contralateral angiography were used for the other patients. The odds ratio (OR) for vascular complications was calculated using a multivariate logistic regression model including as dependent variables all relevant baseline and procedural characteristics (forward stepwise selection process). Vascular complications were adjudicated according to the Valve Academic Research Consortium definitions 3.

Results

Out of 874 patients included in the study, UGC access was performed in 177 subjects. Overall mean age was 80.2±5.8 years old, 60% of patients were females, 35.5% had diabetes, 61.4% had dyslipidemia, and 27.8% had chronic kidney disease, with a mean left ventricular ejection fraction of 52.7±9.7%. Looking at the procedural variables Euroscore II was 5.8±5.4, second and third valves generation have been used in 85% of the cases, while suture-based closure devices in 84% of subjects. After adjustment for clinical and procedural variables, routinely use of UGC was associated with a lower rate of total [Odds Ratio (OR): 0.38; 95% confidence interval (CI) 0.15% to 0.95%)] and major vascular complications [Odds Ratio (OR): 0.21; 95% confidence interval (CI) 0.05% to 0.75%)], while no differences were observed for minor vascular complications.

Conclusions

Routinely use of UGC significantly decreases the risk of vascular complications in patients undergoing TAVR. However, a dedicated randomized clinical trial assessing the safety and efficacy of this approach is warranted to confirm our results in this high-risk population.

508 Incidence and determinants of prosthesis-patient mismatch after transcatheter aortic valve replacement using predicted indexed effective orifice area

Aims

A small effective orifice area (EOA) by body surface area (BSA), defined as prosthesis–patient mismatch (PPM), is associated with elevated transprosthetic pressure gradients, less ventricular remodelling, and a worse prognosis. Calculating PPM by dividing the normal reference value of EOA for the model and size of the prosthetic valve (predicted PPM), instead of using the continuity equation has been recently confirmed as more accurate after trans catheter aortic valve intervention (TAVI), providing a stronger association with post-procedural haemodynamic outcomes. However, current evidence using this new definition is still limited, thus impairing generalizability. Accordingly, this analysis aims to extend such evidence providing incidence, and determinants of predicted PPM (PPMp) in an all-comers population undergoing TAVR with a high prevalence of self-expandable devices.

Methods

395 patients who underwent TAVI at our Institution from September 2008 to November 2020 were included in this analysis. PPMp was then classified as moderate if ≤ 0.85 cm2/m2 and severe if ≤ 0.65 cm2/m2 as well as moderate if ≤ 0.70 cm2/m2 and severe if ≤ 0.55 cm2/m2 for patients with a body mass index &gt; 30, as recommended by the Valve Academic Research Consortium-3 definition. The independent association between baseline clinical and procedural variables and the presence of moderate or severe PPMp was investigated with cross-sectional logistic regression analysis.

Results

11 patients (2.78%) had severe and 33 (8.35%) moderate PPMp. Patients with moderate or severe PPMp (m/s PPMp) were younger, female, with a higher prevalence of hypercholesterolaemia, prior aortic valve implantation and balloon expandable device and lower prevalence of chronic obstructive disease (COPD). Post-procedural mean gradient was higher in patients with m/s PPMp. The independent clinical and procedural correlates associated with higher likelihood of m/s PPMp were valve in valve procedure (ViV) and the use of a balloon-expandable device.

Conclusions

Moderate or severe PPMp was observed only in a small part of patients underwent TAVI, leading, however, a higher post-procedural mean gradient compared to those without PPMp. Balloon expandable devices and ViV were the strongest determinant of moderate or severe PPM.

738 Role of non-coding RNA uc.194 and uc.443+A in the intrastent restenosis

Aims

Vascular smooth muscle cells (VSMCs) play a key role in the vessel wall, being active partaker in vascular remodelling and influencing multiple pathophysiological phenomena, such as progression of atherosclerosis, in-stent restenosis and vascular reactivity. Recently antisense oligonucleotides have shown promising results as a therapeutic option. The aim of this study was to analyse the expression profile and function of T-UCRs in vascular smooth muscle cells (VSMCs)—both in vitro and in vivo—and to evaluate the effects of their inhibition by the use of specific antisense oligonucleotides.

Methods

After obtaining cell cultures of vascular smooth muscle cells, we modified their phenotype varying growth conditions. A microarray and qRT-PCR expression profile analysis and a cell cycle analysis with cell proliferation/apoptosis/migration assay were performed. In vivo studies were performed on rat carotids after cell damage and administration of specific antisense oligonucleotides.

Results

There were significant differences in the expression of T-UCRs in VSMCs with a proliferating and quiescent phenotype. In particular, 5 T-UCRs were found to be upregulated in VSMCs. These types of cells were subsequently transfected with specific antisense oligonucleotides obtaining a reduction in their proliferative activity in particular with the inhibition of the T-UCRs uc.194 and uc.443 + A. MiR-10A and miR-34b-5p were identified with complementary sequences respectively to uc.194 and uc.443 + A. The increase of these miRs following the inhibition of the T-UCRs were closely related to the inhibition of the proliferative signals of VSMCs. Similarly, the same results were obtained in vivo.

Conclusions

The expression levels of non-coding RNAs uc.194 and uc. 443 + A increase in proliferating smooth muscle cells in vitro and in the vascular wall following damage, suggesting an important role of these molecules in the phenomenon of intra-stent restenosis. Through the inhibition of uc.194 and uc.443 + A using an antisense strategy, we demonstrated a reduction in cell proliferation and migration processes and, consequently, in the formation of neointima. A possible relationship was also highlighted between the aforementioned non-coding RNAs and some micro-RNAs (miR-10A and miR-34b-5p), negative regulators of the proliferative phenotype of VSMCs. The inhibition of the analysed T-UCRs would allow the maintenance of the contractile phenotype thanks to the activity of the miRs analysed in this study. Our results might pave the way for the identification of new therapeutic targets in order to prevent and reduce the incidence of intra-stent restenosis.

690 Acute post-implantation enlargement of transcatheter self-expandable valve: insights from a single-centre prospective registry

Aims

Transcatheter implantation of a balloon-expandable aortic valve is associated with an acute stent recoil . Conversely, the acute effects of nitinol-based stent frame- self expandable valve on post-deployment dimensions have not been reported. Accordingly, the aim of this study was to assess the occurrence and degree of acute prosthetic dimension changes after Evolute R valve implantation.

Methods

A total of 58 consecutive patients undergoing transcatheter aortic valve intervention (TAVI) with a widely used nitinol based self-expandable device (Evolute R, Medtronic, Minneapolis, USA) were included in this study. We measured valve diameters at three different sections: a) distal (aortic) level, b) central (annulus) level, and c) proximal (ventricular) level. Valve expansion was calculated as the difference between the diameters calculated immediately after valve deployment (A) and at the end of the procedure (B). The absolute and relative acute stent recoil were defined as B-A and (B-A)/B*100, respectively. A linear regression model was performed to test the association between the degree of valve extension, with baseline, as well as procedural characteristics.

Results

Final stent diameters were significantly higher compared to those achieved immediately after valve implantation in proximal (20.87±3.20 mm versus 20.37±3.27 mm, P &lt;0.001), central (19.58±1.63 mm versus 19.12±1.75 mm, P &lt;0.001) as well as distal (26.99±1.53 mm versus 26.41±1.57 mm, P &lt;0.001) segments. The mean absolute and relative enlargement of the valve was respectively 0.50±0.51 mm and 2.48±2.57% in the proximal, 0.46±0.57 mm and 2.39±2.96% in the central and 0.58±0.59 mm and 2.14±2.14% in the distal segment. Among baseline and procedural characteristics assessed in the logistic regression model no association was observed between pre-dilation and valve expansion across all the segments (proximal: r2=0.004, P=0.885, central: r2=0.004, P=0.637, and distal r2=0.05, P=0.10). Of interest, post dilation affected only the expansion of the central segment (r2=0.241, P&lt;0.001), while no association was observed for the proximal (r2=0.059, P=0.065) and distal (r2=0.0002, P=0.916) parts. The expansion of the proximal segment was associated with higher maximum/minimum diameter ratio measured by CT (r2=0.08, P=0.045), while no association was observed for the central (r2= 0.020; P=0.992) and distal (r2=1.111, P=0.683) segments.

Conclusions

This is the first study that documented a significant degree of post-deployment recoil of the Evolute R self-expandable valve, that was consistent across all the segments. The stent-valve expansion of the proximal segment was associated with a greater annulus dissymmetry reported by the maximum and minimum diameter ratio assessed by CT scan. However, further studies are required to assess the short and long-term time-course of self-expandable valve enlargement and the clinical relevance of this finding.

810 Incidence and determinants of permanent pacemaker implantation after transcatheter aortic valve replacement

Aims

conduction disturbances requiring pacemaker implantation (PPM) are among the most common complications in patients undergoing transcatheter aortic valve replacement (TAVR). Introduction in clinical practice of a new generation of TAVR devices is contributing to a significant reduction in procedural complications. However, limited data is available regarding PPM implantation after TAVR with the latest available devices. Accordingly, in this analysis we aimed to investigate the incidence and risk factors for new permanent pacemaker implantation after TAVR according to the type and diameter of valve implanted.

Methods

Patients who underwent TAVR at our Institution from September 2008 to November 2020 were included in this analysis. Out of 407, 38 (9.3%) were excluded because they already presented a PPM/ICD, received only balloon angioplasty or for procedural unsuccess. The independent association between baseline clinical and procedural variables and the occurrence of PPM implantation was investigated with cross-sectional logistic regression analysis.

Results

Out of 368 TAVR procedures included in the final analysis, 89 (24.2%) required in-hospital PPM implantation. No differences were observed for age and common cardiovascular risk factors between groups. Among procedural variables, patients requiring PPM had lower left ventricular ejection fraction (LVEF) and experienced a longer intensive care unit stay. Valve types used were Corevalve n = 98 (26.6%) (first-generation devices), Evolute R, n = 191 (51.9%), Evolute Pro, n = 3 (1.1%), Portico n = 2 (0.5 %), or Sapien 3, n = 73 (19.8%) (second-generation devices). Clinical and procedural correlates of PPM implantation were depicted in Figure. Of note, compared to the first generation of self-expandable devices, the second generation is associated with a lower risk of PPM implantation, albeit non-significant for the subgroup of second generation self-expandable devices. Finally, valve diameter was also an independent predictor of PPM implantation

Conclusions

PPM was required in 24.2% of patients who underwent TAVR with first- and second-generation balloon or self-expandable valves. For instance, in our population, second-generation TAVR devices were associated with a lower risk of PPM implantation compared to the previous generation. However, further investigations are warranted to assess the impact of new implantation techniques and valve technology on such an important outcome.

808 Frequency and impact of atherothrombotic status in patients undergoing transcatheter aortic valve replacement

Aims

Many efforts have been made in the last decade to minimize the risk of bleeding in patients undergoing transcatheter aortic valve replacement (TAVR), such as a less intensive antithrombotic therapy and technical improvement in devices implantation. Conversely, evidence on high atherothrombotic status (HATR) is still lacking in patients undergoing TAVR. Accordingly, in this analysis, we aimed to evaluate frequency and impact of atherothrombotic status in patients undergoing transcatheter aortic valve replacement.

Methods

Patients who underwent TAVR at our Institution from September 2008 to November 2020 were included in this analysis. Out of 407 patients, 6 (1.5%) were excluded as they underwent only balloon angioplasty or for procedural unsuccess. HATR status includes patients with prior percutaneous coronary intervention/coronary artery bypass graft, prior stroke/transient ischaemic attack (TIA), or with a diagnosis of diabetes. Continuous variables following normal distribution were compared with the student’s t-test and categorical data were analysed with the chi-square test. A Cox regression model was used to evaluate the association between HART status and all-cause mortality at one 1-year follow-up.

Results

Compared to patients with low atherothrombotic status (LATR) (n = 238; 59.4%), HART patients (n = 163; 40.6%) were older, more likely female and with a higher prevalence of common cardiovascular risk factors including chronic kidney disease, smoke, and hyperlipidaemia. Between LATR and HATR groups, no differences have been observed, in terms of procedural time, type of devices used (Balloon vs. self-expandable device), or hospitalization length. Compared to LART, HART patients were more likely to be discharged on statin (63.7% vs. 83%, P &lt; 000.1), on dual antiplatelet therapy (50.4% vs.58.9%, P = 0.03), or on oral anticoagulant if required (27.7% vs. 29.5%, P = 0.03). Furthermore, no differences have been observed in terms of in-hospital adverse events, including death, severe bleeding, any conduction disturbances requiring pacemaker implantation, access complications, myocardial infarction, or stroke/TIA. For instance, HART was not a predictor of mortality at 1 year follow-up, even after adjustment for baseline characteristics.

Conclusion

In our population, no differences in procedural and in-hospital adverse events have been observed according to the atherothrombotic profile. HATR patients were more likely to be discharged with more intensive antithrombotic and hypolipidaemic strategies, despite the coexistent high prevalence of bleeding determinants. However, ATR status does not impact 1-year mortality even after adjustment for baseline characteristics.

809 Frequency and determinants of haemoglobin drop without overt bleeding in patients undergoing transcatheter aortic valve replacement

Aims

Post-procedural bleedings have a significant impact on mortality in patients undergoing transcatheter aortic valve replacement (TAVR). Unfortunately, the source of these bleedings is often undetermined, causing difficulties in diagnosis and related treatment. Furthermore, the frequency and determinants of ‘non-overt’ bleeding are largely lacking in TAVR studies. Accordingly, in this analysis, we aimed to assess the frequency and determinants of haemoglobin drop without overt bleeding in patients undergoing TAVR.

Methods

Patients undergoing TAVR at Magna Graecia University in Catanzaro from September 2008 to November 2020 were included in this study. Post-procedural haemoglobin (Hb) drop was calculated subtracting the lowest value observed after the procedure to the one obtained at admission (Hb drop). The association between baseline clinical and procedural variables with Hb drop was investigated with a linear regression model.

Results

Out of 407 patients undergoing TAVR at our institution, 119 (29.2%) were excluded because experiencing overt bleeding, red blood cells transfusion, were treated with only balloon angioplasty, or for procedural unsuccess. Among the 288 patients included in the final analysis, 239 (83.0%) were older than 74 y.o., 148 (51.4%) were female, 94 (32.6%) were diabetics, and 69 (24.0%) had CKD. All the patients were deemed at intermediate/high operatory risk and treated using the transfemoral approach. After TAVR, Hb significantly decreased (12.6 ± 1.6 g/dL to 9.7 ± 1.3 g/dL, P &lt; 0.001), with an absolute mean reduction of 2.9 ± 1.23 g/dL 126 patients (43.8%) had Hb drop ≥ 3 g/dL, while 11 (3.8%) had Hb drop ≥ 5 g/dL. The table below summarizes the determinants of Hb drop. Among them, the new generation of self-expandable and balloon-expandable devices were associated with a lower post-procedural Hb drop compared to the previous generation of self-expandable devices, alongside, higher body mass index and hypertension.

Conclusions

Post-procedural reduction of Hb without overt bleeding or RBC transfusion is frequent, involving almost half of the patients undergoing TAVR. The introduction in clinical practice of new-generation valve devices is significantly associated with a reduction of this adverse event. However, further and thorough investigation should be accomplished to reclassify this large part of patients into a well-defined category.

38 Transcatheter tricuspid valve edge-to-edge repair in patient with severe tricuspid regurgitation and previous mitraclip treatment: when four orifices are better than two

An 82 years old woman was admitted to our Division for worsening dyspnoea. Her past medical history showed: arterial hypertension, chronic atrial fibrillation on oral anticoagulation, a non-critical single-vessel coronary artery disease, previous mitral transcatheter edge-to-edge repair through 2 Mitraclip NTR. After an initial improvement in clinical symptoms following Mitraclip implantation, the patient was admitted several times for acute decompensated heart failure. Haematological exams at admission were normal, exception of NTproBNP (1909 pg/mL). The ECG documented atrial fibrillation with normal ventricular rate. Transthoracic echocardiography demonstrated mid-range heart failure (EF 45–50%) with D-shape morphology of the left ventricle. Colour-doppler analysis shows presence of Mitraclip devices in place with mild residual insufficiency, dilation of the right side, torrential tricuspid regurgitation (tTR) with estimated pulmonary arterial pressure of 45 mmHg. Preprocedural transesophageal echocardiography confirmed these findings showing dilation of the tricuspid annulus with two large regurgitating jets.

After positioning Amplatzer Superstiff guide in superior vena cava through guide catheter TSGC0202, a Triclip XT was placed in commissural region between anterior and septal leaflets. A two-grade reduction in tricuspid regurgitation (TR) grade from torrential (5+) to moderate (3+) was achieved without significant transvalvular gradient. The patient was successful discharged after 2 days, asymptomatic and in good clinical conditions. A great reduction in NTproBNP values at discharge was observed (1612 pg/mL). We report a case of successful tricuspid transcatheter repair in patient with chronic decompensated heart failure and previous Mitraclip treatment. The clinical impact of TR reduction is probably due to a positive right ventricular (RV) remodelling, with a reduction in RV size. RV dysfunction and its implications (liver, renal, and haemostatic consequences) are definitely a matter of concern for fragile patients with TR. In fact, many patients with severe TR have a reduced RV function. The reduction in volume and pressure overload of the right heart side, the progressive anatomic and functional reverse of the RV disfunction, may lead to a significant clinical benefit and to a lower hospitalizations rates also through to an important improvement of the left ventricular function as a consequence of the reduction in pressure overload.

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