Pacing Using Cardiac Implantable Electric Device During TAVR: 10-Year Experience of a High-Volume Center

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is an effective and safe therapy for severe aortic stenosis. Rapid or fast pacing is required for implantation, which can be performed via a pre-existing cardiac implantable electric device (CIED). However, safety data on CIEDs for pacing in TAVR are missing.

OBJECTIVES

The aim of this study was to elucidate procedural safety and feasibility of internal pacing with a CIED in TAVR.

METHODS

Patients undergoing TAVR with a CIED were included in this analysis. Baseline characteristics, procedural details, and complications according to Valve Academic Research Consortium 3 (VARC-3) criteria after TAVR were compared between both groups.

RESULTS

A total of 486 patients were included. Pacing was performed using a CIED in 150 patients and a transient pacemaker in 336 patients. No differences in technical success according to VARC-3 criteria or procedure duration occurred between the groups. The usage of transient pacers for pacing was associated with a significantly higher bleeding rate (bleeding type ≥2 according to VARC-3-criteria; 2.0% vs 13.1%; P < 0.01). Furthermore, impairment of the CIED appeared in 2.3% of patients after TAVR only in the group in which pacing was performed by a transient pacer, leading to surgical revision of the CIED in 1.3% of all patients when transient pacemakers were used.

CONCLUSIONS

Internal pacing using a CIED is safe and feasible without differences of procedural time and technical success and might reduce bleeding rates. Furthermore, pacing using a CIED circumvents the risk of lead dislocation. Our data provide an urgent call for the use of a CIED for pacing during a TAVR procedure in general.

Atrial Functional Tricuspid Regurgitation in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Knowledge about atrial functional tricuspid regurgitation (afTR) in transcatheter aortic valve replacement (TAVR) patients is scarce.

OBJECTIVES

The aim of the study was to analyze the association between the entity and the development of tricuspid regurgitation (TR) in patients undergoing TAVR for aortic stenosis and concomitant TR.

METHODS

We analyzed patients undergoing TAVR for severe aortic stenosis from January 2013 to December 2020 and concomitant at least moderate TR at baseline. afTR was defined as enlargement of the right atrium in relation to the right ventricle. TR development after TAVR and 3-year all-cause mortality were evaluated.

RESULTS

Out of 3,474 TAVR patients, we identified 420 patients with concomitant at least moderate TR. A total of 363 patients were included in the study, with 178 patients stratified in the afTR and 185 in the non-afTR group based on a receiver-operating characteristic curve cutoff of 1.132 of the right atrial/right ventricular area ratio. TR improvement after TAVR was observed in significantly less patients with afTR compared with non-afTR (31.1% vs 60.6%; P < 0.001). Multivariate regression analysis confirmed afTR as independent predictor for TR persistence (adjusted OR: 2.80; 95% CI: 1.66-4.76; P < 0.001). Moreover, afTR was associated with aggravation of TR after TAVR (17.0% vs 6.8%; P = 0.013). Three-year all-cause mortality was significantly higher in patients with persistence compared with patients with improvement of TR (P < 0.001).

CONCLUSIONS

In TAVR patients, afTR is an independent predictor for TR persistence. Moreover, TR persistence is associated with increased 3-year all-cause mortality.

Concomitant percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Patients undergoing transcatheter aortic valve implantation (TAVI) frequently have coronary artery disease requiring percutaneous coronary intervention (PCI). Usually, PCI and TAVI are performed in two separate procedures and current studies are investigating potential benefits regarding the order. However, the two interventions may also be performed simultaneously, thereby limiting the risk associated with repeated vascular access. Data evaluating benefit and harm of concomitant procedures are scarce.

AIMS

Therefore, this study aimed to evaluate concomitant PCI (coPCI) in TAVI patients regarding Valve Academic Research Consortium 3 (VARC-3) endpoints and long-term mortality.

METHODS

A total of 2233 consecutive TAVI patients from the EVERY-VALVE registry were analyzed according to the VARC-3 endpoint definitions. A total of 274 patients had undergone TAVI and concomitant PCI (coPCI group). They were compared to 226 TAVI patients who had received PCI within 60 days before TAVI in a stepwise approach (swPCI group) and to the remaining 1733 TAVI patients who had not undergone PCI recently (noPCI group).

RESULTS

Overall median age was 81.4 years, median Society of Thoracic Surgeons score was 4.0%. Patients in the coPCI and in the swPCI group were predominantly male with reduced left-ventricular ejection fraction. Rates of VARC-3 composite endpoints technical success and 30-day device success were comparable between all three groups. Mortality rates at 3 years after TAVI were similar (coPCI, 34.2% vs. swPCI, 31.9% vs. noPCI, 34.0% p = 0.84).

CONCLUSIONS

coPCI during TAVI seems comparable in a retrospective analysis. Compared to a stepwise approach, it has similar rates of composite endpoints technical success and device success as well as long-term mortality.

Transcatheter Aortic Valve Replacement for Isolated Aortic Regurgitation Using a New Self-Expanding TAVR System

BACKGROUND

Patients with severe aortic regurgitation (AR) are often not considered for surgery because of increased surgical risk. Because of unique anatomical characteristics among patients with AR, interventional treatment options are limited, and implantation results are inconsistent compared with those among patients with aortic stenosis.

OBJECTIVES

The authors describe the initial commercial experience of the first Conformité Européenne-marked transfemoral transcatheter aortic valve replacement system (JenaValve Trilogy [JV]) for the treatment of patients with AR.

METHODS

This multicenter registry included 58 consecutive patients from 6 centers across Germany. Transcatheter aortic valve replacement was performed with the JV system for isolated severe and symptomatic AR. Patient characteristics, primary implantation outcomes, and valve performance up to 30 days were analyzed using Valve Academic Research Consortium 3 definitions.

RESULTS

The mean patient age was 76.5 ± 9 years, with a mean Society of Thoracic Surgeons score of 4.2% ± 4.3%. Device success was achieved in 98% of patients. The mean gradient was 4.3 ± 1.6 mm Hg, and no moderate or severe paravalvular regurgitation occurred. No conversion to open heart surgery or valve embolization was reported. There were no major vascular complications or bleeding events. The rate of new permanent pacemaker implantation was 19.6%. At 30 days, 92% of the patients were in NYHA functional class I or II, and the 30-day mortality rate was 1.7%.

CONCLUSIONS

Treatment of patients with severe symptomatic AR using the transfemoral JV system is safe and effective. Given its favorable hemodynamic performance and low complication rates, this system may offer a new treatment option for patients with AR not suitable for surgery.

Impact of mitral regurgitation aetiology on the outcomes of transcatheter aortic valve implantation

BACKGROUND

Concomitant moderate/severe mitral regurgitation (MR) is observed in 17-35% of patients undergoing transcatheter aortic valve implantation (TAVI) and contributes to a worse prognosis. Studies analysing outcomes in patients undergoing TAVI with different MR aetiologies, including atrial functional MR (aFMR), are lacking.

AIMS

We aimed to analyse outcomes and changes in MR severity in patients with aFMR, ventricular functional (vFMR) and primary mitral regurgitation (PMR) following TAVI.

METHODS

We analysed all consecutive patients with at least moderate MR undergoing TAVI between January 2013 and December 2020 at the Munich University Hospital. Characterisation of MR aetiology was performed by detailed individual echocardiographic assessment. Three-year mortality, changes in MR severity and New York Heart Association (NYHA) Functional Class at follow-up were assessed.

RESULTS

Out of 3,474 patients undergoing TAVI, 631 patients showed MR ≥2+ (172 with aFMR, 296 with vFMR, 163 with PMR). Procedural characteristics and endpoints were comparable between groups. The rate of MR improvement was 80.2% in aFMR patients, which was significantly higher compared to both other groups (vFMR: 69.4%; p=0.03; PMR: 40.8%; p<0.001). The estimated 3-year survival rates did not differ between aetiologies (p=0.57). However, MR persistence at follow-up was associated with increased mortality (hazard ratio 1.49, 95% confidence interval: 1.04-2.11; p=0.027), mainly driven by the PMR subgroup of patients. NYHA Class improved significantly in all groups. In patients with baseline MR ≥3+, the PMR aetiology was associated with the lowest MR improvement, the lowest survival rates and least symptomatic improvement.

CONCLUSIONS

TAVI reduces MR severity and symptoms in patients with aFMR, vFMR and less-pronounced PMR. The presence of aFMR was associated with the greatest MR severity improvement.

Quantification of physical activity with prospective activity tracking after transfemoral aortic valve replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a well-established, safe and effective therapy for severe symptomatic aortic stenosis (AS). The aim of this study was to objectively quantify improvement of physical activity after TAVR, with consideration of different low-gradient AS subtypes.

METHODS AND RESULTS

All patients undergoing TAVR for severe AS were screened. Participants received a wearable activity tracker (Fitbit®) at hospital discharge following TAVR and 6 months thereafter. The difference of median daily steps was defined as surrogate outcome for physical activity. For analysis, patients were grouped into high-gradient (HG) AS (dPmean ≥40 mmHg), classical low-flow low-gradient (LFLG) AS (dPmean <40 mmHg, EF <50%), paradoxical LFLG-AS (dPmean <40 mmHg, EF ≥50%, SVi ≤35 ml/m2) and normal-flow low-gradient (NFLG) AS (dPmean <40 mmHg, EF ≥50%, SVi >35 ml/m2) according to mean transvalvular pressure gradient (dPmean), stroke volume index (SVi) and left-ventricular ejection fraction (LVEF).

RESULTS AND CONCLUSIONS

The analysis is based on 230 patients. The median daily step count was 4409 [IQR 2581-7487] after hospital discharge and 5326 [IQR 3045-8668] 6 months thereafter. Median difference of daily steps was ∆529 [IQR -702-2152]). Patients with HG-AS and paradoxical LFLG-AS showed a significant improvement of daily steps (∆951 [IQR -378-2323], p <0.001 and (∆1392 [IQR -609-4444], p = 0.02, respectively). Patients with classical LFLG-AS showed no statistically relevant improvement of daily steps (∆192 [IQR -687-770], p = 0.79). Patients with NFLG-AS showed a numerical decline in daily steps without statistical significance (∆-300 [IQR -1334-1406], p = 0.67). This first prospective study of this sample size shows significant improvement of physical activity after TAVR with an objective and reproducible method. This was mainly driven by an improvement in patients with HG-AS and paradoxical LFLG-AS.

Suture-based vs. pure plug-based vascular closure devices for VA-ECMO decannulation-A retrospective observational study

Background

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a valuable treatment option for patients in cardiogenic shock, but complications during decannulation may worsen the overall outcome. Therefore, the aim of this study was to compare the efficacy and safety of suture-based to pure plug-based vascular closure devices for VA-ECMO decannulation.

Methods

In this retrospective study, the procedural outcome of 33 patients with suture-based Perclose ProGlide closure devices was compared to 38 patients with MANTA plug-based closure devices.

Results

Rate of technically correct placement of closure devices was 88% in the suture-based group and 97% in the plug-based group (p = 0.27). There was a significant reduction of severe bleeding events during VA-ECMO decannulation in plug-based versus suture-based systems (3% vs. 21%, p = 0.04). Ischemic complications occurred in 6% with suture-based and 5% with plug-based device (p = 1.00). Pseudoaneurysm formation was detected in 3% in both groups (p = 1.00). No switch to vascular surgery due to bleeding after decannulation was necessary in both groups.

Conclusion

Based on our retrospective analysis, we propose that plug-based vascular closure should be the preferred option for VA-ECMO decannulation. This hypothesis should be further tested in a randomized trial.

CTA-determined tricuspid annular dilatation is associated with persistence of tricuspid regurgitation after transcatheter aortic valve replacement

AIM

The aim of this study was to analyse the predictive value of CTA-determined tricuspid annular dilatation (TAD) on the persistence of tricuspid regurgitation (TR) in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) and concomitant at least moderate TR.

METHODS AND RESULTS

288 consecutive patients treated with TAVR due to severe AS and concomitant at least moderate TR at baseline were included in the analysis. As cutoff for TAD, the median value of the CTA-determined, to the body surface area-normalized tricuspid annulus diameter (25.2 mm/m²) was used. TAD had no impact on procedural characteristics or outcomes, including procedural death and technical or device failure according to the Valve Academic Research Consortium 3 criteria. However, the primary outcome of the study-TR persistence after TAVR was significantly more frequent in patients with compared to patients without TAD (odds ratio 2.60, 95% confidence interval 1.33-5.16, p < 0.01). Multivariable logistic regression analysis, adjusting for clinical and echocardiographic baseline characteristics, which are known to influence aetiology or severity of TR, confirmed TAD as an independent predictor of TR persistence after TAVR (adjusted odds ratio 2.30, 95% confidence interval 1.20-4.46, p = 0.01). Moreover, 2 year all-cause mortality was significantly higher in patients with persistence or without change of TR compared to patients with TR improvement (log-rank p < 0.01).

CONCLUSION

In patients undergoing TAVR for severe AS and concomitant at least moderate TR at baseline, TAD is a predictor of TR persistence, which is associated with increased 2-year all-cause mortality.

Heparin-Induced Thrombocytopenia in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation

Background: Heparin-induced thrombocytopenia (HIT) is a serious, immune-mediated adverse drug reaction to unfractionated heparin (UFH) affecting also patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO). Although the association between VA-ECMO support and the development of thrombocytopenia has long been known and discussed, HIT as one underlying cause is still insufficiently understood. Therefore, the purpose of this study was to further investigate the epidemiology, mortality, diagnosis, and clinical management of HIT occurring in VA-ECMO patients treated with UFH. Methods: We conducted a retrospective single-center study including adult patients (≥18 years) with VA-ECMO support in the cardiac intensive care unit (ICU) of the University Hospital of Munich (LMU) between January 2013 and May 2022, excluding patients with a known history of HIT upon admission. Differences in baseline characteristics and clinical outcome between excluded HIT (positive anti-platelet factor 4 (PF4)/heparin antibody test but negative functional assay) and confirmed HIT (positive anti-PF4/heparin antibody test and positive functional assay) VA-ECMO patients as well as diagnosis and clinical management of HIT were analysed. Results: Among the 373 patients included, anti-PF4/heparin antibodies were detected in 53/373 (14.2%) patients. Functional HIT testing confirmed HIT in 13 cases (3.5%) and excluded HIT in 40 cases (10.7%), corresponding to a prevalence of confirmed HIT of 13/373 (3.5%) [1.6, 5.3] and a positive predictive value (PPV) of 24.5% for the antibody screening test. The platelet course including platelet recovery following argatroban initiation was similar between all groups. One-month mortality in patients with excluded HIT was 14/40 (35%) and 3-month mortality 17/40 (43%), compared to 5/13 (38%) (p > 0.999), and 6/13 (46%) (p > 0.999) in patients with confirmed HIT. Neurological outcome in both groups measured by the cerebral performance category of survivors on hospital discharge was similar, as well as adverse events during VA-ECMO therapy. Conclusions: With a prevalence of 3.5%, HIT is a non-frequent complication in patients on VA-ECMO and was not associated with a higher mortality rate. HIT was ultimately excluded by functional essay in 75% of VA-ECMO patients with clinical suspicion of HIT and positive anti-PF4/heparin antibody test. Argatroban seems to be an appropriate and safe therapeutic option for confirmed HIT-positive patients on VA-ECMO support.

Emergency transcatheter aortic valve implantation for acute heart failure due to severe aortic stenosis in critically ill patients with or without cardiogenic shock

AIMS

Severe aortic stenosis can cause acute heart failure and cardiogenic shock (CS). Transcatheter aortic valve implantation (TAVI) is the standard therapy for aortic stenosis in inoperable patients. However, its role in this setting is poorly evaluated. The study purpose was to explore clinical characteristics of these patients and to assess predictors of mortality.

METHODS AND RESULTS

All 2930 patients undergoing transfemoral TAVI at our centre between 2013 and 2019 were screened for critically ill patients, receiving intensive care therapy and emergency TAVI. Selected patients were subdivided into two groups, according to the presence or absence of CS. Remaining patients undergoing elective TAVI served as a comparison. Primary outcome was 90-day mortality. Out of 179 critically ill patients, 47 fulfilled criteria of CS (shock group) and 132 did not despite a severe decompensation (no shock group). Shock patients were more often male and had higher Society of Thoracic Surgeons scores [15.6, interquartile range (8.0-32.1) vs. 5.5 (3.9-8.5), P < 0.01] compared with severely decompensated patients. Ninety-day mortality was: shock group, 42.6%, vs. no shock group, 15.9%, vs. elective group, 5.3% (P < 0.01). A landmark analysis from day 90 showed similar mortality (P = 0.29). Compared with elective patients, 30-day composite endpoint device failure was higher in critically ill groups [shock group, odds ratio, 2.86 (1.43-5.36), no shock group, odds ratio, 1.74 (1.09-2.69)]. Multivariable regression revealed mechanical ventilation, haemofiltration, elevated C-reactive protein or bilirubin, and hypotension before TAVI as 90-day mortality predictors.

CONCLUSION

Ninety-day mortality after TAVI in critically ill patients is increased but survivors have similar outcomes as elective patients.

Dual ProGlide versus ProGlide and FemoSeal for vascular access haemostasis after transcatheter aortic valve implantation

BACKGROUND

Large-bore arteriotomy for transcatheter aortic valve implantation (TAVI) requires percutaneous vascular closure devices, but real-world data comparing different closure strategies are limited.

AIMS

We sought to compare a dual ProGlide strategy vs a combination of one ProGlide and one FemoSeal for vascular closure after TAVI.

METHODS

We retrospectively analysed 874 propensity score-matched patients undergoing TAVI at the Munich University Hospital from August 2018 to October 2020. From August 2018 to August 2019, a dual ProGlide strategy was used for vascular closure. From October 2019 to October 2020, a combination of one ProGlide and one FemoSeal was used. The primary endpoint was defined as access-related major vascular complications or bleeding ≥Type 2 according to Valve Academic Research Consortium 3 criteria.

RESULTS

Patients in the dual ProGlide group (n=437) had a higher incidence of the primary endpoint than patients treated with one ProGlide and one FemoSeal (n=437; 11.4% vs 3.0%; p<0.001). Furthermore, they had a higher rate of closure device failure (2.7% vs 0.9%; p=0.044) and more often required unplanned surgery or endovascular treatment (3.9% vs 0.9%; p=0.004). The incidence of death did not differ significantly between groups (3.4% vs 1.6%; p=0.08).

CONCLUSIONS

A combined ProGlide and FemoSeal strategy might have the potential to reduce access-related vascular complications following TAVI.

Targeted Temperature Management in Postresuscitation Care After Incorporating Results of the TTM2 Trial

Cardiac arrest still accounts for a substantial proportion of cardiovascular related deaths and is associated with a tremendous risk of neurological injury and, among the few survivors, poor quality of life. Critical determinants of survival and long‐term functional status after cardiac arrest are timely initiation of cardiopulmonary resuscitation and use of an external defibrillator for patients with a shockable rhythm. Outcomes are still far from satisfactory, despite ongoing efforts to improve cardiac arrest response systems, as well as elaborate postresuscitation algorithms. Targeted temperature management at the wide range between 32 °C and 36 °C has been one of the main therapeutic strategies to improve neurological outcome in postresuscitation care. This recommendation has been mainly based on 2 small randomized trials that were published 20 years ago. Most recent data derived from the TTM2 (Targeted Hypothermia Versus Targeted Normothermia After Out‐of‐Hospital Cardiac Arrest) trial, which included 1861 patients, challenge this strategy. It showed no benefit of targeted hypothermia at 33 °C over normothermia at 36 °C to 37.5 °C with fever prevention. Because temperature management at lower temperatures also correlated with an increased risk of side effects without any benefit in the TTM2 trial, a modification of the guidelines with harmonizing temperature management to normothermia might be necessary.

CT-determined tricuspid annular dilatation is associated with persistence of tricuspid regurgitation after transcatheter aortic valve replacement

Introduction

Moderate or severe tricuspid regurgitation (TR) can be observed in 11% to 27% of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Even though in most patients an improvement of TR can be achieved after TAVR, the persistence of severe or massive TR after the procedure is associated with increased all-cause mortality.

Purpose

The aim of this study was to investigate if tricuspid annular dilatation (TAD) measured in pre-procedural CT among TAVR patients who had at least moderate TR at baseline could serve as a predictor for the persistence of TR. Moreover, the predictive value of TR persistence on the composite of 2-year mortality or tricuspid valve intervention was analysed.

Methods

We examined 151 patients with severe AS and at least moderate concomitant TR at baseline, who were treated with TAVR from April 2013 to December 2019. TR persistence was defined as the same or a higher grade of TR in the follow-up echocardiography at least 30 days after the procedure compared to preprocedural TR grade. To identify patients with TAD, the maximum septolateral diameter of the tricuspid annulus was measured in pre-procedural cardiac computed tomography images and normalized to the body surface area.

Results

The median value of 25.5 mm/m2 was determined as cut-off value for TAD. Out of 151 patients with moderate or more TR before TAVR, 75 patients (49.7%) were above the threshold of 25.5 mm/m2. Improvement of TR after TAVR of at least one grade was significantly more frequent in patients without TAD than with TAD (59% vs. 32%, corresponding odds ratio for persistence of TR: 3.06, 95% confidence interval: 1.50–6.35, p=0.001) (Figure 1A). Multivariable logistic regression analysis with adjustment for baseline TR severity confirmed that the predictive value of TAD for TR persistence after TAVR was irrespective of baseline TR (adjusted odds ratio: 2.79, 95% confidence interval: 1.42–5.59, p=0.003). Tricuspid valve intervention was conducted in 11 patients with TAD after TAVR (14.6%) and in no patients without TAD. Accordingly, at 2-years, tricuspid valve intervention-free survival was lowest among patients with TAD and persistent TR (Figure 1B).

Conclusion

Our analysis demonstrates for the first time that in patients undergoing TAVR for severe AS and at least moderate concomitant TR, CT-derived TAD is associated with persistence of TR after the procedure. Furthermore, TR persistence is associated with an adverse outcome.

Funding Acknowledgement

Type of funding sources: None.

Suture-based vs. pure plug-based vascular closure devices for VA-ECMO decannulation

Background

VA-ECMO is a valuable treatment option for patients in cardiogenic shock, but complications during decannulation may worsen the overall outcome. To date, no larger study has ever compared suture-based to pure plug-based vessel closure devices for VA-ECMO decannulation.

Purpose

The aim of the study was to compare the efficacy and safety of suture-based to pure plug-based vascular closure devices for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation for patients with cardiogenic shock.

Methods

In this retrospective study, the outcome of 33 patients with suture-based closure devices implanted between 02/2019 to 05/2020 were compared to 38 patients with plug-based closured device implanted between 06/2020 to 11/2021.

Results

Closure device success rate was 88% in the suture-based group versus 97% in the plug-based group (Figure 1, p=0.27). Median number of devices used was two for patients with suture-based closure device and 1 for patients with plug-based closure device (p&lt;0.01). Severe bleeding was more frequent in the suture-based (21%) compared to the plug-based group (3%) (Figure 2, p=0.04). Ischemic complications occurred in 6% with suture-based and 5% with plug-based device (p=1.00). Pseudoaneurysm formation was detected in 3% in both groups (p=1.00). Application of the femoral compression system was required in 27% of patient with suture-based closure device and 11% of patients with plug-based closure device (p=0.13). No switch to open vascular surgery due to closure device failure occurred in both groups.

Conclusions

Based on our retrospective analysis, we propose that plug-based vascular closure should be the preferred option for VA-ECMO decannulation. This hypothesis should be further tested in a randomized trial.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft

TAVI in patients with low-flow low-gradient aortic stenosis-short-term and long-term outcomes

OBJECTIVES

The study objective was to characterize different groups of low-flow low-gradient (LFLG) aortic stenosis (AS) and determine short-term outcomes and long-term mortality according to Valve Academic Research Consortium-3 (VARC-3) endpoint definitions.

BACKGROUND

Characteristics and outcomes of patients with LFLG AS undergoing transcatheter aortic valve implantation (TAVI) are poorly understood.

METHODS

All patients undergoing TAVI at our center between 2013 and 2019 were screened. Patients were divided into three groups according to mean pressure gradient (dPmean), ejection fraction (LVEF), and stroke volume index (SVi): high gradient (HG) AS (dPmean ≥ 40 mmHg), classical LFLG (cLFLG) AS (dPmean < 40 mmHg, LVEF < 50%), and paradoxical LFLG (pLFLG) AS (dPmean < 40 mmHg, LVEF ≥ 50%, SVi ≤ 35 ml/m²).

RESULTS

We included 1776 patients (956 HG, 447 cLFLG, and 373 pLFLG patients). Most baseline characteristics differed significantly. Median Society of Thoracic Surgeons (STS) score was highest in cLFLG, followed by pLFLG and HG patients (5.0, 3.9 and 3.0, respectively, p < 0.01). Compared to HG patients, odds ratios for the short-term VARC-3 composite endpoints, technical failure (cLFLG, 0.76 [95% confidence interval, 0.40-1.36], pLFLG, 1.37 [0.79-2.31]) and device failure (cLFLG, 1.06 [0.74-1.49], pLFLG, 0.97 [0.66-1.41]) were similar, without relevant differences within LFLG patients. NYHA classes improved equally in all groups. Compared to HG, LFLG patients had a higher 3-year all-cause mortality (STS score-adjusted hazard ratios, cLFLG 2.16 [1.77-2.64], pLFLG 1.53 [1.22-193]), as well as cardiovascular mortality (cLFLG, 2.88 [2.15-3.84], pLFLG, 2.08 [1.50-2.87]).

CONCLUSIONS

While 3-year mortality remains high after TAVI in LFLG compared to HG patients, symptoms improve in all subsets after TAVI.

Transcatheter Aortic Valve Replacement with the Self-Expandable Core Valve Evolut Prosthesis Using the Cusp-Overlap vs. Tricusp-View

Despite the rapid increase in experience and technological improvement, the incidence of conduction disturbances in patients undergoing transcatheter aortic valve replacement (TAVR) with the self-expandable CoreValve Evolut valve remains high. Recently, a cusp-overlap view (COP) implantation technique has been proposed for TAVR with self-expandable valves offering an improved visualization during valve expansion compared to the three-cusp view (TCV). This study aims to systematically analyze procedural outcomes of TAVR patients treated with the CoreValve Evolut valve using a COP compared to TCV in a high-volume center. The primary endpoint was technical success according the 2021 VARC-3 criteria. A total of 122 consecutive patients (61 pts. TCV: April 2019 to November 2020; 61 pts. COP: December 2020 to October 2021) that underwent TAVR with the CoreValve Evolut prosthesis were included in this analysis. Although there was no difference in the primary endpoint technical success between TCV and COP patients (93.4% vs. 90.2%, OR 0.65, 95% CI 0.16, 2.4, p = 0.51), we observed a significantly lower risk for permanent pacemaker implantation (PPI) among COP patients (TCV: 27.9% vs. COP: 13.1%, OR 0.39, 95% CI 0.15, 0.97, p = 0.047). Implantation of the CoreValve Evolut prosthesis using the COP might help to reduce the rate of PPI following TAVR.

TAVR in patients with low-flow low-gradient aortic stenosis – outcome data after three years from one large centre

Background

The outcome of patients with low-flow low-gradient (LFLG) aortic stenosis after transcatheter aortic valve replacement (TAVR) is not well evaluated. Long-term clinical success is thought to be less pronounced in LFLG patients compared to patients with high gradient (HG) aortic stenosis.

Purpose

The purpose of this study was to characterise different LFLG groups and determine their outcome after TAVR. We hypothesised that there would be relevant differences in baseline characteristics and patient survival after TAVR.

Methods

All patients undergoing TAVR for severe aortic stenosis at our centre between 2013 and 2019 were included in the study. Patients have been split into groups according preinterventional echocardiography data according to mean pressure gradient (dPmean), ejection fraction (EF), and stroke volume index (SVi). Patients with a dPmean &lt;40 mmHg and SVi ≤35 ml/m2 were subdivided into classical low-flow low-gradient (cLFLG, EF &lt;50%) and paradoxical low-flow (pLFLG, EF ≥50%). Patients with previous aortic valve replacement or severe aortic regurgitation were excluded from the analysis.

Results

1,772 patients were analysed (mean follow-up 2.2 years, median age 81.7 [77.5–85.7] years) and split into groups: HG, 953 patients (54.3%), cLFLG, 446 patients (25.2%), and pLFLG 373 patients (21.1%). Baseline characteristics showed significant differences (p&lt;0.01), among others, in sex (male sex, HG 46.1% vs. cLFLG 69.5% vs. pLFLG 44.5%), rate of atrial fibrillation (HG 20.3% vs. cLFLG 36.3% vs. pLFLG 41.6%), coronary artery disease (HG 56.2% vs. cLFLG 73.5% vs. pLFLG 63.4%), and grade 3 or 4 mitral regurgitation (HG 2.2% vs. cLFLG 5.5% vs. pLFLG 6.8%). Accordingly, Society of Thoracic Surgeons (STS) Scores differed significantly: HG, 3.0 [2.0–5.0], cLFLG, 5.0 [3.0–7.3] pLFLG, 3.9 [2.2–6.0] (p&lt;0.01).

Rates of periprocedural complications including death, device failure, pericardial effusion, stroke or myocardial infarction were comparable between groups. Mortality rate (figure 1) was highest for cLFLG patients (43.4% [95% confidence interval, 37.3–48.6%]) compared to HG (25.1% [21.6–28.5%]) or pLFLG (32.9% [26.9–38.4%]), Log-rank test, &lt;0.001. Corresponding hazard ratios were 2.1 [1.7–2.6] (p&lt;0.001) for cLFLG and 1.5 [1.2–2.0] (p&lt;0.001) for pLFLG. Similar results were obtained when adjusting to STS score (figure 2).

Conclusion

In this all-comer analysis, almost half of the patients belong toLFLG groups with considerable differences in patient characteristics. While equally safe during the procedure, patients with LFLG aortic stenosis show increased 3-year mortality rates compared to patients with HG aortic stenosis. Further studies evaluating this are needed.

Funding Acknowledgement

Type of funding sources: None. Figure 1. 3-year mortalityFigure 2. STS score-adjusted mortality

Quantification of physical activity with activity tracking after transfemoral aortic valve replacement (TAVR)

Background and hypothesis

TAVR is a well-established, safe and effective therapy for severe symptomatic aortic stenosis (AS), but improvement of physical activity after TAVR is difficult to assess objectively. The aim of this study was to quantify improvement of physical activity with Activity Tracking after TAVR with special focus on the different low-gradient subtypes of AS.

Methods

All patients who underwent TAVR for severe AS in our center between 01/2019 and 12/2019 were screened. Participants received an Activity Tracker for 7 days at two times: after hospital discharge following TAVR procedure and 6 months thereafter. The difference of mean daily steps was defined as study endpoint.

Results

The analysis is based on 230 patients. The median age was 79.7 years with 53.7% male participants. The median aortic valve area (AVA) was 0.75 cm2 and median mean pressure gradient was 38.7 mmHg (Table 1). The median amount of daily steps was 4409 [IQR 2581–7487] steps/day after hospital discharge and 5326 [IQR 3045–8668] steps/day 6 months thereafter. On a patient base, median difference of steps per day was Δ 529 [IQR −702–2152]). Whenever possible, patients were categorized into different subgroups of AS. Patients with high-gradient (HG) AS showed significant improvement in difference of daily steps at 6 months-FUP (Δ 951 [IQR −378–2.323], p&lt;0.001), as well as patients with paradox low-flow-low-gradient (LFLG) AS (Δ 1392 [IQR −609–4444], p=0.02). Patients with classical LFLG AS also showed an improvement of daily steps at 6-months-FUP but without statistical significance (Δ 192 [IQR −687–770], p=0.79). Patients with a normal-flow-low-gradient (NFLG) AS have no significant difference in daily steps after 6-months and show a tendency of decline in daily steps at 6-months-FUP (Δ −300 [IQR −1334–1406], p=0.67) (Figure 1).

Conclusions

This is the first study of this sample size to evaluate physical activity after TAVR with an objective and reproducible method. Overall, physical activity improved significantly 6 months after TAVR and daily steps per day increased in all subtypes of AS besides NFLG AS, where a tendency of decline in daily steps without statistical significance was shown. However the increase in daily steps did not reach statistical significance in classical LFLG AS patients.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

TAVR in nonagenarians: An analysis investigating safety, efficacy, symptomatic improvement, and long-term survival

BACKGROUND

In the aging western societies, an increasing prevalence of severe, symptomatic aortic stenosis is observed. The aim of this study was to examine the safety and efficacy of transcatheter aortic valve replacement (TAVR) in patients aged 90 years and older.

METHODS

All patients with severe symptomatic aortic stenosis undergoing TAVR at LMU Munich-University-Hospital between 2013 and 2018 were included. Procedure-related mortality (<30 days) was defined as the primary endpoint and survival rates at two years, device failure, and procedural complications were defined as secondary endpoints according to the Valve Academic Research Consortium II criteria.

RESULTS AND CONCLUSIONS

Out of 2336 patients, 2183 were younger than 90 years (<90y.-group) and 153 patients were aged 90 or older (≥90y.-group). Procedure-related mortality (3.6% <90y.-group vs. 3.3% ≥90y.-group, log-rank p=0.9) and device success (97.2% <90y.-group vs. 96.0% ≥90y.-group, p=0.44) were similar. Estimated survival rates at 2 years were 62.8% (95% CI 55.3 and 71.4) in the elder and 76.0% (95% CI 74.1 and 77.8) in the younger patients (p<0.01). The incidence of acute kidney injury, stroke, major bleeding, and permanent pacemaker implantations were comparable between both groups. TAVR procedure is equally safe and feasible in patients aged 90 years or older compared to younger patients. Differences in 2-year survival appear to be patient-related rather than procedure-related.

Long-Term Clinical Outcome of Cardiogenic Shock Patients Undergoing Impella CP Treatment vs. Standard of Care

The number of patients treated with the mechanical circulatory support device Impella Cardiac Power (CP) for cardiogenic shock is steadily increasing. The aim of this study was to investigate long-term survival and complications related to this modality. Patients undergoing Impella CP treatment for cardiogenic shock were retrospectively enrolled and matched with cardiogenic shock patients not treated with mechanical circulatory support between 2010 and 2020. Data were collected from the cardiogenic shock registry of the university hospital of Munich (DRKS00015860). 70 patients with refractory cardiogenic shock without mechanical circulatory support were matched with 70 patients treated with Impella CP. At presentation, the mean age was 67 ± 15 years with 80% being male in the group without support and 67 ± 14 years (p = 0.97) with 76% being male (p = 0.68) in the group with Impella. There was no significant difference in the rate of cardiac arrest (47% vs. 51%, p = 0.73) and myocardial infarction was the predominant cause of cardiogenic shock in both groups (70% vs. 77%). A total of 41% of patients without cardiocirculatory support and 54% of patients with Impella support died during the first month (p = 0.17). After one year, mortality rates were similar in both groups (55% in conventional vs. 59% in Impella CP group, p = 0.30) as was mortality rate at long-term 5-years follow-up (64% in conventional vs. 73% in Impella CP group, p = 0.33). The rate of clinically significant bleedings during ICU stay was lower in the conventional group than in the Impella support group (15% vs. 43%, p = 0.002). In this small observational and non-randomized analysis no difference in long-term outcome between patients treated with Impella CP vs. guideline directed cardiogenic shock therapy without mechanical circulatory support could be detected. Care must be taken regarding the high rate of bleeding and vascular complications when using Impella CP. Large, adequately powered studies are urgently needed to investigate the efficacy and safety of Impella CP in cardiogenic shock.

Incremental prognostic value of tricuspid annular dilatation over the STS score

Background

Transcatheter aortic valve replacement (TAVR) is the treatment of choice in most patients with severe aortic stenosis. The Society of Thoracic Surgeons (STS) score is a well established risk score to estimate morbidity, mortality and procedural risk of patients undergoing TAVR. However, tricuspid annular Dilatation (TAD), which is an increasingly recognized pathology associated with increased mortality, is not implemented in the STS Score.

Purpose

The purpose of this analysis was to investigate the incremental prognoctic value of TAD over the STS score.

Methods

Maximal septo-lateral diameter of the tricuspid annulus was measured in 923 patients on 3-dimensional MDCT datasets. A cut-off of 23 mm/m2 body-surface area was revealed by receiver-operating curve statistics and used to define TAD. Incremental prognostic Information was tested with c-index statistics and continuous net reclassification improvement (NRI). Patients were followed for 2 years and all-cause mortality was defined as study endpoint.

Results

Of 923 patients included in this analyis, TAD was found in 370 patients (40%). Patients with TAD had a significantly higher mortality (hazard ratio 2.18 with 95% CI 1.71 and 2.78, p&lt;0.001). The mean STS score in the investigated patient cohort was 5.6±5.0. TAD provided incremental prognostic Information over the STS score when assessed with c-index statistics (rise from 0.63 to 0.66, p&lt;0.01) or continuous NRI (0.209 with 95% CI 0.127 and 0.292, p&lt;0.001). Estimated survival rates at 2 years were 88.2% (95% CI 84.5 and 92.1) in patients with a low STS score (&lt;4) and no TAD and 57.5% (95% CI 51.1 and 64.7) in patients with a high STS score (&gt;4) and TAD. Estimated survival rates in patients with a low STS score and TAD and patients with a high STS score and no TAD were similiar (75.8% with 95% CI 68.9 and 83.5 and 74.8% with 95% CI 69.2 and 80.7, respectively). Kaplan-Meier curves are shown in Figure 1.

Conclusion

TAD is a common entity in patients undergoing TAVR for severe aortic stenosis. It is associated with significantly higher mortality and provides incremental prognostic Information over the STS score.

Funding Acknowledgement

Type of funding source: None

P5584Causes of death within the first year after transcatheter aortic valve implantation: Lessons from EVERY-TAVI registry

Background

According to current recommendations, transcatheter aortic valve implantation (TAVI) should only be performed among patients with a life expectancy of at least one year. However, many deaths occur within the first year after TAVI.

Purpose

To assess the causes of death within one year after TAVI.

Methods

Data was taken between November 2007 and December 2017 from the EVERY-TAVI registry. Patients who died during TAVI or experienced mechanical complications requiring surgery were excluded from the analysis. We assessed the causes of death over 3 periods post-TAVI: within the first 30 days, between 30 and 90 days, and between 90 and 365 days.

Results

Overall, 2389 patients underwent TAVI without mechanical complications. Among them, 320 (1.3%) died within one year. Age was the main cause of death, accounting for 73 deaths (22.8%), followed by heart failure (20.6%) and infections (18.7%). During the first month, cardiogenic shock was the main cause of death (25.4%), followed by infections (22.2%) and terminal heart failure (20.6%), while age was responsible of only one death (1.6%). During the two following months, heart failure was the main cause of death (33.3%), followed by infections (21.2%), and the percentage of deaths due to age increased to 18.2%. After 3 months, age was the main cause of death (31.4%), followed by infection (16.8%) and heart failure (16.2%).

Causes of death within one year of TAVI Cause of death All (n=320) <30 days (n=63) 30–90 days (n=66) >90 days (n=191) Older age, n (%) 73 (22.8) 1 (1.6) 12 (18.2) 60 (31.4) Terminal heart failure, n (%) 66 (20.6) 13 (20.6) 22 (33.3) 31 (16.2) Infection, n (%) 60 (18.7) 14 (22.2) 14 (21.2) 32 (16.8) Terminal renal failure, n (%) 26 (8.1) 4 (6.3) 5 (7.6) 17 (8.9) Cardiogenic shock, n (%) 26 (8.1) 16 (25.4) 4 (6.1) 6 (3.1) Malignancies, n (%) 18 (5.6) 0 (0.0) 2 (3.0) 16 (8.4) Sudden death, n (%) 17 (5.3) 6 (9.5) 2 (3.0) 9 (4.7) Stroke, n (%) 12 (3.7) 4 (6.3) 2 (3.0) 6 (3.1) Accident, n (%) 7 (2.2) 2 (3.2) 0 (0.0) 5 (2.6) Myocardial infarction, n (%) 7 (2.2) 2 (3.2) 2 (3.0) 3 (1.6) Non-cardiac surgery, n (%) 5 (1.6) 1 (1.6) 1 (1.5) 3 (1.6) Pulmonary embolism, n (%) 3 (0.9) 0 (0.0) 0 (0.0) 3 (1.6)

Conclusion

Cardiogenic shock is the main cause within the first month after TAVI, while older age is the main cause overall and after the initial months, highlighting the need to more carefully selection of patients undergoing TAVI.

Predictors of cerebrovascular events at mid-term after transcatheter aortic valve implantation - Results from EVERY-TAVI registry

BACKGROUND

Clinical relevant cerebrovascular events (CVE) following transcatheter aortic valve implantation (TAVI) still remain a devastating complication associated with mortality and severe impairments. Therefore, identification of particularly modifiable predictors of this complication is clinically relevant and an important step for planning preventive strategies.

METHODS

A total of 985 patients who underwent trans-femoral TAVI for aortic valve stenosis in our institution from February 2008 to January 2015 were considered. The influence of demographics, clinical and procedural data on the occurrence of CVE was assessed with a competing risk model with death as competing event. Clinical events were defined according to VARC-2 criteria.

RESULTS

At a median follow-up of 838days, 95% CI 807-892, 59 patients experienced any CVE (5.9%) and the overall cumulative mortality rate was 46.1%. CVEs mainly occur later than 30days after TAVI (47.5%), 88.1% of them were of ischemic origin and 52.5% were disabling events. Independent predictors of CVEs were age (hazard ratio 1.05; 95% CI 1.01 to 1.09), history of CVE (hazard ratio 2.54; 95% CI 1.39 to 4.63) and use of balloon post-dilation (hazard ratio 1.85; 95% CI 1.08 to 3.18).

CONCLUSION

In patients undergoing TAVI incidence of clinically relevant CVEs is frequent with half of the events occurring after the first 30days post-TAVI. Identification of balloon post-dilation as the only modifiable predictor of CVE risk at mid-term, urges its cautious performance after prosthesis implantation. CLINICALTRIALS.

GOV IDENTIFIER

NCT02289339.

Short-term inhibition of DPP-4 enhances endothelial regeneration after acute arterial injury via enhanced recruitment of circulating progenitor cells

BACKGROUND

Endothelial injuries regularly occur in atherosclerosis and during interventional therapies of the arterial occlusive disease. Disturbances in the endothelial integrity can lead to insufficient blood supply and bear the risk of thrombus formation and acute vascular occlusion. At present, effective therapeutics to restore endothelial integrity are barely available. We analyzed the effect of pharmacological DPP-4-inhibition by Sitagliptin on endogenous progenitor cell-based endothelial regeneration via the SDF-1α/CXCR4-axis after acute endothelial damage in a mouse model of carotid injury.

METHODS AND RESULTS

Induction of a defined endothelial injury was performed in the carotid artery of C57Bl/6 mice which led to a local upregulation of SDF-1α expression. Animals were treated with placebo, Sitagliptin or Sitagliptin+AMD3100. Using mass spectrometry we could prove that Sitagliptin prevented cleavage of the chemokine SDF-1α. Accordingly, increased SDF-1α concentrations enhanced recruitment of systemically applied and endogenous circulating CXCR4+ progenitor cells to the site of vascular injury followed by a significantly accelerated reendothelialization as compared to placebo-treated animals. Improved endothelial recovery, as well as recruitment of circulating CXCR4+ progenitor cells (CD133+, Flk1+), was reversed by CXCR4-antagonization through AMD3100. In addition, short-term Sitagliptin treatment did not significantly promote neointimal or medial hyperplasia.

CONCLUSION

Sitagliptin can accelerate endothelial regeneration after acute endothelial injury. DPP-4 inhibitors prevent degradation of the chemokine SDF-1α and thus improve the recruitment of regenerative circulating CXCR4+ progenitor cells which mediate local endothelial cell proliferation without adversely affecting vessel wall architecture.

Connexin 40 promoter-based enrichment of embryonic stem cell-derived cardiovascular progenitor cells

BACKGROUND

Pluripotent embryonic stem (ES) cells that can differentiate into functional cardiomyocytes as well as vascular cells in cell culture may open the door to cardiovascular cell transplantation. However, the percentage of ES cells in embryoid bodies (EBs) which spontaneously undergo cardiovascular differentiation is low (<10%), making strategies for their specific labeling and purification indispensable.

METHODS

The human connexin 40 (Cx40) promoter was isolated and cloned in the vector pEGFP. The specificity of the construct was initially assessed in Xenopus embryos injected with Cx40-EGFP plasmid DNA. Stable Cx40-EGFP ES cell clones were differentiated and fluorescent cells were enriched manually as well as via fluorescence-activated cell sorting. Characterization of these cells was performed with respect to spontaneous beating as well as via RT-PCRs and immunofluorescent stainings.

RESULTS

Cx40-EGFP reporter plasmid injection led to EGFP fluorescence specifically in the abdominal aorta of frog tadpoles. After crude manual enrichment of highly Cx40-EGFP-positive EBs, the appearance of cardiac and vascular structures was increased approximately 3-fold. Immunofluorescent stainings showed EGFP expression exclusively in vascular-like structures simultaneously expressing von Willebrand factor and in formerly beating areas expressing alpha-actinin. Cx40-EGFP-expressing EBs revealed significantly higher numbers of beating cardiomyocytes and vascular-like structures. Semiquantitative RT-PCRs confirmed an enhanced cardiovascular differentiation as shown for the cardiac markers Nkx2.5 and MLC2v, as well as the endothelial marker vascular endothelial cadherin.

CONCLUSIONS

Our work shows the feasibility of specific labeling and purification of cardiovascular progenitor cells from differentiating EBs based on the Cx40 promoter. We provide proof of principle that the deleted CD4 (DeltaCD4) surface marker-based method for magnetic cell sorting developed by our group will be ideally suitable for transference to this promoter.