Bioprosthetic valve fracture during valve-in-valve transcatheter aortic valve replacement: multicenter propensity matched analysis

Background

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) can be completed by bioprosthetic valve fracture (BVF) to reduce final transvalvular gradients. The aim was to compare outcomes in ViV-TAVI patients with versus without BVF.

Methods

Consecutive patients undergoing ViV-TAVI procedure in four international centers were included, from 2010 to 2021. We used a 1:2 propensity score-matching method to compare postprocedural hemodynamic, complications, and long-term outcomes. Patients were matched for baseline characteristics, time since prior surgery, and characteristics of surgical bioprothesis (type and size).

Results

A total of 390 patients were analyzed, including 40 BVF. Propensity matching 1:2 yielded 38 patients in BVF group and 76 patients in no-BVF group. There was no difference in procedural complications rate and in-hospital deaths (5.1%) between the two groups. Post-procedural hemodynamic parameters significantly improved using BVF: aortic valve area (1.4 cm2 [IQR: 1.23 to 2.3] vs. 1.3 cm2 [IQR: 1.05 to 1.61], p=0.008), mean aortic gradient (12mmHg [IQR: 7.5 to 16.5] vs. 17mmHg [IQR: 11 to 22], p=0.008) and peak velocity (2.2m/s [IQR: 1.8 to 2.7] vs. 2.6m/s [IQR: 2.2 to 3.1], p=0.027). BVF had an additional benefit in the smallest surgical valve (≤21 mm). The use of BVF was independently associated with improved hemodynamic parameters. Overall survival in the matched cohort was 87.8±3.7% at 2-year follow-up, without difference between groups (87.5±6.9% in the BVF group vs. 88.4±4.2% in the no-BVF group, p=0.85).

Conclusion

Compared to ViV-TAVI alone, BVF was safe and improved immediate hemodynamic and long-term outcomes, especially in patients with small surgical aortic bioprosthesis.

Funding Acknowledgement

Type of funding sources: None.

Impact of epicardial fat on the duration of radiofrequency energydelivery during catheter ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Aims

This study aimed to determine the impact of the volume of epicardial fat on the duration of radiofrequency (RF) energy delivery during the procedure of ablation of atrial fibrillation (AF).

Methods

The volume of epicardial fat was measured from spiral computerized tomography scan. The primary endpoint was the duration of RF delivery for pulmonary vein isolation (PVI), and the overall total duration of RF application. Secondary endpoint was conversion of AF to sinus rhythm or organisation of the arrhythmia after PVI.

Results

From March 2015 to May 2018, 222 patients (45,5% with persistent AF) underwent a first RF catheter ablation procedure for AF. The total duration of RF delivery, and the duration of RF delivery specifically for PVI were significantly associated with higher total volume of epicardial fat (p = 0,0002; p = 0,009 respectively), periatrial (p = 0,003; p = 0,045) and periventricular epicardial fat (p = 0,001; p = 0,012). In multivariate analysis, total epicardial fat volume was not significantly associated with total RF delivery duration (p = 0,743). For patients with arrhythmia at the time of the procedure, patients who achieved conversion or organisation of their arrhythmia after PVI had similar levels of total epicardial fat to those whose arrhythmia persisted (65 ± 35,2 vs 74,5 ± 31,2 ml ; p = 0,192).

Conclusion We observed a significant relation between total, periatrial, and periventricular epicardial fat, and the duration of RF delivery during ablation of AF. This relation was not significant by multivariate analysis meaning that epicardial fat maybe a marker, but not an independent factor,of ablation complexity.

Comparison of clinical outcomes after transcarotid and transsubclavian versus transfemoral TAVI: a propensity-matched analysis

 

Transcarotid (TC) and transsubclavian (TSc) accesses are increasingly used as alternative approaches for TAVI when the transfemoral (TF) access is not suitable. However, concerns remain about the risk of peri-procedural stroke and long-term outcomes following TC or TSc TAVI.

The present study sought to compare early- and long-term outcomes of TC/TSc vs. TF TAVI after propensity-score matching.

260 patients who underwent TAVI through a TF (n=220), TC (n=32) or TSc (n=8) approach at our institution during a 4 years period were identified. A 1:1 matching based on the propensity-score was performed, leading to a population of 40 TF and 40 TC/TSc. Primary endpoints were early complications whereas secondary endpoints were long-term outcomes.

There was no difference in the baseline characteristics. At 30-day post-TAVI, there was no difference in mortality and stroke rates between TF and TC/TSc TAVI (5% vs. 5% mortality, p=1.0 and 2 vs. 1 stroke, p=1.0). After a median follow-up of 21 months, the risk of death (p=0.950), stroke (p=0.817) and myocardial infarction (p=0.155) did not differ between the 2 groups.

After propensity-score matching, no significant difference in early and long-term outcomes was observed between TF and TSc/TSc TAVI. These findings should encourage Heart-Teams to consider a TC or TSc approach when TF access is not available.

Table 1. 30-day and 1-year outcomes according to the arterial access (TF vs. TC/TSc) Variables TF-TAVI (n=40) TC/TSc-TAVI (n=40) p-value 30-day outcomes  All-cause mortality 2 (5.0) 2 (5.0) 1.000  All-stroke 2 (5.0) 1 (2.5) 1.000  Life-threatening bleeding 4 (10.0) 1 (2.5) 0.375  Acute kidney injury stage 2 or 3 2 (5.0) 1 (2.5) 1.000  Major vascular complication 6 (15.0) 6 (15.0) 1.000  Coronary obstruction 0 0 –  Early safety composite endpoint (VARC-2) 10 (25.0) 8 (20.0) 0.804 1-year outcomes  All-cause mortality 6 (15.0) 7 (17.5) 1.000  Cardiovascular mortality 5 (12.5) 3 (7.5) 0.727  Stroke 3 (7.5) 2 (5.0) 1.000  Myocardial infarction 0 (0) 2 (5) 0.500  MACCE 8 (20.0) 9 (22.5) 1.000  Readmission for heart failure 6 (15.0) 2 (5) 0.219

Figure 1

Funding Acknowledgement

Type of funding source: None