Quantification of Aortic Valve Calcification in Contrast-Enhanced Computed Tomography

Background: The goal of our study is to evaluate a method to quantify aortic valve calcification (AVC) in contrast-enhanced computed tomography for patients with suspected severe aortic stenosis pre-interventionally. Methods: A total of sixty-five patients with aortic stenosis underwent both a native and a contrast-enhanced computed tomography (CECT) scan of the aortic valve (45 in the training cohort and 20 in the validation cohort) using a standardized protocol. Aortic valve calcification was semi-automatically quantified via the Agatston score method for the native scans and was used as a reference. For contrast-enhanced computed tomography, a calcium threshold of the Hounsfield units of the aorta plus four times the standard deviation was used. Results: For the quantification of aortic valve calcification in contrast-enhanced computed tomography, a conversion formula (691 + 1.83 x AVCCECT) was derived via a linear regression model in the training cohort. The validation in the second cohort showed high agreement for this conversion formula with no significant proportional bias (Bland-Altman, p = 0.055) and with an intraclass correlation coefficient in the validation cohort of 0.915 (confidence interval 95% 0.786-0.966) p < 0.001. Conclusions: Calcium scoring in patients with aortic valve stenosis can be performed using contrast-enhanced computed tomography with high validity. Using a conversion factor led to an excellent agreement, thereby obviating an additional native computed tomography scan. This might contribute to a decrease in radiation exposure.

Outcomes and predictors of left ventricle recovery in patients with severe left ventricular dysfunction undergoing transcatheter aortic valve implantation

BACKGROUND

Data on the likelihood of left ventricle (LV) recovery in patients with severe LV dysfunction and severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) and its prognostic value are limited.

AIMS

We aimed to assess the likelihood of LV recovery following TAVI, examine its association with midterm mortality, and identify independent predictors of LV function.

METHODS

In our multicentre registry of 17 TAVI centres in Western Europe and Israel, patients were stratified by baseline LV function (ejection fraction [EF] >/≤30%) and LV response: no LV recovery, LV recovery (EF increase ≥10%), and LV normalisation (EF ≥50% post-TAVI).

RESULTS

Our analysis included 10,872 patients; baseline EF was ≤30% in 914 (8.4%) patients and >30% in 9,958 (91.6%) patients. The LV recovered in 544 (59.5%) patients, including 244 (26.7%) patients whose LV function normalised completely (EF >50%). Three-year mortality for patients without severe LV dysfunction at baseline was 29.4%. Compared to this, no LV recovery was associated with a significant increase in mortality (adjusted hazard ratio 1.32; p<0.001). Patients with similar LV function post-TAVI had similar rates of 3-year mortality, regardless of their baseline LV function. Three variables were associated with a higher likelihood of LV recovery following TAVI: no previous myocardial infarction (MI), estimated glomerular filtration rate >60 mL/min, and mean aortic valve gradient (mAVG) (expressed either as a continuous variable or as a binary variable using the standard low-flow, low-gradient aortic stenosis [AS] definition).

CONCLUSIONS

LV recovery following TAVI and the extent of this recovery are major determinants of midterm mortality in patients with severe AS and severe LV dysfunction undergoing TAVI. Patients with no previous MI and those with an mAVG >40 mmHg show the best results following TAVI, which are at least equivalent to those for patients without severe LV dysfunction. (ClinicalTrials.gov: NCT04031274).

Ultrashort VIBE-Dixon versus Cine and late gadolinium enhancement MRI sequences for cardiac thrombus detection

PURPOSE

To determine the diagnostic accuracy of volumetric interpolated breath-hold examination sequences with fat suppression in Dixon technique (VIBE-Dixon) for cardiac thrombus detection.

METHOD

From our clinical database, we retrospectively identified consecutive patients between 2014 and 2022 who had definite diagnosis or exclusion of cardiac thrombus confirmed by an independent adjudication committee, serving as the reference standard. All patients received 2D-Cine plus 2D-Late-Gadolinium-Enhancement (Cine + LGE) and VIBE-Dixon sequences. Two blinded readers assessed all images for the presence of cardiac thrombus. The diagnostic accuracy of Cine + LGE and VIBE-Dixon was determined and compared.

RESULTS

Among 141 MRI studies (116 male, mean age: 61 years) mean image examination time was 28.8 ± 3.1 s for VIBE-Dixon and 23.3 ± 2.5 min for Cine + LGE. Cardiac thrombus was present in 49 patients (prevalence: 35 %). For both readers sensitivity for thrombus detection was significantly higher in VIBE-Dixon compared with Cine + LGE (Reader 1: 96 % vs.73 %, Reader 2: 96 % vs. 78 %, p < 0.01 for both readers), whereas specificity did not differ significantly (Reader 1: 96 % vs. 98 %, Reader 2: 92 % vs. 93 %, p > 0.1). Overall diagnostic accuracy of VIBE-Dixon was higher than for Cine + LGE (95 % vs. 89 %, p = 0.02) and was non-inferior to the reference standard (Delta ≤ 5 % with probability > 95 %).

CONCLUSIONS

Biplanar VIBE-Dixon sequences, acquired within a few seconds, provided a very high diagnostic accuracy for cardiac thrombus detection. They could be used as stand-alone sequences to rapidly screen for cardiac thrombus in patients not amenable to lengthy acquisition times.

Photon-counting CT-angiography in pre-TAVR aortic annulus assessment: effects of retrospective vs. prospective ECG-synchronization on prosthesis valve selection

To compare the diagnostic value of ultrahigh-resolution CT-angiography (UHR-CTA) compared with high-pitch spiral CTA (HPS-CTA) using a first-generation, dual-source photon-counting CT (PCD-CT) scanner for preprocedural planning of transcatheter aortic valve replacement (TAVR). Clinically referred patients with severe aortic valve stenosis underwent both, retrospective ECG-gated cardiac UHR-CTA (collimation: 120 × 0.2 mm) and prospective ECG-triggered aortoiliac HPS-CTA (collimation: 144 × 0.4 mm, full spectral capabilities) for TAVR planning from August 2022 to March 2023. Radiation dose was extracted from the CT reports, and the effective dose was calculated. Two radiologists analyzed UHR-CTA and HPS-CTA datasets, assessing the image quality of the aortic annulus, with regard to the lumen visibility and margin delineation using a 4-point visual-grading scale (ranges: 4 = "excellent" to 1 = "poor"). Aortic annulus area (AAA) measurements were taken for valve prosthesis sizing, with retrospective UHR-CTA serving as reference standard. A total of 64 patients were included (mean age, 81 years ± 7 SD; 28 women) in this retrospective study. HPS-CTA showed a lower radiation dose, 4.1 mSv vs. 12.6 mSv (p < 0.001). UHR-CTA demonstrated higher image quality to HPS-CTA (median score, 4 [IQR, 3-4] vs. 3 [IQR, 2-3]; p < 0.001). Quantitative assessments of AAA from both CTA datasets were strongly positively correlated (mean 477.4 ± 91.1 mm2 on UHR-CTA and mean 476.5 ± 90.4 mm2 on HPS-CTA, Pearson r2 = 0.857, p < 0.001) with a mean error of 22.3 ± 24.6 mm2 and resulted in identical valve prosthesis sizing in the majority of patients (91%). Patients with lower image quality on HPS-CTA (score value 1 or 2, n = 28) were more likely to receive different sizing recommendations (82%). Both UHR-CTA and HPS-CTA acquisitions using photon-counting CT technology provided reliable aortic annular assessments for TAVR planning. While UHR-CTA offers superior image quality, HPS-CTA is associated with lower radiation exposure. However, severely impaired image quality on HPS-CTA may impact on prosthesis sizing, suggesting that immediate post-scan image evaluations may require complementary UHR-CTA scanning.

Photon-counting computed tomography - clinical application in oncological, cardiovascular, and pediatric radiology

BACKGROUND

 Photon-counting detector computed tomography (PCD-CT) is a promising new technology with the potential to fundamentally change workflows in the daily routine and provide new quantitative imaging information to improve clinical decision-making and patient management.

METHOD

 The contents of this review are based on an unrestricted literature search of PubMed and Google Scholar using the search terms "photon-counting CT", "photon-counting detector", "spectral CT", "computed tomography" as well as on the authors' own experience.

RESULTS

 The fundamental difference with respect to the currently established energy-integrating CT detectors is that PCD-CT allows for the counting of every single photon at the detector level. Based on the identified literature, PCD-CT phantom measurements and initial clinical studies have demonstrated that the new technology allows for improved spatial resolution, reduced image noise, and new possibilities for advanced quantitative image postprocessing.

CONCLUSION

 For clinical practice, the potential benefits include fewer beam hardening artifacts, a radiation dose reduction, and the use of new or combinations of contrast agents. In particular, critical patient groups such as oncological, cardiovascular, lung, and head & neck as well as pediatric patient collectives benefit from the clinical advantages.

KEY POINTS

  · Photon-counting computed tomography (PCD-CT) is being used for the first time in routine clinical practice, enabling a significant dose reduction in critical patient populations such as oncology, cardiology, and pediatrics.. · Compared to conventional CT, PCD-CT enables a reduction in electronic image noise.. · Due to the spectral data sets, PCD-CT enables fully comprehensive post-processing applications..

CITATION FORMAT

· Hagen F, Soschynski M, Weis M et al. Photon-counting computed tomography - clinical application in oncological, cardiovascular, and pediatric radiology. Fortschr Röntgenstr 2024; 196: 25 - 34.

Investigation of factors determining haemodynamic relevance of leaflet thrombosis after transcatheter aortic valve implantation

AIMS

To determine the conditions under which early hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve implantation (TAVI) becomes haemodynamically relevant.

METHODS AND RESULTS

The study included 100 patients (age: 81.5 ± 5.5 years; female 63%), thereof 50 patients with HALT. After anonymization and randomization, blinded readers measured maximum thrombus thickness per prosthesis (MT_pr) and movement restriction (MR_pr) on electrocardiogram (ECG)-gated whole heart cycle computed tomography angiography. These measurements were compared with echocardiographic mean pressure gradient (mPG), its increase from baseline (ΔmPG), and Doppler velocity index (DVI). Haemodynamic valve deterioration (HVD) was defined as mPG > 20 mmHg. Age, body mass index, valve type, valve size, left ventricular ejection fraction, and atrial fibrillation were considered as influencing factors. Multiple regression analysis revealed that only valve size (P = 0.001) and MT_pr (P = 0.02) had a significant influence on mPG. In an interaction model, valve size moderated the effect of MT_pr on mPG significantly (P = 0.004). Sub-group analysis stratified by valve sizes showed a strong correlation between MT_pr and echocardiographic parameters for 23 mm valves (mPG: r = 0.57, ΔmPG: r = 0.68, DVI: r = 0.55, each with P < 0.001), but neither for 26 nor 29 mm valves (r < 0.2, P > 0.2 for all correlations). Six of seven prostheses with HVD had a 23 mm valve diameter, while one had 29 mm (P = 0.02).

CONCLUSION

Early HALT rarely causes significant mPG increase. Our study shows that valve size is a key factor influencing the haemodynamic impact of HALT. In small valve sizes, mPG is more likely to increase. Our study is the first to offer in vivo evidence supporting previous in vitro findings on this topic.

Pre-Procedural Assessment of the Femoral Access Route for Transcatheter Aortic Valve Implantation: Comparison of a Non-Contrast Time-of-Flight Magnetic Resonance Angiography Protocol with Contrast-Enhanced Dual-Source Computed Tomography Angiography

Background: We aimed to evaluate the feasibility of a non-contrast time-of-flight magnetic resonance angiography (TOF-MRA) protocol for the pre-procedural access route assessment of transcatheter aortic valve implantation (TAVI) in comparison with contrast-enhanced cardiac dual-source computed tomography angiography (CTA). Methods and Results: In total, 51 consecutive patients (mean age: 82.69 ± 5.69 years) who had undergone a pre-TAVI cardiac CTA received TOF-MRA for a pre-procedural access route assessment. The MRA image quality was rated as very good (median of 5 [IQR 4-5] on a five-point Likert scale), with only four examinations rated as non-diagnostic. The TOF-MRA systematically underestimated the minimal effective vessel diameter in comparison with CTA (for the effective vessel diameter in mm, the right common iliac artery (CIA)/external iliac artery (EIA)/common femoral artery (CFA) MRA vs. CTA was 8.04 ± 1.46 vs. 8.37 ± 1.54 (p < 0.0001) and the left CIA/EIA/CFA MRA vs. CTA was 8.07 ± 1.32 vs. 8.28 ± 1.34 (p < 0.0001)). The absolute difference between the MRA and CTA was small (for the Bland-Altman analyses in mm, the right CIA/EIA/CFA was -0.36 ± 0.77 and the left CIA/EIA/CFA was -0.25 ± 0.61). The overall correlation between the MRA and CTA measurements was very good (with a Pearson correlation coefficient of 0.87 (p < 0.0001) for the right CIA/EIA/CFA and a Pearson correlation coefficient of 0.9 (p < 0.0001) for the left CIA/EIA/CFA). The feasibility agreement between the MRA and CTA for transfemoral access was good (the right CIA/EIA/CFA agreement was 97.9% and the left CIA/EIA/CFA agreement was 95.7%, Kohen's kappa: 0.477 (p = 0.001)). Conclusions: The TOF-MRA protocol was feasible for the assessment of the access route in an all-comer pre-TAVI population. This protocol might be a reliable technique for patients at an increased risk of contrast-induced nephropathy.

Improved mini-Tn7 Delivery Plasmids for Fluorescent Labeling of Stenotrophomonas maltophilia

Fluorescently labeled bacterial cells have become indispensable for many aspects of microbiological research, including studies on biofilm formation as an important virulence factor of various opportunistic bacteria of environmental origin such as Stenotrophomonas maltophilia. Using a Tn7-based genomic integration system, we report the construction of improved mini-Tn7 delivery plasmids for labeling of S. maltophilia with sfGFP, mCherry, tdTomato and mKate2 by expressing their codon-optimized genes from a strong, constitutive promoter and an optimized ribosomal binding site. Transposition of the mini-Tn7 transposons into single neutral sites located on average 25 nucleotides downstream of the 3'-end of the conserved glmS gene of different S. maltophilia wild-type strains did not have any adverse effects on the fitness of their fluorescently labeled derivatives. This was demonstrated by comparative analyses of growth, resistance profiles against 18 antibiotics of different classes, the ability to form biofilms on abiotic and biotic surfaces, also independent of the fluorescent protein expressed, and virulence in Galleria mellonella. It is also shown that the mini-Tn7 elements remained stably integrated in the genome of S. maltophilia over a prolonged period of time in the absence of antibiotic selection pressure. Overall, we provide evidence that the new improved mini-Tn7 delivery plasmids are valuable tools for generating fluorescently labeled S. maltophilia strains that are indistinguishable in their properties from their parental wild-type strains. IMPORTANCE The bacterium S. maltophilia is an important opportunistic nosocomial pathogen that can cause bacteremia and pneumonia in immunocompromised patients with a high rate of mortality. It is now considered as a clinically relevant and notorious pathogen in cystic fibrosis patients but has also been isolated from lung specimen of healthy donors. The high intrinsic resistance to a wide range of antibiotics complicates treatment and most likely contributes to the increasing incidence of S. maltophilia infections worldwide. One important virulence-related trait of S. maltophilia is the ability to form biofilms on any surface, which may result in the development of increased transient phenotypic resistance to antimicrobials. The significance of our work is to provide a mini-Tn7-based labeling system for S. maltophilia to study the mechanisms of biofilm formation or host-pathogen interactions with live bacteria under non-destructive conditions.

Predictive value of late gadolinium enhancement cardiovascular magnetic resonance in patients with persistent atrial fibrillation: dual-centre validation of a standardized method

Aims

With recurrence rates up to 50% after pulmonary vein isolation (PVI) in persistent atrial fibrillation (AF), predictive tools to improve patient selection are needed. Patient selection based on left atrial late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) has been proposed previously (UTAH-classification). However, this approach has not been widely established, in part owed to the lack of standardization of the LGE quantification method. We have recently established a standardized LGE-CMR method enabling reproducible LGE-quantification. Here, the ability of this method to predict outcome after PVI was evaluated.

Methods and results

This dual-centre study (n = 219) consists of a prospective derivation cohort (n = 37, all persistent AF) and an external validation cohort (n = 182; 66 persistent, 116 paroxysmal AF). All patients received an LGE-CMR prior to first-time PVI-only ablation. LGE was quantified based on the signal-intensity-ratio relative to the blood pool, applying a uniform LGE-defining threshold of >1.2.  In patients with persistent AF in the derivation cohort, left atrial LGE-extent above a cut-off value of 12% was found to best predict relevant low-voltage substrate (≥2 cm two with <0.5 mV during sinus rhythm) and arrhythmia-free survival 12 months post-PVI. When applied to the external validation cohort, this cut-off value was also predictive of arrhythmia-free survival for both, the total cohort and the subgroup with persistent AF (LGE < 12%: 80% and 76%; LGE > 12%: 55% and 44%; P = 0.007 and P = 0.029, respectively).

Conclusion

This dual-centre study established and validated a standardized, reproducible LGE-CMR method discriminating PVI responders from non-responders, which may improve choice of therapeutic approach or ablation strategy for patients with persistent AF.

Quantification of aortic valve calcification in contrast enhanced computer tomography

Introduction

Aortic valve calcification (AVC) is linked to higher gradients and worse prognosis in aortic valve stenosis. Current guidelines recommend calcium scoring of the aortic valve as additional factor for decision making in low-flow, low-gradient aortic stenosis. Calcium Scoring is performed by native computed tomography (CT). For planning of interventional valve replacement (TAVR) a second scan with contrast agent (CECT) is needed at the cost of additional radiation exposure and work up time. The aim of this study is to assess and validate an estimate conversion factor of aortic valve quantification by using CECT without native imaging.

Methods

The Agatston score was measured on native CT in 45 patients and used as a reference. In contrast enhanced CT, mean aortic attenuation values in Hounsfield units (HU) were determined by placement of a region of interest in the ascending aorta with a standard deviation of 4xHU for calcification threshold. AVC was segmented semi-automatically. A conversion formula was created by plotting of native Agatston score versus aortic valve calcification segmented on contrast enhanced CT and linear regression. Validation of calculated conversion formula was established by Intra-class coefficient (ICC) and Bland Altman analysis.

Results

The linear regression model yielded an Agatston score conversion formula of 691 + 1.83 × AVCCECT. Validation of the formula in a validation cohort (n=20) showed high agreement (r2=0.802, ICC 0.915 (CI 95%: 0.786–0.966) p&lt;0.001, p=0.055).

Conclusion

Approximation by our calculated conversion factor from contrast enhanced CT has shown excellent reliability to determine aortic valve calcification. Further studies are needed to extend this finding to larger cohorts and diverse clinical environments.

Funding Acknowledgement

Type of funding sources: None.

Toxicity and virucidal activity of a neon-driven micro plasma jet on eukaryotic cells and a coronavirus

Plasma medicine is a developing field that utilizes the effects of cold physical plasma on biological substrates for therapeutic purposes. Approved plasma technology is frequently used in clinics to treat chronic wounds and skin infections. One mode of action responsible for beneficial effects in patients is the potent antimicrobial activity of cold plasma systems, which is linked to their unique generation of a plethora of reactive oxygen and nitrogen species (ROS). During the SARS-CoV-2 pandemic, it became increasingly clear that societies need novel ways of passive and active protection from viral airway infections. Plasma technology may be suitable for superficial virus inactivation. Employing an optimized neon-driven micro plasma jet, treatment time-dependent ROS production and cytotoxic effects to different degrees were found in four different human cell lines with respect to their metabolic activity and viability. Using the murine hepatitis virus (MHV), a taxonomic relative of human coronaviruses, plasma exposure drastically reduced the number of infected murine fibroblasts by up to 3000-fold. Direct plasma contact (conductive) with the target maximized ROS production, cytotoxicity, and antiviral activity compared to non-conductive treatment with the remote gas phase only. Strikingly, antioxidant pretreatment reduced but not abrogated conductive plasma exposure effects, pointing to potential non-ROS-related mechanisms of antiviral activity. In summary, an optimized micro plasma jet showed antiviral activity and cytotoxicity in human cells, which was in part ROS-dependent. Further studies using more complex tissue models are needed to identify a safe dose-effect window of antiviral activity at modest toxicity.

Center Valve Preference and Outcomes of Transcatheter Aortic Valve Replacement: Insights From the AMTRAC Registry

BACKGROUND

Data on outcomes of transcatheter aortic valve replacement (TAVR) using balloon-expandable valves (BEVs) or self-expandable valves (SEVs) as well as the impact of center valve preference on these outcomes are limited.

OBJECTIVES

The aim of this study was to compare outcomes of TAVR procedures using third-generation BEVs and SEVs stratified by center valve preference.

METHODS

In a multicenter registry (n = 17), 13 centers exhibited valve preference (66.6%-90% of volume) and were included. Outcomes were compared between BEVs and SEVs stratified by center valve preference.

RESULTS

In total, 7,528 TAVR procedures (3,854 with SEVs and 3,674 with BEVs) were included. The mean age was 81 years, and the mean Society of Thoracic Surgeons score was 5.2. Baseline characteristics were similar between BEVs and SEVs. Need for pacemaker implantation was higher with SEVs at BEV- and SEV-dominant centers (17.8% vs 9.3% [P < 0.001] and 12.7% vs 10.0% [P = 0.036], respectively; HR: 1.51; P for interaction = 0.021), risk for cerebrovascular accident was higher with SEVs at BEV-dominant but not SEV-dominant centers (3.6% vs 1.1% [P < 0.001] and 2.2% vs 1.4% [P = 0.162]; HR: 2.08; P for interaction < 0.01). Aortic regurgitation greater than mild was more frequent with SEVs at BEV-dominant centers and similar with BEVs regardless of center dominance (5.2% vs 2.8% [P < 0.001] and 3.4% vs 3.7% [P = 0.504], respectively). Two-year mortality was higher with SEVs at BEV-dominant centers but not at SEV-dominant centers (21.9% vs 16.9% [P = 0.021] and 16.8% vs 16.5% [P = 0.642], respectively; HR: 1.20; P for interaction = 0.032).

CONCLUSIONS

Periprocedural outcomes, aortic regurgitation greater than mild, and 2-year mortality are worse when TAVR is performed using SEVs at BEV-dominant centers. Outcomes are similar regardless of valve type at SEV-dominant centers. The present results stress the need to account for this factor when comparing BEV and SEV outcomes. (The Aortic+Mitral Transcatheter [AMTRAC] Valve Registry; NCT04031274).

Long-Term Follow-Up of Hypoattenuated Leaflet Thickening After Transcatheter Aortic Valve Replacement

BACKGROUND

Early hypoattenuated leaflet thickening (HALT) occurs in at least 10% of all transcatheter aortic valve replacement (TAVR) patients. The long-term prognostic impact of HALT is uncertain.

OBJECTIVES

The aim of this study was to assess the long-term risk of early HALT post-TAVR.

METHODS

We report outcome data from our prospective observational registry with post-TAVR computed tomography angiography performed between May 2012 and December 2017. The outcomes were survival, cardiovascular mortality, ischemic cerebrovascular events, and symptomatic hemodynamic valve deterioration.

RESULTS

Early HALT was diagnosed in 115 (16.0%) of 804 patients. During a median follow-up of 3.25 years, survival rates did not differ significantly between patients with and without HALT (Kaplan-Meier 3-year estimates for survival 70.1% vs 74.0%, P = 0.597). The 3-year cardiovascular mortality rate was 13.2% versus 11.3% (with vs without HALT, P = 0.733). The 3-year event rate for cerebrovascular events was 2.0% versus 4.4% (with vs without HALT, P = 0.246), and the 3-year event rate of symptomatic hemodynamic valve deterioration was 9.4% versus 1.5% (with vs without HALT, P < 0.001). Multivariable analysis revealed the following predictors of symptomatic hemodynamic valve deterioration: HALT (HR: 6.10; 95% CI: 2.59-14.29; P < 0.001), the mixed valve-type group (HR: 6.51; 95% CI: 2.38-17.81; P < 0.001), and prosthesis diameter (HR valve size per 3 mm [HR: 0.37; 95% CI: 0.17-0.79]; P = 0.011).

CONCLUSIONS

During a median follow-up of more than 3 years, HALT was not associated with mortality or cerebrovascular events. However, we observed an association of HALT with symptomatic hemodynamic valve deterioration.

Comparison of various late gadolinium enhancement magnetic resonance imaging methods to high-definition voltage and activation mapping for detection of atrial cardiomyopathy

Funding Acknowledgements

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

Background/Introduction

Atrial cardiomyopathy (ACM) is associated with the progression from paroxysmal through persistent to permanent atrial fibrillation (AF) and increased arrhythmia recurrence rates after pulmonary vein isolation (PVI).

Purpose

We compare the most common left atrial (LA) late gadolinium enhancement magnetic resonance imaging (LGE-MRI)-methods (Utah-method and image-intensity-ratio (IIR)-methods) and endocardial voltage mapping for ACM-detection and outcome prediction after PVI for AF.

Methods

In this prospective study, 37 ablation-naive patients (66±9 years, 84% male) with persistent AF were included and electrically cardioverted into sinus rhythm. Subsequently, they underwent LA-LGE-MRI and high-definition voltage and activation mapping (2129±484 sites) in sinus rhythm prior to PVI. MRI-post-processing-analyses were performed by two independent expert laboratories (Marrek for the Utah segmentation as describers of this methodology and Adas 3D medical as developers of the Adas software for the IIR-methods) which were blinded to any clinical data. Arrhythmia recurrence was recorded within 12 months following PVI.

Results

The global ACM-extent was highly variable: median LA low-voltage substrate (LA-LVS) was 12.9% at &lt;1.0mV and 2.7% at &lt;0.5mV; median LA-LGE-extent using the Utah-method was 18.3% and 0.03%-93.1% using the IIR-methods. LA activation time was significantly correlated with LA-LVS (r=0.76 at &lt;0.5mV and r=0.82 at &lt;1.0mV, both p&lt;0.0001), but not with LA-LGE-extent.

The highest regional matching between LA-LVS &lt;0.5mV and LA-LGE was found for the anterior wall in 57% of patients using the Utah-method and in 59% using IIR 1.20. The corresponding values for the posterior wall were 19% and 38%, respectively.

Arrhythmia recurrence occurred in 15 (41%) patients. Freedom from arrhythmia was significantly lower in those with relevant LA-LVS (≥2cm2 at 0.5mV) but not in those with relevant LGE (Utah-stages III&IV): 43% versus 81%, p=0.009 and 50% versus 67%, p=0.338, respectively. Furthermore, relevant

LA-LVS was the only predictor for arrhythmia recurrence in multivariate regression analysis.

Conclusion

The different LA-LGE-MRI methods have large dicrepancies regarding extent and distribution of ACM and are different to the extent and regional distribution of LA-LVS as assessed in endocardial high-definition voltage mapping in sinus rhythm. Further improvements of the LA-LGE-MRI-methods are required to enable correct diagnosis of ACM and for future evaluation of MRI-guided ablation protocols.

A human factors approach to evaluate predicators of acute care nurse occupational fatigue

Nurses function at the point of care and assume a significant role in intercepting errors. They work in a mentally and physically demanding profession that is comprised of shift-work, subjecting nurses to considerable fatigue. Yet, few studies constructed a comprehensive model that integrates personal and occupational factors to explore their relationship with various types of fatigue (acute, chronic, physical, mental, and total). Here, we examine this type of comprehensive fatigue-model, in a report that represents one aim of a larger, mixed-methods study. The study sample comprised of 1137 registered nurses working in eight hospitals in a Midwestern state. Nurses reported higher levels of acute and total fatigue than chronic and physical fatigue. Staffing and resource adequacy, exercise, and sleep were among the strongest predictors. Since fatigue is a multi-faceted construct, a comprehensive fatigue-management strategy that targets both day and night-shift nurses is the optimal way to manage nurse fatigue.

Clinical outcomes of transcatheter aortic valve implantation in patients younger than 70 years rejected for surgery: the AMTRAC registry

BACKGROUND

The mean age of transcatheter aortic valve implantation (TAVI) patients is steadily decreasing.

AIMS

The aim of the study was to describe the characteristics, the indications for and the outcomes of TAVI in patients <70 years old.

METHODS

All patients undergoing TAVI (n=8,626) from the 18 participating centres between January 2007 and June 2020 were stratified by age (</>70). For patients <70, the indications for TAVI were extracted from Heart Team discussions and the baseline characteristics and mortality were compared between the two groups.

RESULTS

Overall, 640 (7.4%) patients were <70 (9.1% during 2018-2020, p<0.001); the mean age was 65.0±2.3 years. The younger patients were more often male, with bicuspid valves or needing valve-in-valve procedures. They had a higher prevalence of lung disease and diabetes. In 80.7% of cases, the Heart Team estimated an increased surgical risk and TAVI was selected, reflected by an STS score >4% in 20.4%. Five-year mortality was similar (29.4 vs 29.8%, HR 0.95, p=0.432) in the <70 and >70 groups. In the <70 group, mortality was higher for those referred for TAVI due to an increased surgical risk compared to those referred for other reasons (31.6 vs 24.5%, HR 1.23, p=0.021). Mortality was similar regardless of the STS stratum in patients judged by the Heart Team to be at increased surgical risk (32.6 vs 30.4%, HR 0.98, p=0.715).

CONCLUSIONS

Use of TAVI in patients <70 is becoming more frequent. The main reason for choosing TAVI is due to an increased surgical risk not adequately represented by the STS score. The outcomes for these patients are similar to those for older TAVI patients. Dedicated trials of TAVI/SAVR in younger patients are needed to guide decisions concerning expansion of TAVI indications. ((ClinicalTrials.gov: NCT04031274).

Comparison of various late gadolinium enhancement magnetic resonance imaging methods with high-definition voltage and activation mapping for detection of atrial cardiomyopathy

AIMS

Atrial cardiomyopathy (ACM) is associated with increased arrhythmia recurrence rates after pulmonary vein isolation (PVI). We compare the most common left atrial (LA) late gadolinium enhancement magnetic resonance imaging (LGE-MRI)-methods [Utah-method and image intensity ratio (IIR)-methods] and endocardial voltage mapping for ACM-detection and outcome prediction after PVI for atrial fibrillation (AF).

METHODS AND RESULTS

In this prospective observational study, 37 ablation-naive patients (66 ± 9 years, 84% male) with persistent AF underwent LA-LGE-MRI and high-definition voltage and activation mapping (2129 ± 484 sites) in sinus rhythm prior to PVI. The MRI-post-processing-analyses were performed by two independent expert laboratories. Arrhythmia recurrence was recorded within 12 months following PVI. The global ACM-extent was highly variable: median LA low-voltage substrate (LA-LVS) was 12.9% at <1.0 mV and 2.7% at <0.5 mV; median LA-LGE-extent using the Utah-method was 18.3% and 0.03-93.1% using the IIR-methods. The LA activation time was significantly correlated with LA-LVS (r = 0.76 at <0.5 mV and r = 0.82 at <1.0 mV, both P < 0.0001), but not with LA-LGE-extent. The highest regional matching between LA-LVS <0.5 mV and LA-LGE was found for the anterior wall in 57% of patients using the Utah-method and in 59% using IIR 1.20. The corresponding values for the posterior wall were 19% and 38%, respectively. Arrhythmia recurrence occurred in 15(41%) patients. Freedom from arrhythmia was significantly lower in those with LA-LVS ≥2 cm2 at 0.5 mV but not in those with LGE ≥20% (Utah-stages III and IV): 43% vs. 81%, P = 0.009 and 50% vs. 67%, P = 0.338, respectively.

CONCLUSION

Comparison of the most common LA-LGE-MRI methods and endocardial voltage mapping revealed large discrepancies in global and regional ACM-extent.

Update for the Performance of CT Coronary Angiography

BACKGROUND

 Coronary CT angiography (cCTA) is a class 1 recommendation in the current guidelines by the European Society of Cardiology (ESC) for excluding significant coronary artery stenosis. To achieve optimal image quality at a low radiation dose, the imaging physician may choose different acquisition modes. Therefore, the consensus guidelines by the Society of Cardiovascular Computed Tomography (SCCT) provide helpful guidance for this procedure.

METHOD

 The article provides practical recommendations for the application and acquisition of cCTA based on the current literature and our own experience.

RESULTS AND CONCLUSION

 According to current ESC guidelines, cCTA is recommended in symptomatic patients with a low or intermediate clinical likelihood for coronary artery disease. We recommend premedication with beta blockers and nitrates prior to CT acquisition under certain conditions even with the latest CT scanner generations. The most current CT scanners offer three possible scan modes for cCTA acquisition. Heart rate is the main factor for selecting the scan mode. Other factors may be coronary calcifications and body mass index (BMI).

KEY POINTS

  · CCTA is a valid method to exclude coronary artery disease in patients with a low to intermediate clinical likelihood.. · Even with the latest generation CT scanners, premedication with beta blockers and nitrates can improve image quality at low radiation exposure.. · Current CT scanners usually provide retrospective ECG gating and prospective ECG triggering. Dual-source scanners additionally provide a "high pitch" scan mode to scan the whole heart during one heartbeat, which may also be achieved using single-source scanners with broad detectors in some cases.. · Besides the available scanner technology, the choice of scan mode primarily depends on heart rate and heart rate variability (e. g., arrhythmia)..

CITATION FORMAT

· Soschynski M, Hagar MT, Taron J et al. Update for the Performance of CT Coronary Angiography. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1747-3554.

Non-invasive body surface electrocardiographic imaging for diagnosis of atrial cardiomyopathy

AIMS

Atrial cardiomyopathy (ACM) is associated with new-onset atrial fibrillation, arrhythmia recurrence after pulmonary vein isolation (PVI) and increased risk for stroke. At present, diagnosis of ACM is feasible by endocardial contact mapping of left atrial (LA) low-voltage substrate (LVS) or late gadolinium-enhanced magnetic resonance imaging, but their complexity limits a widespread use. The aim of this study was to assess non-invasive body surface electrocardiographic imaging (ECGI) as a novel clinical tool for diagnosis of ACM compared with endocardial mapping.

METHODS AND RESULTS

Thirty-nine consecutive patients (66 ± 9 years, 85% male) presenting for their first PVI for persistent atrial fibrillation underwent ECGI in sinus rhythm using a 252-electrode-array mapping system. Subsequently, high-density LA voltage and biatrial activation maps (mean 2090 ± 488 sites) were acquired in sinus rhythm prior to PVI. Freedom from arrhythmia recurrence was assessed within 12 months follow-up. Increased duration of total atrial conduction time (TACT) in ECGI was associated with both increased atrial activation time and extent of LA-LVS in endocardial contact mapping (r = 0.77 and r = 0.66, P < 0.0001 respectively). Atrial cardiomyopathy was found in 23 (59%) patients. A TACT value of 148 ms identified ACM with 91.3% sensitivity and 93.7% specificity. Arrhythmia recurrence occurred in 15 (38%) patients during a follow-up of 389 ± 55 days. Freedom from arrhythmia was significantly higher in patients with a TACT <148 ms compared with patients with a TACT ≥148 ms (82.4% vs. 45.5%, P = 0.019).

CONCLUSION

Analysis of TACT in non-invasive ECGI allows diagnosis of patients with ACM, which is associated with a significantly increased risk for arrhythmia recurrence following PVI.

Impact of high-sensitivity cardiac troponin T on survival and rehospitalization after transcatheter aortic valve replacement

BACKGROUND

Constant elevations of the serum concentration of cardiac troponin T (TnT) indicate a myocardial injury that may affect the long-term outcome of transcatheter aortic valve replacement (TAVR).

OBJECTIVES

We sought to investigate the impact of pre-TAVR TnT on outcomes after TAVR during long-term follow-up.

METHODS

In a retrospective, observational study we compared long term outcomes after TAVR between tertiles of preinterventional high-sensitivity TnT. Systematic follow-up was performed annually for 5 years. The primary endpoint was a composite of all-cause death and any rehospitalization.

RESULTS

Between 2010 and 2018, 2,129 patients with severe aortic valve stenosis underwent TAVR at our institution (mean age 82.6 years, 57.2% female, logistic EuroSCORE 20.5 ± 15.8). Boundaries for TnT tertiles were <21 ng/L and >42 ng/L. The median follow-up was 895 days. Three-year incidences for the primary endpoint were 70.9%, 76.6%, and 81.7% in the low, middle, and high tertile (log rank p < .001). Compared with the first tertile, the corresponding adjusted hazard ratios were 1.23 (95%-CI 1.08-1.40, p < .001) and 1.50 (95%-CI 1.32-1.70, p < .001) for the second and third tertile. We found consistent differences between TnT strata for all-cause death (3-year incidences 23.3%, 33.3%, and 47.1%; adjusted p < .001) and rehospitalization (3-year incidences 64.7%, 68.7% and 72.0%; adjusted p < .001), including significant differences in deaths (p < .001). The association between TnT and outcome was independent of coronary artery disease or low aortic valve gradient.

CONCLUSIONS

TnT before TAVR is strongly associated with all-cause death and rehospitalization during 3-year follow-up.

Prognostic impact of invasive exercise haemodynamics in patients with severe mitral regurgitation

OBJECTIVES

Abnormal invasive exercise haemodynamics in asymptomatic patients with severe mitral regurgitation were associated with higher regurgitation burden. We analysed the association between parameters of invasive exercise testing with mortality and valve surgery compared to guideline defined non-invasive criteria.

METHODS

This single centre, retrospective cohort study assesses the association of invasive exercise haemodynamics and mortality with and without surgery in patients with severe mitral regurgitation and normal ejection fraction (≥55%) as primary outcome. The secondary outcome was the need for mitral valve surgery in 113 asymptomatic patients primarily managed conservatively.

RESULTS

We identified 314 patients [age 59 years (standard deviation 13), 27% female] with available exercise haemodynamics with a median follow-up of 8.2 (interquartile range 5.2-11.2) years. Five-year survival rate was 93.0%. Pulmonary capillary wedge pressure at maximum exercise >30 mmHg was the only parameter independently associated with mortality after adjustment for age and guideline criteria [hazard ratio (HR) 2.7 (1.3-5.6), P = 0.007]. In the 113 patients primarily managed conservatively, maximum pulmonary capillary wedge pressure was independently associated with mitral valve surgery during follow-up in multivariable analysis (HR 2.10 (1.32-3.34), P = 0.002; after adjustment for workload and weight: HR 1.31 (1.14-1.52), P < 0.001], whereas systolic pulmonary artery pressure and current guideline criteria were not. Adding maximum pulmonary capillary wedge pressure >25 mmHg improved the predictive power of current guideline criteria for surgery (area under the curve 0.61-0.68, P = 0.02).

CONCLUSIONS

Invasive exercise haemodynamics predict mortality and improve prognostic information about surgery during follow-up derived from current guideline criteria in asymptomatic patients with severe mitral regurgitation.

Prosthesis position and its influence on complications after transcatheter aortic valve implantation with self-expanding valves

Background/Introduction

Prior studies in patients with transcatheter aortic valve implantation (TAVI) demonstrated an influence of transcatheter heart valve (THV) position on the occurrence of new conductions disturbances (CD) and paravalvular leakage (PVL) post TAVI in balloon-expandable valves (BEV).

Purpose

Purpose of this study was to investigate the THV position and its influence on the occurrence of CD and PVL in self-expanding valves (SEV).

Methods

We performed fusion imaging of pre- and post-procedural computed tomography angiography in 104 TAVI-patients (all with Evolut R) to receive a 3-D reconstruction of the THV within the native annulus region. The THV length below the native annulus was measured for assessment of implantation depth. Electrocardiograms pre-discharge were assessed for conduction disturbances (CD), PVL was determined in transthoracic echocardiography.

Results

The mean implantation depth of the THV in the whole cohort was 4.3±3.0 mm. Using the best cut-off of &gt;4 mm in receiver operating characteristic curve analysis (sensitivity 83.3%, specificity 60.0%) patients with lower THV position developed more new CD after TAVI (68.2 vs. 23.7%, P&lt;0.001). A deep THV position was identified as the only predictor for new CD after TAVI (odds ratio [CI]: 1.312 [1.119–1.539], P=0.001). The implantation depth showed no influence on the grade of PVL (r=0.052, P=0.598).

Conclusions

In patients with TAVI using the Evolut R SEV, a lower THV positioning (&gt;4 mm length below annulus) was a predictor for new conduction disturbances. In contrast, prosthesis position was not associated with the extent of PVL.

Funding Acknowledgement

Type of funding sources: None.

Transcatheter Treatment of Residual Significant Mitral Regurgitation Following TAVR: A Multicenter Registry

OBJECTIVES

The aim of this study was to describe baseline characteristics, and periprocedural and mid-term outcomes of patients undergoing transcatheter mitral valve interventions post-transcatheter aortic valve replacement (TAVR) and examine their clinical benefit.

BACKGROUND

The optimal management of residual mitral regurgitation (MR) post-TAVR is challenging.

METHODS

This was an international registry of 23 TAVR centers.

RESULTS

In total, 106 of 24,178 patients (0.43%) underwent mitral interventions post-TAVR (100 staged, 6 concomitant), most commonly percutaneous edge-to-edge mitral valve repair (PMVR). The median interval post-TAVR was 164 days. Mean age was 79.5 ± 7.2 years, MR was >moderate in 97.2%, technical success was 99.1%, and 30-day device success rate was 88.7%. There were 18 periprocedural complications (16.9%) including 4 deaths. During a median follow-up of 464 days, the cumulative risk for 3-year mortality was 29.0%. MR grade and New York Heart Association (NYHA) functional class improved dramatically; at 1 year, MR was moderate or less in 90.9% of patients (mild or less in 69.1%), and 85.9% of patients were in NYHA functional class I/II. Staged PMVR was associated with lower mortality versus medical treatment (57.5% vs. 30.8%) in a propensity-matched cohort (n = 156), but this was not statistically significant (hazard ratio: 1.75; p = 0.05).

CONCLUSIONS

For patients who continue to have significant MR, remain symptomatic post-TAVR, and are anatomically suitable for transcatheter interventions, these interventions are feasible, safe, and associated with significant improvement in MR grade and NYHA functional class. These results apply mainly to PMVR. A staged PMVR strategy was associated with markedly lower mortality, but this was not statistically significant. (Transcatheter Treatment for Combined Aortic and Mitral Valve Disease. The Aortic+Mitral TRAnsCatheter Valve Registry [AMTRAC]; NCT04031274).

[Atypical depression as a risk factor for obstructive sleep apnea syndrome in young adults]

OBJECTIVES

In the literature, several studies have investigated the particular relationship between major depression and obstructive sleep apnoea syndrome (OSAS). However, most of these studies have focused primarily on middle-aged to elderly individuals (≥40 years) which means that this problem has been little studied in young adults (<30 years). Nevertheless, in young adults the prevalence of major depression (particularly its atypical subtype) is not negligible, which seems to justify carrying out additional investigations in order to allow a better understanding of the potential role played by major depression in the pathophysiology of OSAS in this particular subpopulation. The aim of this study was therefore to empirically investigate the prevalence of OSAS in young adults and to study the risk of OSAS associated with major depression in this particular subpopulation.

METHODS

Polysomnographic and demographic data from 264 young adults were collected from the Erasme Hospital Sleep Laboratory (Brussels, Belgium) database to enable our analyses. During their two-night stay (including a first night of habituation and a night of polysomnography) at the Sleep Laboratory, these individuals underwent a complete somatic assessment (including blood test, electrocardiogram, daytime electroencephalogram and urinalysis), a systematic psychiatric assessment by a unit psychiatrist and an assessment of their complaints related to sleep. These different steps made it possible to systematically diagnose all somatic pathologies, psychiatric disorders according to the diagnostic criteria of the DSM-IV-TR and sleep pathologies according to the diagnostic criteria of the AASM. This allowed the selection of young adults included in our study based on our inclusion and exclusion criteria. Polysomnographic recordings from our Sleep Laboratory were visually scored according to AASM criteria. An obstructive sleep apnoea-hypopnoea index ≥5/hour was used for the diagnosis of OSAS. At the statistical level, in order to allow our analyses, we subdivided our sample of young adults into two groups: a control group without OSAS (n=215) and a patient group with OSAS (n=49). After checking the normal distribution of our data, normally distributed data were analysed with t-tests whereas asymmetrically or dichotomously distributed data were analysed with Wilcoxon tests or Chi² tests. Univariate regression models were used to study the risk of OSAS associated with major depression (categorized: absent, typical, atypical) in young adults and potential confounding factors. In multivariate regression models, the risk of OSAS associated with major depression (categorized: absent, typical, atypical) in young adults was adjusted only for confounding factors significantly associated with OSAS during univariate analysis. These confounding factors were introduced in a hierarchical manner in the various multivariate regression models constructed.

RESULTS

The prevalence of OSAS in our population of young adults was 18.6 %. During univariate analyses, atypical depression [OR 2.51 (95% CI 1.18-5.32), p-value=0.014], male gender [OR 4.53 (95% CI 2.20-9.34), P-value <0.001], presence of snoring [OR 2.51 (95% CI 1.33-4.75), P-value=0.005], presence of at least one cardio-metabolic alteration [OR 2.26 (95% CI 1.19-4.28), P-value=0.012], body mass index>30 kg/m² [OR 4.55 (95% CI 2.07-10.03), P-value <0.001] and ferritin ≥150 μg/L [OR 3.28 (95% CI 1.69-6.36), P-value<0.001] were associated with increased risk of OSAS in our population of young adults. After adjusting for these major confounding factors associated with OSAS (gender, body mass index, cardio-metabolic alterations, ferritin level, and snoring) in the four models studied, multivariate regression analyses confirmed that unlike typical depression, atypical depression [OR 3.09 (95% CI 1.26-7.54), P-value=0.019] was a risk factor for OSAS in young adults.

CONCLUSIONS

In our study, we demonstrated that the prevalence of OSAS was 18.6 % in young adults referred to the Erasme Hospital Sleep Laboratory. In addition, we have shown that unlike typical depression, atypical depression was associated with an increased risk of OSAS in young adults, which seems to justify more systematic research of this pathology in young adults suffering from atypical depression in order to allow the establishment of adapted therapeutic strategies and avoid the negative consequences associated with the co-occurrence of these two pathologies.

Implantation depth and its influence on complications after TAVI with self-expanding valves

Prior studies in patients with transcatheter aortic valve implantation (TAVI) demonstrated an influence of transcatheter heart valve (THV) position on the occurrence of new conductions disturbances (CD) and paravalvular leakage (PVL) post TAVI in balloon-expandable valves (BEV). Purpose of this study was to investigate the THV implantation depth and its influence on the occurrence of CD and PVL in self-expanding valves (SEV). We performed fusion imaging of pre- and post-procedural computed tomography angiography in 104 TAVI-patients (all with Evolut R) to receive a 3-D reconstruction of the THV within the native annulus region. The THV length below the native annulus was measured for assessment of implantation depth. Electrocardiograms pre-discharge were assessed for conduction disturbances (CD), PVL was determined in transthoracic echocardiography. The mean implantation depth of the THV in the whole cohort was 4.3 ± 3.0 mm. Using the best cut-off of ≥ 4 mm in receiver operating characteristic curve analysis (sensitivity 83.3%, specificity 60.0%) patients with lower THV position developed more new CD after TAVI (68.2 vs. 23.7%, P < 0.001). A deep THV position was identified as the only predictor for new CD after TAVI (odds ratio [CI] 1.312[1.119–1.539], P = 0.001). The implantation depth showed no influence on the grade of PVL (r = 0.052, P = 0.598). In patients with TAVI using the Evolut R SEV, a lower THV positioning (≥ 4 mm length below annulus) was a predictor for new conduction disturbances. In contrast, implantation depth was not associated with the extent of PVL.

Effect of Transcatheter Aortic Valve Replacement on Concomitant Mitral Regurgitation and Its Impact on Mortality

OBJECTIVES

The purpose of this study was to examine the impact of residual mitral regurgitation (MR) on mortality in patients undergoing transcatheter aortic valve replacement (TAVR).

BACKGROUND

MR is common in patients undergoing TAVR. Data on optimal management of patients with significant MR after TAVR are limited.

METHODS

The registry consisted of 16 TAVR centers (n = 7,303). Outcomes of patients with ≥ moderate versus lesser grade MR after TAVR were compared.

RESULTS

In 1,983 (27.2%) patients, baseline MR grade was ≥ moderate. MR regressed in 874 (44.1%) patients and persisted in 1,109 (55.9%) after TAVR. Four-year mortality was higher for those with MR persistence, but not for those with MR regression after TAVR, compared with nonsignificant baseline MR (43.8% vs. 35.1% vs. 32.4%; hazard ratio [HR]: 1.38; p = 0.008; HR: 1.02; p = 0.383, respectively). New York Heart Association functional class III to IV after TAVR was more common in those with MR persistence vs. regression (14.4% vs. 3.9%; p < 0.001). In a propensity score-matched cohort (91 patients' pairs), with significant residual MR after TAVR who did or did not undergo staged mitral intervention, staged intervention was associated with a better functional class through 1 year of follow-up (82.4% vs. 33.3% New York Heart Association functional class I or II; p < 0.001), and a numerically lower 4-year mortality, which was not statistically significant (64.6% vs. 37.5%; HR: 1.66; p = 0.097).

CONCLUSIONS

Risk stratification based on improvement in MR and symptoms after TAVR can identify patients at increased mortality risk after TAVR. These patients may benefit from a staged transcatheter mitral intervention, but this requires further proof from future studies. (Transcatheter Treatment for Combined Aortic and Mitral Valve Disease. The Aortic+Mitral TRAnsCatheter [AMTRAC] Valve Registry [AMTRAC]; NCT04031274).

Flow rate and stroke volume index as predictors of mortality in patients undergoing transcatheter aortic valve implantation

Background

Reduced flow rate and stroke volume are a common finding in patients with severe aortic stenosis. The aim of this study was to assess their impact on mortality in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods

A total of 1080 patients with severe aortic stenosis who underwent TAVI between 2007 and 2017 were followed for a mean of 2.4±1.6 years. Patients were allocated into two groups according to flow rate (cut-off 200mL/s), 805 patients had a normal flow rate and 275 patients had reduced flow rate. Long-term survival was summarized using Kaplan-Meier curves and Cox-regression models.

Results

Patients with reduced flow rate were older (83.8±5.5 years; P&lt;0.01) with more diabetics (36.7% P=0.02). Kaplan-Meier survival curves demonstrated inferior survival for patients with reduced flow rate (global log rank, P&lt;0.01), Multivariable Cox-regression analysis (adjusted for age, creatinine, diabetes, hemoglobin and presence of atrial fibrillation) confirmed flow rate as an independent risk factor of all-cause mortality (HR: 0.998; 95%-CI: 0.997–0.999; P&lt;0.01). Similar results were obtained for stroke volume index (SVI).

Conclusion

Patients with a reduced flow rate exhibit an increased mortality even after TAVI (similar to patients with reduced SVI) and should therefore be carefully evaluated in the heart-team.

PostTAVI survival according to flow rate

Funding Acknowledgement

Type of funding source: None

Invasive exercise hemodynamics in patients with severe primary mitral regurgitation and preserved ejection fraction predicts future valve surgery

Background

The role of invasive exercise hemodynamics in the management of asymptomatic patients with severe primary mitral regurgitation (MR) is unclear.

Methods and results

We compared the predictive power of parameters of invasive exercise testing for future valve surgery to guideline-defined non-invasive criteria. Maximal pulmonary capillary wedge pressure (PCWP), PCWP normalized to workload and weight (PCWL), and invasive maximal systolic pulmonary artery pressure (SPAP) were assessed in 113 asymptomatic patients with severe primary MR between 1996 and 2012. Mean age was 52±11 years, 16% were female, ejection fraction was ≥55% in all patients. During a median follow up of 4.5 years (IQR2.0; 8.3) 54 patients (48%) underwent valve surgery. In univariate analysis PCWP (P&lt;0.001), PCWL (P&lt;0.001), and maximal SPAP (P=0.009) were significantly associated with future mitral valve surgery. In multivariate analysis maximum PCWP and PCWL predicted future mitral valve surgery (HR 2.1 (1.44–3.10), P=0.005 and HR 1.31 (1.14–1.52), P&lt;0.001, respectively) whereas SPAP did not. Adding maximum PCWP &gt;25mmHg to a Cox regression model based on non-invasive guideline criteria resulted in a significant increase in the area under the curve (0.61 to 0.68, P=0.02).

Conclusion

In asymptomatic patients with severe primary mitral regurgitation and preserved left ventricular function invasive exercise hemodynamics improves information derived from current non-invasive guideline criteria.

Figure 1

Funding Acknowledgement

Type of funding source: None

Influence of prosthesis related factors on the occurrence of early leaflet thrombosis after transcatheter aortic valve implantation

Background

Early leaflet thrombosis (LT) is a well described phenomenon after transcatheter aortic valve implantation (TAVI) with an incidence between 10 and 16%. So far, data about predictors of LT are scarce.

Purpose

The purpose of the study was to investigate the influence of prosthesis related factors on the occurrence of LT.

Methods

Fusion imaging of pre- and post-procedural CTA was performed in 140 TAVI-patients (55 with LT, 85 without LT) to obtain a 3D-reconstruction of the transcatheter heart valve (THV) within the native annulus region. All patients received a balloon-expandable Sapien 3 THV. The length of the THV above and below the native annulus was measured within the fused images to assess the implantation depth. The deployed THV area was quantified on three heights (left ventricular outflow tract end, center of the stent, aortic end) to determine the average expansion of the prosthesis as percent of the nominal area. We also calculated the extent of prosthesis waist in percent of maximum area. The stent tilt was determined in relation to the annulus plane.

Results

After multivariate adjustment the extent of THV expansion (odds ratio per 10 percent [CI]: 0.660 [0.555–0.786], P&lt;0.001) and waist (odds ratio per 10 percent [CI]: 0.725 [0.615–0.854], P&lt;0.001) had significant, independent influence on the occurrence of LT. Neither the implantation depth nor the stent tilt showed any influence on LT manifestation (P=0.393 and 0.578).

Conclusion

Our study suggests that less than fully expanded Sapien 3 THVs are more prone to LT, whereas some degree of waist was protective. These deployment characteristics may help identify patients who qualify for intensified surveillance.

Funding Acknowledgement

Type of funding source: None

Fusion imaging of pre- and post-procedural computed tomography angiography in transcatheter aortic valve implantation patients: evaluation of prosthesis position and its influence on new conduction disturbances

AIMS

The purpose of this study was to evaluate prosthesis position by fusion of pre- and post-transcatheter aortic valve implantation (TAVI) computed tomography angiography (CTA) images and to investigate its influence on the occurrence of new conduction disturbances (CD).

METHODS AND RESULTS

We performed CTA fusion imaging in 120 TAVI patients (Edwards Sapien 3) on a standard image post-processing workstation to obtain a 3D reconstruction of the transcatheter heart valve (THV) position within the native annulus region. Optimal implantation depth of the THV was defined according to the manufacturers recommendations as 70-80% of the prosthesis above (aortic) and 20-30% below (ventricular) the native annulus plane. Pre- and post-interventional electrocardiograms (ECGs) were assessed for the development of new CD. THV position was found to be within, above, or below the prespecified margins in 32 patients (27%), 71 patients (59%), and 17 patients (14%), respectively. Interobserver reliability was high for fusion measurements [e.g. median THV position 0.983, 95% confidence interval (CI): 0.935-0.996]. Patients with low stent position were significantly more likely to develop new CD compared with patients with optimal or high stent position (P = 0.039). Independent predictors of CD in multivariate analysis were low THV position [odds ratio (CI): 1.362 (1.093-1.698), P = 0.006] and calcification of the device landing zone [odds ratio (CI): 1.149 (1.024-1.289), P = 0.018].

CONCLUSION

Fusion imaging of pre- and post-TAVI-CTA allows for the exact evaluation of THV position in relation to the native annulus plane. A low THV position as assessed by fusion imaging is associated with the development of new CD post-TAVI.

Influence of prosthesis-related factors on the occurrence of early leaflet thrombosis after transcatheter aortic valve implantation

Aims

Early leaflet thrombosis (LT) is a well-described phenomenon after transcatheter aortic valve implantation (TAVI) with an incidence around 15%. Data about predictors of LT are scarce. The purpose of the study was to investigate the influence of prosthesis-related factors on the occurrence of LT.

Materials and results

Fusion imaging of pre- and post-procedural computed tomography angiography was performed in 55 TAVI patients with LT and 140 selected patients as control groups (85 patients in an unmatched and 55 in a matched control) to obtain a 3D reconstruction of the transcatheter heart valve (THV) within the native annulus region. All patients received a balloon-expandable Sapien 3 THV. The THV length above and below the native annulus was measured within the fused images to assess the implantation depth. The deployed THV area was quantified on three heights (left ventricular outflow tract end, stent centre, and aortic end) to determine the average expansion of the prosthesis as percent of the nominal area. We also calculated the extent of prosthesis waist in percent of maximum area. After multivariate adjustment, the extent of THV waist [odds ratio (OR) per 10% (confidence interval, CI) 0.636 (0.526–0.769), P &lt; 0.001] as prosthesis-related factor and previous oral anticoagulation [OR (CI) 0.070 (0.020–0.251), P &lt; 0.001] had significant, independent influence on the occurrence of LT. The implantation depth showed no influence on LT manifestation (P = 0.704).

Conclusion

Besides the absence of previous oral anticoagulation, a less pronounced waist of the implanted THV was a prosthesis-position-related independent predictor of LT after TAVI using the Sapien 3.

Predictors for low TAVI-prosthesis position assessed by fusion imaging of pre- and post-procedural CT angiography

Background

Low prosthesis position after transcatheter aortic valve implantation (TAVI) is associated with higher rates of new onset conduction disturbances and permanent pacemaker implantations. Purpose of this study was to investigate possible predictors of a low prosthesis position of the SAPIEN 3 (Edwards Lifesciences, Irvine, California, USA) valve type using fusion imaging of pre- and post-procedural computed tomography angiography (CTA).

Methods

CTA fusion imaging was performed in 120 TAVI-patients with 3D-reconstruction of the transcatheter heart valve (THV) position within the device landing zone. A low implantation position was defined according to the manufacturer’s recommendations as > 30% of the prosthesis below the native annulus plane.

Results

A low THV position was found in 17 patients (14%). Patients with low THV position had less calcification of the annulus region and a smaller annulus size compared to patients with a normal or high THV position (P = 0.003 and 0.041, respectively). The only independent predictor of a low THV position in multivariate logistic regression analysis was the extent of calcification of the cusp region (odds ratio [CI] 0.842 [0.727–0.976], P = 0.022).

Conclusions

Fusion imaging of pre-and post-procedural CTA identified reduced calcification of the cusp region as an independent predictor of a low THV position of the SAPIEN 3. This should be considered when planning the TAVI procedure.

Graphic abstract

Correlation of cusp region calcification and prosthesis position after TAVI

Medium-Term Follow-Up of Early Leaflet Thrombosis After Transcatheter Aortic Valve Replacement

OBJECTIVES

The aim of this study was to investigate medium-term outcomes in patients with leaflet thrombosis (LT).

BACKGROUND

The clinical significance of early LT after transcatheter aortic valve replacement, diagnosed by computed tomography angiography in approximately 10% of patients, is uncertain.

METHODS

In this observational study, computed tomographic angiography was performed a median of 5 days after transcatheter aortic valve replacement and assessed for evidence of LT. Follow-up consisted of clinical visits, telephone contact, or questionnaire.

RESULTS

LT was diagnosed in 120 of 754 patients (15.9%). Patients with LT were less likely male (36.7% vs. 47.0%, p = 0.045), with a lower rate of atrial fibrillation (28.3% vs. 41.5%, p = 0.008). Peri- and post-procedural characteristics were comparable between groups (e.g., valve implantation technique; p = 0.116). During a median follow-up period of 406 days, there were no significant differences in the primary endpoint of all-cause mortality and the secondary combined endpoint of stroke and transient ischemic attack between patients with LT and those without LT (18-month Kaplan-Meier estimate for mortality 86.6% vs. 85.4%, p = 0.912; for stroke- or transient ischemic attack-free survival 98.5% vs. 96.8%, p = 0.331). In univariate and multivariate analyses, LT was not predictive of either endpoint, whereas male sex (p = 0.03), atrial fibrillation (p = 0.002), and more than mild paravalvular leak (p = 0.015) were associated with all-cause mortality.

CONCLUSIONS

In this prospective observational cohort undergoing post-transcatheter aortic valve replacement computed tomographic angiography, LT was not associated with increased mortality or rates of stroke over a follow-up period of 406 days.

Need for pacemaker implantation in patients with normal QRS duration immediately after transcatheter aortic valve implantation

Aims

We sought to assess the need for permanent pacemaker implantation (PPI) in patients with QRS <120 ms in electrocardiogram (ECG) after transcatheter aortic valve implantation (TAVI).

Methods and results

We retrospectively analysed 1139 consecutive patients who underwent transfemoral TAVI between 2008 and 2016, receiving different valve types. All patients were surveyed by continuous ECG monitoring for 48 h, 12-lead ECGs starting immediately after procedure, as well as 24-h Holter recording the day before discharge. Indication for PPI was at the discretion of the attending physician. Among 760 patients with QRS <120 ms prior to the TAVI procedure, 400 patients showed QRS <120 ms immediately after procedure, whereas 360 patients had QRS ≥120 ms. In the group with QRS <120 ms, PPI was performed in 34 patients [8.5%; 95% confidence interval (CI) 5.6–11.2%] during the first week. Eight of the PPIs in the group with QRS <120 ms (2%; CI 0.8–3.5%) fulfilled Class I indications for PPI after TAVI, whereas 26 PPIs had different indications [left bundle branch block, sick sinus, low-grade atrioventricular (AV) block]. Complete AV block developed in three patients of the group of QRS <120 ms (0.75%; CI 0.0–1.7%), which in all cases occurred after the 48 h-surveillance period. During 1-year follow-up, 11 PPIs were performed (2.8%; CI 1.2–4.5%), thereof three PPI for Class I indications including one complete AV block.

Conclusion

In patients with QRS duration <120 ms immediately after TAVI, the risk for complete AV block was low during the first week after TAVI and 1-year follow-up.

Impact of On-Clopidogrel Platelet Reactivity on Incidence of Hypoattenuated Leaflet Thickening After Transcatheter Aortic Valve Replacement

OBJECTIVES

To assess the impact of on-clopidogrel platelet reactivity (PR) on HALT, the authors prospectively tested whether patients with below-median on-clopidogrel PR have a lower incidence of HALT compared with those with above-median on-clopidogrel PR.

BACKGROUND

It is unclear whether the apparent ineffectiveness of clopidogrel in preventing hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVR) questions the concept of P2Y₁₂ inhibition after TAVR or is a consequence of an inadequate response to clopidogrel in elderly patients with severe aortic stenosis.

METHODS

Patients were either on long-term dual antiplatelet therapy with clopidogrel and acetylsalicylic acid or were given bolus doses of both drugs the day before TAVR. Adenosine diphosphate (ADP)-induced multielectrode impedance aggregometry was performed before TAVR. After TAVR, clopidogrel was continued in all patients. Computed tomographic angiography was performed to detect HALT.

RESULTS

Of 331 patients enrolled, computed tomographic angiography was performed in 200 at 5 days (interquartile range: 4 to 6 days). Among patients with below-median ADP-induced PR (<180 AU · min), 16 were diagnosed with HALT, whereas 20 patients with above-median PR were diagnosed with HALT (p = 0.58). Among patients with high on-clopidogrel PR (>468 AU · min; n = 29), 7 (24%) displayed HALT, compared with 19 (17%) with ADP-induced PR ≤468 AU · min (p = 0.43). Consistently, ADP-induced PR as a continuous variable was not significantly associated with HALT (p = 0.75). Oral anticoagulation was associated with reduced rates of HALT (odds ratio: 0.41; 95% CI: 0.18 to 0.96; p = 0.04).

CONCLUSIONS

On-clopidogrel ADP-induced PR was not significantly associated with the occurrence of HALT. In contrast, oral anticoagulation was associated with reduced rates of HALT.