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

Background

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

Methods

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

Results

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

Conclusion

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

1046 DIAGNOSTIC PERFORMANCE OF CALCIUM SCORE ASSESSMENT IN ATRIOVENTRICULAR CONDUCTION DETERIORATION AFTER TAVI: A SINGLE CENTRE PILOT STUDY

Background

The risk of cardiac conduction system defects (CCD) after transcatheter aortic valve implantation (TAVI) remains high and requiring permanent pacemaker implantation (PPI) in 20% of the patients. Numerous studies have suggested that up to half of patients who underwent PPI within 30 days after TAVI do not depend on their PM at one year. The micro-calcific deposits of the atrioventricular node cannot be detected by standard echocardiography, while CT scan can reliably identify them. While pacemaker implantation was recommended according to clinical status and current guideline, in this small retrospective analysis, pre-procedural CT scan calcium quantification was considered an anatomical predictor of AV conduction prolongation until advanced disorder and cardiac block. We assume that differential calcium localization into the AV node might contribute to progression of conduction disorders until complete heart block.

Aims

The objective of this pilot study is to evaluate the impact of calcium score assessment as a predictor of the development of CCD after TAVI. The goal is to evaluate the interaction between PM dependency and the value of calcium score at the CT scan pre-TAVI. the data collected in this single-center cohort analysis AIMS TO help identify patients at higher risk of permanent pacemaker implantation after TAVI pacemaker insertion and pacemaker-dependent patients at one year through CT calcium scoring.

Methods

From January 2020 to September 2021, we retrospectively collected data from our institute. One-hundred and thirty patients without prior PM underwent TAVI in our institution. Overall mean age was 79,7 years old with 57,1% of females, with a pre-procedural diagnosis of aortic stenosis and a mean gradient of 47,4 mmHg. At 30 days, PPI was reported in 21 patients (16,1%). Out of twenty-one patients 47,6% developed complete atrioventricular block, 19% developed atrioventricular block II grade type 2 and 33,3% other conduction defects. The dependency at the implantation was 51,1%. With a dedicated software at the CT scan, we assessed the calcium score located in three regions near the atrioventricular node: aortic valve, left ventricular outflow tract (LVOT) and anterior mitral annular (Figure 1). Two patients were excluded for the diagnosis of severe aortic stenosis low-flow low-gradient. The Primary endpoint was to identify patients who had higher risk of PPI after TAVI pacemaker insertion.

Results

At 12 months follow-up, 23,8% of patients died (n=5). All the remaining patients, 28,5% had a high rate of ventricular pacing (Vp) at implantation (n=6). One year later at the follow up, three of these patients restored intrinsic rhythm and had a low Vp rate. The rate of patients found pacemaker-dependent at one year of follow-up was 76,2%.

Conclusions

Among 21 patients who requiring PPI after TAVI, at 12 months 14,2% restored intrinsic rhythm. The methodology of calcium scoring outside the coronary arteries is still an active area of study. In the coming months, the collected data will be analyzed to assess the association between PM dependence at follow-up and calcium score on CT scan before TAVI.

1155 CORONARY ARTERY DISEASE AND SEVERE AORTIC STENOSIS IN THE COVID-19 ERA: A CASE REPORT

An 81-years-old with a history of hypertension, dyslipidemia, and chronic ischemic heart disease with prior stent implantation of right coronary artery in 2011. Due to its poor compliance, no recurrent symptoms, and, finally, the COVID-19 pandemic, the patient did not perform any cardiological follow-up during these years. Unfortunately, the last six months he has reported the onset of dyspnea and typical angina due to moderate efforts, undervalued by the patient. Because of the rapid worsening of dyspnea and typical angina in the last 5 days, he went to the local emergency department (ED). The role in/role out routine exams performed in the ED documented a COVID-19 infection. At the ED, his vital signs were normal, with a blood pressure of 135/75 mm Hg, heart rate of 74 regular beats/min, body temperature of 36.5 °C, oxygen saturation of 97% in ambient air, and respiratory rate of 16/min. Of note, the chest x-ray was normal, as well as no alterations were documented at the CT scan performed a few hours later. First-line blood sample tests were within range except for Hb 10 mg/dl. Therefore, a cardiological evaluation was requested. Electrocardiogram (ECG) showed inverted T-waves in V1-4 leads, and echocardiography showed normal left ventricular ejection fraction (FE 55% Simpson), left ventricular anterolateral wall hypokinesia, and severe aortic stenosis (V max 4.78 m/s, Gr max 4.78 m/s, Gr medium 59 mmHg). Since myocardial necrosis enzymes were increased (T-hs 118.7 ng/dl; CK-MB 6.3 ng/L; NT-ProBNP 761 ng/dl), leading to the suspicion of acute coronary syndrome the patient underwent coronary angiography, showing critical stenoses of the left descending artery (LAD), circumflex (LCX), I obtuse marginal (IOM), and patent stent of the right coronary artery. Therefore, the Heart team deemed the patient at high operatory risk choosing, in agreement with the patient, for a percutaneous coronary intervention (PCI) followed by TAVR. Accordingly, the patients underwent PCI of LAD with the implantation of a Xience-Serra 3.0×15 mm and PCI of LCX with the implantation of an Onyx 2.75×18 mm stent. After COVID -19 resolution, which happen 7 days later, the patient was moved to our cardiology department. Two days later in the same procedure, we performed the first PCI of I-OM with the implantation of a Xience Sierra 3.0×18 mm stent following a TAVI with the implantation of Evolute Pro valve 29 mm. The post-procedure echocardiogram showed an optimal valve position with a transvalvular mean pressure gradient of 4 mm Hg. After six days post-TAVI, for a complete atrioventricular block, the patient also underwent a pacemaker implantation. The patient was finally discharged after 10 from TAVI.

Discussion

This case report offers several foods for thought. First, the COVID-19 pandemic has negatively affected primary and secondary prevention, even for patients affected by cardiovascular disease. Our patient has postponed clinical checks even when the symptoms reappeared, also because of the concerns lead by the COVID-19 pandemic. Second, completeness and timing of coronary disease revascularization, which in this case was staged and performed before TAVI. Finally, the late occurrence of advanced heart block requiring PM implantation. For instance, in an era of fast-track TAVI, more studies are warranted to identify patients who are at higher risk of late PM implantation.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

870 COMBINING PERCUTANEOUS CORONARY INTERVENTION AND TRASCATHETER AORTIC VALVE REPLACEMENT PROCEDURES: THE IMPORTANCE OF INTRAVASCULAR LITHOTRIPSY

Background

Calcified coronary artery disease and severe valvular aortic stenosis (AS) often coexist. For instance, severely calcified lesions may strongly influence the revascularization strategy in patients undergoing transcutaneous aortic valve replacement (TAVR). Shock wave intravascular lithotripsy (S-IVL) (Shockwave Medical Inc. Santa Clara, CA) is the only technology available that cracks both medial and intimal calcium while minimizing trauma to the vessel wall, thus allowing a safe plaque debulking. We report a case of percutaneous coronary intervention (PCI) and TAVR in the same procedure, where S-IVL has been used to treat a heavily calcified lesion and optimize stent under-expansion.

Case Report

A 79 years-old male patient with a history of diabetes mellitus type 2, hypertension, and peripheral artery disease, was admitted to our institution with symptomatic severe AS and severe calcified left anterior descending (LAD) artery lesion at CT scan. Deemed eligible for TAVR, Heart Team planned a percutaneous coronary intervention (PCI) of LAD and TAVR in the same procedure. Through the left radial artery, coronary angiography confirmed 90% stenosis of the LAD at the central segment. Accordingly, pre-dilatation of the stenosis was performed with a 2.5×12 mm non-compliant balloon (NCB) and, because of the severe calcification, S-IVL with a 3.0×12 mm balloon inflated at 4-6 Atmospheres (ATM), delivering 40 pulses. Following, a 3.5×18-mm drug-eluting stent was implanted at 18 ATM. After implantation, an inadequate expansion of the stents was observed, which persisted despite post-dilation with 3.75×8 mm NCB at high-pressure. Bail-out S-IVL was then performed with the 3.0×12 mm balloon inflated at 4-6 ATM, delivering 40 pulses in-stent, followed by a further stent post-dilated with a 3.75×8 mm NCB up to 20 ATM. The final angiogram showed a satisfactory stent expansion. Since the low contrast volume was used, we decided to go ahead with transfemoral TAVR. Therefore, through the left femoral artery access, a 34-mm self-expandable Evolut R valve was implanted. Transthoracic echocardiography showed optimal valve implantation with a trivial periprosthetic leak. No complications were observed after the procedures and the patient was discharged after 6 days with 6 months of mandated dual antiplatelet therapy (Aspirin and Clopidogrel).

Discussion

In this case, the bail-out use of S-IVL was essential for an optima stent implantation, allowing TAVR procedure and avoiding prolonged theoretical antithrombotic therapy underlying suboptimal stent implantation. Despite encouraging initial results, future large studies with long-term observation are required to evaluate the safety and efficacy of S-IVL in this scenario.

1154 MYOCARDIAL INFARCTION IN A TRANSGENDER FEMALE UNDERGOING HORMONE THERAPY: THE IMPACT PROLONGED EXPOSURE TO HORMONE THERAPY

Background

Gender Identity (GI) is defined by a complex interplay between biological, psychological, environmental, and cultural factors. Health care services provide counseling, hormone treatment, and gender-affirming surgery. Testosterone is used for cross-sex hormone therapy in female-to-male transgender persons. Previous evidence suggests that testosterone administration is associated with hypertension, decreased high-density lipoprotein (HDL), increased low-density lipoprotein (LDL), and obesity, thus increasing cardiovascular risk.

Hereafter, we report the case of a patient female-to-male on testosterone therapy undergoing percutaneous coronary intervention (PCI) and stent implantation for acute myocardial infarction.

Case Description

A 44-year-old Italian transgender (female-to-male) without common cardiovascular risk factors and family risk was admitted to the local emergency room with a sudden onset of anterior chest pain. The electrocardiogram showed anterior ST-Segment Elevation, and accordingly, the patient was transferred to our Institution for emergency coronary angiography. Past medical history revealed breast reduction, osteosynthesis of the right femur, hemorrhoidal pathology, and iron deficiency anemia. Of interest, drug history revealed a hormonal therapy with intramuscular testosterone undecanoate over the from 2005 for gender conversion (250 mg every 3 weeks) and Tamoxifen 20 mg/die from 2006. The coronary angiography performed after 90 minutes to the symptom onset revealed a total occlusion of the proximal left anterior descending artery (LAD) and minimal atherosclerosis of the remaining vessels. Recanalization of the LAD was achieved by pre-dilatations with a 2.5×15mm balloon catheter, showing diffuse atherosclerosis of the middle and distal LAD involving the origin of a diagonal branch (Medina 1,1,1). Then the lesion was treated with the implantation of three drug-eluting stents in overlap, followed by POBA (Plain Old Balloon Angioplast) of the diagonal branch with a 2.5×12 mm balloon at the ostium (Final TIMI flow III). The patient was then moved to the intensive care unit. Laboratory tests showed an altered lipid panel (overall cholesterol 210 mg/dl and LDL-cholesterol 153 mg/dl), elevated levels of cardiac enzymes (CK-MB 92.5 ng/ml, myoglobin 1606 ng/ml, TnT hs 1014 ng/L and NTproBNP 1263 pg/ml) and anaemia (Hb 9,1 mg/dl). The echocardiogram revealed akinesia of the apex with thrombotic formation (2.0×1.0 mm) and mid-distal anterior wall, with a 40% ejection fraction. Accordingly, parenteral anticoagulant was started. No further complications were observed the day after the procedure, with a progressive reduction of the miocardionecrosis enzymes and thrombotic formation. Ten days after, at the resolution of the thrombotic formation, the patient was discharged.

Discussion

This case report highlights the importance of primary prevention in patients undergoing long-term testosterone therapy for gender conversion, regardless of age and risk factors. For instance, prior evidence about the risk of recurrent ischemic events in these high-risk patients is poor with a high heterogeneity across the studies. Accordingly, high quality prospective and multicentric studies are needed to assess if there is a correlation between hormonal therapy for gender conversion and cardiovascular disease.

Association Between Sleep Apnea and Valvular Heart Diseases

Background: Although sleep respiratory disorders are known as a relevant source of cardiovascular risk, there is a substantial lack of trials aimed to evaluate the eventual occurrence of associations between sleep apnea (SA) and valvular heart diseases (VHD).

Methods: We recruited 411 patients referring to our sleep disorder unit, among which 371 had SA. Ninety-three subjects with SA also suffered from VHD. Physical examination, echocardiography, nocturnal cardio-respiratory monitoring, and laboratory tests were performed in each patient. Patient subgroups were comparatively evaluated through cross-sectional analysis.

Results: A statistically significant increase in the prevalence of VHD was detected in relation to high apnea hypopnea index (AHI) values (p = 0.011). Obstructive sleep apnea occurrence was higher in SA patients without VHD (p < 0.0001). Conversely, central and mixed sleep apneas were more frequent among SA patients with VHD (p = 0.0003 and p = 0.002, respectively). We observed a direct correlation between AHI and BMI values (p < 0.0001), as well as between AHI and serum uric acid levels (p < 0.0001), high sensitivity C-reactive protein (p < 0.0001), and indexed left ventricular end-diastolic volume (p < 0.015), respectively. BMI and VHD resulted to be the main predictors of AHI values (p < 0.0001).

Conclusions: Our study suggests that a significant association can occur between SA and VHD. It is clinically relevant that when compared to SA patients without VHD, higher frequencies of central and mixed apneas were found in subjects with SA and VHD. Moreover, after elevated BMI, VHD represented the second predictor of AHI values.