Mitral valve leaflet stiffness predicts residual mitral regurgitation after transcatheter edge-to-edge mitral valve repair

BACKGROUND

Residual regurgitation after transcatheter edge-to-edge mitral valve repair (TMVR) is a predictor of poor prognosis in patients with functional mitral regurgitation (FMR). This study sought to identify the mitral valve (MV) parameters measured by three-dimensional transesophageal echocardiography (3D-TEE) and MV leaflet features that predict residual mitral regurgitation (MR) after TMVR in patients with FMR.

METHODS

Consecutive patients with FMR who underwent TMVR were classified into two groups based on the degree of residual MR just after TMVR: < 2+ in the optimal MR reduction group and ≥ 2+ in the suboptimal MR reduction group. The two groups were compared with respect to 3D-TEE parameters and the MV leaflet features, including the following parameters: stiffness, defined as a leaflet that remains at a fixed angle even during diastole, and thickness, measured in both clear and rough zones.

RESULTS

Thirty-four of 46 patients (74%) were classified as the optimal MR reduction group. Multivariable analysis showed that anterior mitral leaflet + posterior mitral leaflet length/anteroposterior annulus diameter (p = .044) and MV leaflet stiffness (p = .007) were independent predictors of residual MR.

CONCLUSION

MV leaflet stiffness and the ratio of MV leaflet lengths to the annulus diameter may be good predictors of residual MR after TMVR in patients with FMR.

Usefulness of catheter pressure measurement using the Navvus RXi system to determine left ventricular outflow tract obstruction and aortic stenosis severity: a case report

Background

Left ventricular outflow tract obstruction (LVOTO) sometimes presents with aortic stenosis (AS). Echocardiography is used to assess the diagnosis and severity of LVOTO or AS. However, LVOTO is one of the conditions that makes AS assessment difficult, and catheter pressure measurement is frequently useful in such cases.

Case summary

An 84-year-old female patient presented with New York Heart Association functional Class III dyspnoea. Transthoracic echocardiography revealed LVOTO caused by upper septal hypertrophy, mitral valve systolic anterior motion with moderate mitral regurgitation, and a highly calcified aortic valve, which suggested the possibility of severe AS. The continuous Doppler echocardiography revealed a late-systolic peaking dagger-shaped profile with a peak jet velocity of 5.6 m/s. Cardiac catheterization was performed to determine the contribution of AS or LVOTO to her symptoms. Catheter pressures were measured at the ascending aorta (using a coronary catheter) and the LV (using the Navvus RXi system). The initial mean pressure gradient between the apex of the LV, just below the aortic valve and aorta, was measured at 65 and 25 mmHg, respectively. The mean pressure gradient between the apex and the aorta decreased from 65 to 40 mmHg after a 50 mg disopyramide administration. Oral medication therapy effectively stabilized her symptom after catheterization.

Discussion

To the best of our knowledge, this is the first reported case of assessing the severity of LVOTO and AS using the Navvus RXi system. Catheter pressure measurement using the Navvus RXi system is a useful method of determining the severity of LVOTO and AS.

Gastrointestinal Angiodysplasia in Patients with Severe Aortic Stenosis: The Endoscopic Features of Heyde's Syndrome

INTRODUCTION

Aortic stenosis (AS) is sometimes associated with gastrointestinal bleeding, and this phenomenon is known as Heyde's syndrome. Such bleeding is most often considered to originate from gastrointestinal angiodysplasias, but the frequency and endoscopic features of such bleeding remain unclear. This study aimed to determine the frequency and endoscopic features of gastrointestinal angiodysplasia in patients with severe AS.

PATIENTS AND METHODS

In this multicenter, retrospective study, we evaluated consecutive patients who underwent transcatheter aortic valve implantation (TAVI) with severe AS from May 2016 to December 2019. We extracted the data on the clinicopathological features according to the status of anemia, the proportion of patients who underwent gastrointestinal endoscopic examinations and demonstrated gastrointestinal angiodysplasia, and identified the endoscopic features associated with such patients.

RESULTS

In 325 patients, the rates of moderate/severe anemia (hemoglobin < 11 g/dL) were 52%. Regarding medicine, there were no significant differences between the patients with and without moderate/severe anemia. Patients were examined by esophagogastroduodenoscopy (21%), colonoscopy (12%), and balloon-assisted enteroscopy or small bowel capsule endoscopy (1.5%). Patients with moderate/severe anemia had significantly more angiodysplasia (38.3% vs. 7.7%; p < 0.0001) and active bleeding (23.4% vs. 0%; p < 0.01). Angiodysplasia was detected in 21 patients (stomach, n = 9; small intestine, n = 5, and colon, n = 10).

CONCLUSIONS

The results suggest, for the first time, that patients with severe AS who underwent TAVI and moderate/severe anemia frequently had gastrointestinal angiodysplasia and active bleeding throughout the entire gastrointestinal tract.

Doppler Underestimates Transvalvular Gradient Measured by Catheterization in Patients With Severe Aortic Stenosis

We sought to clarify characteristics of patients with severe aortic stenosis (AS) in whom transvalvular mean pressure gradient (MPG) was underestimated with Doppler compared with catheterization. Study subjects included 127 patients with severe AS who underwent transcatheter aortic valve implantation. Between subjects with Doppler MPG underestimation ≥10 mm Hg (group U) and those without (group C), we retrospectively compared echocardiographic parameters and aortic valve calcification score using the Agatston method. Despite a strong correlation (r_S = 0.88) and small absolute difference (2.1 ± 10.1 mm Hg) between Doppler and catheter MPG, 27 patients (21%) were in group U. Among 48 patients with catheter MPG ≥60 mm Hg, 10 patients (21%) revealed Doppler MPG of 40 to 59 mm Hg, suggesting they had been misclassified as having severe AS instead of very severe AS. According to the guidelines, indication of valve replacement for patients without symptoms should be considered for very severe AS but not for severe AS. Therefore, sole reliance on Doppler MPG could cause clinical misjudgments. Group U had larger relative wall thickness (median [interquartile range: 0.60 [0.50 to 0.69] vs 0.53 [0.46 to 0.60], p = 0.003) and higher calcification score (3,024 [2,066 to 3,555] vs 1,790 [1,293 to 2,501] arbitrary units, p <0.001). Both calcification score (per 100 arbitrary unit increment, odds ratio 1.10, 1.04 to 1.17, p = 0.002) and relative wall thickness (per 0.05 increment, odds ratio 1.29, 95% confidence interval 1.05 to 1.60, p = 0.02) were independently associated with Doppler underestimation. In conclusion, Doppler might underestimate transvalvular gradient compared with catheterization in patients with severe AS who have heavy valve calcification and prominent concentric remodeling left ventricular geometry.

Left ventricular hypertrophy as a predictor of cardiovascular outcomes after transcatheter aortic valve replacement

AIMS

This study aimed to clarify the relationship between cardiovascular prognosis and left ventricular hypertrophy (LVH) in patients with severe aortic stenosis who underwent transcatheter aortic valve replacement (TAVR) and to investigate the relationship between cardiac sympathetic nerve (CSN) function and these factors using ¹²³ I-metaiodobenzylguanidine scintigraphy.

METHODS AND RESULTS

In this single-centre, retrospective observational study, 349 patients who underwent TAVR at our institution between July 2017 and May 2020 were divided into two groups: those with severe LVH pre-operatively [severe LVH (+) group] and those without LVH pre-operatively [severe LVH (-) group]. The rates of freedom from cardiovascular events (cardiovascular death and heart failure hospitalization) were compared. The relationship between changes in left ventricular mass index (LVMi) and changes in delay heart-mediastinum ratio (H/M) from before TAVR to 6 months after TAVR was also investigated. The event-free rate was significantly lower in the severe LVH (+) group (87.1% vs. 96.0%, log-rank P = 0.021). The severe LVH (+) group exhibited a significantly lower delay H/M value, scored by ¹²³ I-metaiodobenzylguanidine scintigraphy, than the severe LVH (-) group (2.33 [1.92-2.67] vs. 2.67 [2.17-3.68], respectively, P < 0.001). Moreover, the event-free rate of post-operative cardiovascular events was lower among patients with a delay H/M value < 2.50 than that among other patients (87.7% vs. 97.2%, log-rank P = 0.012). LVMi was significantly higher (115 [99-130] vs. 90 [78-111] g/m² , P < 0.001) and delay H/M value was significantly lower (2.53 [1.98-2.83] vs. 2.71 [2.25-3.19], P = 0.025) in the severe LVH (+) group than in the severe LVH (-) group at 6 months after TAVR. Patients with improved LVH at 6 months after TAVR also had increased delay H/M (from 2.51 [2.01-2.81] to 2.67 [2.26-3.02], P < 0.001), whereas those without improved LVH had no significant change in delay H/M (from 2.64 [2.23-3.06] to 2.53 [1.97-3.00], P = 0.829).

CONCLUSIONS

Severe LVH before TAVR is a prognostic factor for poor post-operative cardiovascular outcomes. LVH associated with aortic stenosis and CSN function are correlated, suggesting their involvement in LVH prognosis.

Additional balloon aortic valvuloplasty to overcome the difficult removal of a self-expandable transcatheter aortic valve system due to valve infolding

Transcatheter aortic valve replacement (TAVR) is a well-established treatment for severe aortic stenosis. Advances in the devices used and operators' technique have reduced the frequency of complications. However, valve infolding is a rare but serious outcome after the implantation of self-expanding prostheses. We report a case of a successful bailout of a device that was difficult to remove because of valve infolding. TAVR using a 26 mm Evolut PRO+ system (Medtronic) was planned for a 91-year-old woman with severe aortic stenosis. After the valve was deployed in a satisfactory position on the second release, the system could not be removed because the nose cone was hooked to the basal frame of the deployed valve. To overcome this situation, an additional balloon was inserted from the contralateral femoral side and inflated, and we extracted the system successfully by pulling out the device while simultaneously deflating the balloon. Postoperative computed tomography revealed valve infolding, which was considered to cause the difficulty in system removal. Infoldings of self-expandable prostheses should be considered when faced with difficulty in removing the catheter system, and the method elucidated in this case report can be effective to manage it.

Serial changes in cardiac sympathetic nervous function after transcatheter aortic valve replacement: A prospective observational study using 123I-meta-iodobenzylguanidine imaging

BACKGROUND

Transcatheter aortic valve replacement (TAVR) can rapidly improve cardiac sympathetic nervous function (CSNF) within 2 weeks in patients with aortic stenosis (AS). However, whether such short-term improvements will be sustained thereafter remains unclear.

METHODS

Patients with severe AS who underwent TAVR between October 2017 and June 2019 were enrolled in this single-center, prospective, observational study. 123I-meta-iodobenzylguanidine imaging was performed at baseline, within 2 weeks after TAVR, and at 6 to 12 months post-TAVR to evaluate the heart-mediastinum ratio (H/M) and washout rate.

RESULTS

Of 183 consecutive patients, 75 (19 men; median age: 86 years) were evaluated. The late H/M significantly improved within 2 weeks after TAVR (P = .041) and further improved over 6 to 12 months after TAVR (P = .041). Multivariate analysis revealed that the baseline mean aortic valve pressure gradient (mPG) was an independent predictor of mid-term improvement in the late H/M (> 0.1) (P = .037). Patients with a high baseline mPG (≥ 58 mmHg) exhibited a significantly greater increase in the late H/M than those with a low baseline mPG (< 42 mmHg) (0.24 vs 0.01; P = .029).

CONCLUSION

CSNF demonstrated sustained improvement from within 2 weeks after TAVR until 6 to 12 months later. Such improvement was related to baseline hemodynamic AS severity.

Incidence and predictors of transcatheter aortic valve replacement device emboligenic matter detected by transesophageal echocardiography

During transfemoral (TF) or transcatheter aortic valve replacement (TAVR), transesophageal echocardiography (TEE) sometimes reveals an unexpected mobile membranous mass on the catheter tip within the proximal part of the descending thoracic aorta. Such mobile masses may cause critical embolic events if the TAVR device advances into the ascending aorta in the absence of preventive measures. This study aimed to investigate the incidence and predictors of emboligenic matter (EM) during TAVR, impact of EM on the procedure, and incidence of symptomatic ischemic stroke post procedure. Among 436 consecutive patients who underwent TF-TAVR, 407 were evaluated in this study. The primary end point was incidence of symptomatic ischemic stroke within 24 h post procedure while taking appropriate preventive measures. Incidence of EM, factors associated with EM, and the impact of EM on the procedure were also investigated. Among the 407 cases, 15 cases (3.7%) of EM were identified but no ischemic stroke occurred in the EM (+) group (0% vs. 2.04%, p = 1.00). In the EM (+) group, a self-expandable valve was used in all 15 cases (100% vs. 42.6%, p < 0.0001) while 14 cases used a CoreValve's InLine sheath system initially (93.3% vs. 27.3%, p < 0.0001). CoreValve's InLine sheath system usage was the only independent predictor of EM. The CoreValve's InLine delivery system was identified as a predictor of EM during TF-TAVR, but symptomatic ischemic stroke was avoided while taking appropriate embolization preventive measures.

Cystatin C in risk prediction after transcatheter aortic valve replacement: a retrospective analysis

Aims

No study has evaluated the prognostic value of the chronic kidney disease (CKD) classification by cystatin C‐based estimated glomerular filtration rate (eGFR) (CKD_Cys classification) in patients undergoing transcatheter aortic valve replacement (TAVR). This study aimed to compare the prognostic value of CKD_Cys classification and CKD classification by creatinine‐based eGFR (CKD_Cr classification) in risk prediction after TAVR.

Methods and results

We retrospectively analysed consecutive 219 patients with symptomatic severe aortic stenosis who underwent TAVR at our institute between December 2016 and June 2019. Pre‐operative CKD_Cr and CKD_Cys classifications were evaluated for their prognostic value of 2‐year major adverse cardiovascular and cerebrovascular events (MACCE) after TAVR. MACCE was defined as the composite of all‐cause mortality, non‐fatal myocardial infarction, stroke, and rehospitalization for worsening congestive heart failure. Participants had a median age of 86.0 years and were predominantly female (76.9%). In 96.6% of the cases, TAVR was performed using transfemoral access. The median creatinine‐based eGFR (52.85 mL/min/1.73 m²) was higher than the cystatin C‐based eGFR (41.50 mL/min/1.73 m²). Downward reclassification in CKD stages based on eGFR_Cys was observed in 49.0% of patients. During a median follow‐up period of 575.5 (interquartile range: 367.0–730.0) days, 58 patients presented with MACCE. CKD_Cys classification, but not CKD_Cr classification, significantly stratified the risk of 2‐year MACCE in patients after TAVR by log‐rank test (P = 0.003). In multivariate Cox regression analysis, only CKD_Cys stage 3b [hazard ratio (HR) = 4.37; 95% confidence interval (CI): 1.28–14.91; P = 0.019] and CKD_Cys stage 4 + 5 (HR = 3.72; 95% CI: 1.06–12.99; P = 0.040) were significant predictors of MACCE after adjustment for potential confounders.

Conclusions

The CKD_Cys classification could better assess the risk than the CKD_Cr classification in patients undergoing TAVR. CKD_Cys stage 3b and stage 4 + 5 correlated with adverse outcomes.

Prognostic value of cardiac 123 I-metaiodobenzylguanidine imaging for predicting cardiac events after transcatheter aortic valve replacement

Aims

In patients with aortic valve stenosis (AS), cardiac sympathetic nervous (CSN) dysfunction and its improvement after transcatheter aortic valve replacement (TAVR) have been reported. The prognostic impact of CSN function remains unclear. This study investigated the prognostic value of cardiac ¹²³I‐metaiodobenzylguanidine (MIBG) imaging for predicting cardiac events after TAVR.

Methods and results

This single‐centre prospective observational study enrolled patients with AS between July 2017 and May 2019. MIBG scintigraphy was performed before and soon after TAVR to evaluate the late heart–mediastinum ratio (L‐H/M). Patients were classified into three pairs of groups based on the baseline and post‐TAVR L‐H/M (≥2.0 or <2.0) and on the presence of TAVR‐related improvement in L‐H/M. The study endpoint was the occurrence of major adverse cardiac events (MACE), defined as a composite of all‐cause death, non‐fatal myocardial infarction, and hospitalization due to heart failure. Among the 187 consecutive patients who underwent TAVR, 107 (27 men; median age: 86 years) were evaluated. Over a median follow‐up of 366 days, 15 (14.0%) patients had MACE. The incidence of MACE was significantly low in patients with L‐H/M improvement and/or high post‐TAVR L‐H/M (≥2.0). Baseline L‐H/M and frailty were associated with poor response of L‐H/M to TAVR treatment. TAVR‐related improvement in L‐H/M had significant effects on MACE, with an adjusted hazard ratio of 0.233 (95% confidence interval, 0.064–0.856; P = 0.028).

Conclusions

TAVR‐related improvement in L‐H/M was an independent predictor of cardiac events, 1 year after TAVR. Cardiac MIBG imaging is useful for predicting cardiac events after TAVR.

Prognostic value of cardiac 123I-metaiodobenzylguanidine imaging for predicting cardiac events after transcatheter aortic valve replacement

Background

In patients with aortic valve stenosis (AS), cardiac sympathetic nervous (CSN) dysfunction and its improvement after TAVR have been reported; however, the prognostic impact of CSN function remains unclear. This study investigated the prognostic value of cardiac 123I-metaiodobenzylguanidine (MIBG) imaging for the prediction of cardiac events after transcatheter aortic valve replacement (TAVR).

Methods

This study was a single-center prospective observational study that enrolled patients with AS or failed surgical bioprostheses between July 2017 and May 2019. MIBG scintigraphy was performed before and after TAVR to evaluate the delayed heart–mediastinum ratio (d-H/M). Patients were classified into three pairs of groups based on the baseline and post-TAVR d-H/M (≥2.0 or &lt;2.0) and on the presence of TAVR-related improvement of d-H/M. The study endpoints were major adverse cardiac events (MACE), including all-cause death, myocardial infarction, and hospitalization due to heart failure. The association of d-H/M with MACE following TAVR was based on a Cox proportional hazards ratio model adjusted for multiple prognostic variables.

Results

Of 187 consecutive patients who underwent TAVR, 111 (31 men; median age: 86 years) were evaluated. Over a median follow-up of 366 days, 16 (14.4%) patients had MACE. The incidence of MACE was significantly lower in patients with d-H/M improvement and/or the high post-TAVR d-H/M (≥2.0). Post-TAVR d-H/M had significant impacts on MACE, with an adjusted hazard ratio of 1.326 (95% confidence interval, 0.139–2.515; p=0.027).

Conclusions

Both d-H/M improvement and high post-TAVR d-H/M were associated with better prognosis in patients who underwent TAVR. Cardiac MIBG imaging was useful for predicting cardiac events after TAVR.

Funding Acknowledgement

Type of funding source: None

Comparative Analysis of the Paclitaxel-Eluting Peripheral Igaki-Tamai Stent and the Drug-Free Igaki-Tamai Stent Using Optical Coherence Tomography and Histological Analysis in a Porcine Iliac Artery Model

BACKGROUND

The combination of a bioresorbable scaffold and antiproliferative drugs is a promising treatment for peripheral artery disease. The novel paclitaxel-eluting peripheral Igaki-Tamai stent (PTX-ITS) has the same backbone design as the drug-free peripheral Igaki-Tamai stent and a paclitaxel coating. Arterial responses to the PTX-ITS and ITS using optical coherence tomography (OCT) and histological analysis in a porcine iliac artery model were compared.Methods and Results:In total, 6 PTX-ITSs and 6 ITSs implanted in porcine iliac arteries were evaluated. Quantitative measurements of the scaffold, lumen, neointimal areas, and percent area stenosis were performed using OCT at 1 and 3 months. Histological evaluations (PTX-ITS [n=5], ITS [n=4]) were performed following euthanasia at 3 months. Injury, inflammation, endothelialization, and fibrin scores were measured. Baseline angiographic characteristics were similar in both groups. The ITS group showed significantly smaller scaffold areas than the PTX-ITS group at 1 month (18.50±3.62 mm²vs. 23.54±3.64 mm²; P=0.037) and 3 months (15.82±2.57 mm²vs. 21.67±3.57 mm²; P=0.009). Percent area stenosis was significantly lower in the PTX-ITS group at 3 months (28.70±7.24% vs. 40.36±7.07%; P=0.018). Histological evaluations revealed similar low-grade inflammatory reactions for both scaffolds.

CONCLUSIONS

PTX-ITSs showed significantly better suppression of late scaffold shrinkage and lower in-scaffold stenosis for up to 3 months. Additionally, PTX-ITSs exhibited high biocompatibility, which is comparable to ITSs.

Primary Percutaneous Coronary Intervention Followed by Valve Surgery for Acute Coronary Syndrome at Left Main Trunk Complicated With Severe Aortic Stenosis

An 89-year-old woman appeared to have acute coronary syndrome at the left main trunk (LMT) complicated with severe aortic stenosis, moderate-severe mitral regurgitation, depressed left ventricular (LV) function, and multivessel disease. Because of sustained hypotension even under intra-aortic balloon pumping support during emergency coronary angiograhy, we performed primary percutaneous coronary intervention solely for the LMT lesion using a bare metal stent, leading to recovery from the shock state. On the second hospital day, based on our heart-team consensus, we performed aortic valve replacement and coronary artery bypass grafting surgery, and added edge-to-edge repair (Alfieri stitch) of the mitral valve, resulting in complete revascularization and dramatically improved LV function.