P102 NEW THREE–DIMENSIONAL ECHOCARDIOGRAPHIC PREDICTING PARAMETERS IN TRANS–VENTRICULAR HEART–BEATING MITRAL VALVE REPAIR WITH NEOCHORDAE: A MONOCENTRIC RETROSPECTIVE STUDY

Background

Trans–ventricular off pump mitral valve (MV) repair with neochordae implantation (Neochord procedure) is a minimally invasive surgical technique for correction of degenerative mitral regurgitation (MR) due to prolapse or flail. The aim of this study was to evaluate mid–term results of patients undergoing this procedure and find new three–dimensional pre–operative echocardiographic parameters to predict MR recurrence at follow–up.

Methods

We performed a retrospective analysis of 72 consecutive patients with severe MR due to prolapse or flail who underwent Neochord procedure at our hospital from March 2015 to February 2021. MV pre–operative anatomical parameters were assessed using 2D TEE, 3D TEE and dedicated three–dimensional (3D) post–processing analysis with dedicated software (QLAB, Philips). TTE follow–up and clinical evaluation were performed at 3 months, 6 months, 1 year and then annually.

Results

Twenty–seven patients were female (37.5%), mean age was 77±9 years. The average preoperative EuroSCORE II was 2.2%±1.5%. Twenty–three patients (32%) had an history of paroxysmal or persistent atrial fibrillation. Procedural success at discharge was achieved in sixty–eight patients (94.5%). Mean follow–up was 30±16 months. Three years follow–up was completed by fifty patients. At three years thirteen patients (26%) presented with recurrence of severe MR or underwent new surgical operation. Prevalence of mild or trace MR at three years follow–up visit was 70%. End–systolic annulus area (12.5±2.5 cm2 vs 14.1±2.6 cm2; p = 0.038), end–systolic annulus diameter (13.2±1.2 cm vs 14±1.3 cm; p = 0.042) and indexed left atrial volume (59±17 ml/m2 vs 76±37 ml/m2; p = 0.041) were lower in patients with residual MR less than moderate (MR < 3+/4+). Three–dimensional indexes specifically focused on coaptation reserve and annular disfunction were the best predictors of MR < 3+/4+ at follow–up, in particular diastolic sum of the leaflets/end–systolic annulus area ([AUC] 0.74; p = 0.029) and systo–diastolic annulus area fractional change ([AUC] 0.743; p = 0.035). Furthermore, each of these annular parameters, calculated using dedicated 3D software, were predictive of residual MR, whereas annular 2D dimensions were not (p = 0.347).

Conclusion

In patients with degenerative MR treated with Neochord procedure, 3D analysis focused on annular measures and coaptation indexes, that included 3D annular dimensions, predicts better MR relapse than conventional 2D parameters.

C40 THREE–DIMENSIONAL FINGER TEST: A NEW ECHOCARDIOGRAPHIC METHOD TO LOCATE THE BEST ACCESS SITE DURING NEOCHORD PROCEDURE

Background

The NeoChord procedure is a trans–ventricular, beating–heart chordal implantation for severe degenerative mitral valve regurgitation due to prolapse or flail leaflet and it is performed using a dedicated device (DS 1000 system, NeoChord, Inc. St. Louis Park, MN). The use of the transesophageal echocardiography (TEE) is crucial to guide the procedure. Bi–dimensional (2D) imaging completed with simultaneous biplane view during surgeon finger pushing on the LV wall (finger test) is currently used to choose the LV access, which is usually on the mid–distal infero–lateral wall (ILW), between the papillary muscles (PMs) at the inferior level of their insertion on LV wall. This simulation helps the operators to evaluate the safe distance to PMs to minimize the risk of damaging the sub–valvular apparatus during the insertion of the device. We aimed to compare a new 3D method with the conventional one in terms of safety and better localization of the desired entry site.

Methods

During the procedure finger test has been performed with conventional 2D imaging and simultaneous biplane method. It has been completed using the real time 3D TEE placing the sample box in the bi–commissural view of the LV including the PMs and the apex. The resulting 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator finger pushing on the desired segment of the LV wall. We asked the first operator, the second operator and the cardiac surgery fellow, separately, to evaluate location of their finger pushing, in terms of desired position and safety of access, both with 2D method and the 3D method to estimate the inter–operator concordance.

Results

From March 2019 to September 2021 42 consecutive cases have been performed using finger test completed with 3D method without complications related to the trans–ventricular access. Regarding the choice of the right and safe entry site, the percentage of agreement between operators was higher using LV real time 3D rendering compared to the conventional finger test [82 + 21% Vs 59% + 29%, IC 95%, p: 0,04].

Conclusion

Three–dimensional finger test is easy to perform and decreases inter–operator variability of image interpretation facilitating the surgeons to choose the best entry site in term of anatomical localization and safety.

Valve-in-valve transcatheter aortic valve replacement or re-surgical aortic valve replacement in degenerated bioprostheses: a systematic review and meta-analysis of short and mid-term results

Introduction

Despite limited to short and mid-term outcomes, Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a less invasive alternative to redo surgery for high and intermediate-risk patients with good outcomes across different surgical risk profiles.

Purpose

The aim of the resent meta-analysis is to compare short and mid-term outcomes of VIV and surgical redo fo patients with a degenerative aortic bioprosthesis.

Methods

All studies comparing with multivariate adjustment between ViV TAVI and re-SAVR were screened. All-cause mortality at 30-day and at follow-up were the primary endpoints, while Valve Academy research Consortium (VARC) endpoints at 30 days including stroke, myocardial infarction (MI), major vascular complications, major bleeding, new onset atrial fibrillation (AF) and permanent pacemaker implantation (PPI) during the index hospitalization were the secondary endpoints. Subgroup analysis were performed according to the surgical risk. All the analyses were stratified according to the design of the study (observational vs propensity-matched study).

Results

We obtained data from 11 studies, encompassing 8570 patients, 4224 undergoing ViV TAVI and 4346 re-SAVR. Four studies included intermediate-risk patients and seven high-risk patients. Mean age was 76 and 71.5 years in the ViV and re-SAVR group respectively, with a 60.2% and 61.3% of male. For the ViV procedure, BE prostheses were used in the 49.6% of patients and SE prostheses in the 45.8%. The ViV group have higher prevalence of previous CAD (53.8% vs 41.1%) and CABG (35% vs 23.6%) and more history of HF (72.1% vs 65.6%), CKD (26.6% vs 14.8%) and COPD (25.4 vs 14.8%). 30-day all-cause and CV mortality were significantly lower in ViV (OR 0.43, 0.29–0.64 and OR 0.44, 0.26–0.73 respectively), while after a mean follow-up of 717 (180–1825) days, there were no difference between the two groups (OR 1.04, 0.87–1.25 and OR 1.05, 0.78–1.43 respectively). The result were consistent both in intermediate and high-risk classes. The risk of stroke (OR 1.03, 0.59–1.82), MI (OR 0.70, 0.34–1.44), major vascular complications (OR 0.92, 0.50–1.67) and permanent pacemaker implantation (OR 0.67, 0.36–1.25) at 30 days did not differ, while major bleedings and new onset atrial fibrillation were significantly lower in ViV patients (OR 0.41, 0.25–0.67 and OR 0.23, 0.12–0.42 respectively, all CI 95%).

Conclusions

In patients with a degenerated aortic bioprosthesis, ViV TAVI is associated with better short-term outcomes, including all-cause mortality, without any difference in all-cause and cardiovascular mortality at mid-term follow-up compared to surgical redo.

Funding Acknowledgement

Type of funding sources: None.

Fractional flow reserve (FFR) guided vs angiography guided coronary artery bypass graft (CABG): a systematic review and meta-analysis

Background

A strategy of percutaneous coronary intervention (PCI) driven by FFR (Fractional Flow Reserve) has demonstrated to reduce adverse events through the “deferring” of unnecessary stenting procedures compared to PCI guided by angiographic evaluation of stenosis. Coronary Artery Bypass Graft (CABG) represents another option for revascularization, being superior to PCI in patients with diffuse disease. In this setting, some evidence has been provided about physiological driven CABG procedures, but studies reported contrasting results regarding clinical benefits and outcomes at follow up.

The aim of this meta-analysis is to evaluate clinical and procedural impact of FFR versus angiographic guided surgical revascularization and assess outcomes at follow up.

Methods

All randomized controlled trials (RCTs) or observational studies with multivariable adjustment or propensity matching were included. MACE (Major Adverse Cardiac Events) was the primary end point, while its single components (death, myocardial infarction and revascularization) along with number of grafts and percent of off-pump CABG were the secondary ones. Of 86 studies identified, 4 articles were included in this review, representing a combined total of 777 patients (426 angio-guided and 351 FFR-guided). Mean age was 66±2.1, 80% man, 74% hypertension, 71% hyperlipidemia, 33% diabetes, 39% smokers. Mean EuroSCORE I was 2.7. 18% a prior MI, and 25% a prior PCI. Coronary lesions were allocated as follow: 36% left anterior descending artery, 32% circumflex artery, 27% right coronary artery. Mean follow up was 30 months. At the follow up, rates of MACE did not differ (MACE OR 1.31:0.88–1.96), as those of death (OR 1.47:0.86–2.51), of MI (OR 1.80:0.89–3.63), and of target vessel revascularization (1.03: 0.54–1.97.). FFR-guided CABG was associated with more off-pump surgical procedure (OR 0.58, IC 0.34–0.97) and shorter hospitalization time (8.2±2.49 vs 8,87±3,25 p<0.01). FFR- guided CABG was associated more frequently with off-pump surgical procedure (OR 0.58:0.34–0.97) with fewer anastomes (2.5 vs 3), leading to higher rates of global arteria revascularization in FFR group (56% vs. 45%) and higher rates of venous grafts in angio-guided group (55% vs. 44%). Shorter hospitalization time was recorded in FFR patients (8.2±2.49 vs 8,87±3,25 days, p<0.01). Graft patency at follow up was not statistically higher in the FFR guided group (OR 0.67, CI 95% 0.32–1,39, all CI 95%).

Conclusions

FFR-guided surgical revascularization is associated with more off-pump procedures, a lower number of surgical anastomoses and more arterial grafts compared to angiography guided CABG. These differences lead to a shorter hospitalization time in the FFR-guided group compared to the angiography-guided group. No difference between two groups in MACE, overall death and MI was observed during the follow up. RCT with longer follow up are needed to evaluate long term outcomes.

Funding Acknowledgement

Type of funding source: None

Percutaneous vs. surgical revascularization for patients with unprotected left main stenosis: a meta-analysis of 5 years follow-up RCTs

Introduction

5-year survival of patients with ULM (Unprotected Left Main) stenosis according to the choice of revascularization (percutaneous vs. surgical) remains to be defined.

Methods and results

Randomized Controlled Trials (RTCs) comparing Percutaneous Coronary Intervention (PCI) vs. Coronary Artery Bypass Graft (CABG) with a follow-up of at least 5 years were included. All-cause death was the primary endpoint. MACCE (a composite endpoint of all-cause mortality, myocardial infarction [MI], stroke and repeat revascularization) along with its single components and cardiovascular (CV) death were the secondary ones. Analyses were stratified according to use of first vs. last generation coronary stents. Subgroup comparisons were performed according to Syntax Score (below or above 33) and to age (using cutoffs of each trial's subgroup analysis). 4 RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation and 1540 with last generation stents. At 5 years rates of all-cause death did not differ (OR 0.93: 0.71–1.21), as those of CV death and stroke. CABG reduced rates of MACCE (OR 0.69: 0.60–0.79), mainly driven by MI (OR 0.48: 0.36–0.65) and revascularization (OR 0.53: 0.45–0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of Syntax Score (OR 0.76: 0.59–0.97 for values <32 and OR 0.63: 0.47–0.84 for values ≥33) while was not evident for “younger” patients (OR 0.83: 0.65–1.07 vs. OR 0.65: 0.51–0.84 for “older” patients, all CI 95%).

Conclusion

For patients with ULM disease, PCI and CABG yielded same survival benefit at 5 years. CABG reduced risk of MI, revascularization and MACCE especially in older patients and in those with diffuse coronary disease.

Funding Acknowledgement

Type of funding source: None

Incidence, predictors and outcomes of Valve-in-valve (ViV) Transcatheter aortic valve replacement (TAVR): a systematic review and meta-analysis

Background

Surgical aortic valve replacement has been the treatment of choice for patients with aortic valve disease before the arrival of transcatheter aortic valve replacement (TAVI), although limited by degeneration of the bioprosthesis. “Redo” intervention itself is burdened by high risk of complications and valve-in-valve (ViV) TAVI could be a valid strategy of redo for patients with comorbidities. The aim of this meta-analysis is to give an overview of the state of the art of ViV TAVI in high-risk patients, analyzing efficacy, safety, intra-hospital outcomes and 1-year outcomes and assess predictors of survival at short and mid-term follow up.

Methods

Two independent reviewers screened all studies investigating patients undergoing ViV TAVI. PubMed database was searched for reports published in English according to the following highly sensitive strategy: (Transcatheter[All Fields] AND “aortic”[All Fields]) AND valve-in-valve[All Fields] AND “implantation”[All Fields] NOT (review[pt] OR editorial[pt] OR letter[pt])AND “humans”[MeSH Terms]). Mortality at 30 days and at 1 year were the primary end point, while procedural and short-term outcomes and echocardiographic parameters at hospital discharge were the secondary end points.

Results

Of 286 studies identified, 26 articles were included, with a total of 1448 patients. Median age was 78.8 years, 57.7% of the patients were male. Median STS-predicted risk of mortality was 9.4% while median Logistic EuroSCORE was 31.3%. Median age of bioprosthesis was 10 years with 84.6% of stented valves. Stenosis (45%), followed by regurgitation (31%) and mixed defects (21%) were the causes of prosthesis failure. Diameter of the degenerated valve was ≤21 mm in 25.4%, 22–25 mm in 55% and >25mm in 11.7% of the patients. Transfemoral approach was preferred (76%), with a prevalence of balloon expandable valve (73.3%). Mean post procedural gradient was 16.7±0.8 mmHg. Mean follow up was 376 days. Overall and cardiovascular mortality at 30 days was 6.5% and 5.5% respectively, while at 1 year it was 14.5% and 8.9% respectively. Regarding short-term outcomes, overall bleeding (10.4%), pacemaker implantation (9.4%) and vascular complications (8.3%) were the most common peri-procedural complications, while stroke (2.3%), myocardial infarction (2.7%) and coronary obstruction (2.8%) were less frequent. At meta-regression analysis study year (p<0.001), Logistic Euroscore (p<0.01) and valve diameter ≤21 mm (p<0.05) at 30 days, and stenosis as reason for failure (p=0.05) at 1 year were identified as possible predictors of survival.

Conclusions

Percutaneous valve-in-valve aortic valve implantation offers a valid strategy to treat high risk patients with a degenerative bioprosthesis. Short and mid-term outcomes are substantially superimposable to those of TAVI, except for coronary obstruction which appears more frequent. Future studies are needed to find predictors of long- term survival and outcomes in lower risk patients.

Outcome of VIV TAVI

Funding Acknowledgement

Type of funding source: None

P513Electrocardiographic and clinical predictors for permanent pacemaker requirement after transcatheter aortic valve implantation: a 10-year single center experience

Funding Acknowledgements

None of the author have conflict of interest to disclose.

Background

 As transcatheter aortic-valve implantation (TAVI) procedures have increased, the need of a permanent pacemaker (PPM) is a complication to be taken into account. 

Objective

 The aim of this study is to identify clinical, electrocardiographic (ECG) and procedural predictors for PPM requirement after TAVI.

Methods

 The present is a single centre, retrospective study. All consecutive patients with severe symptomatic aortic stenosis who underwent TAVI had continuous ECG monitoring. Pre and post TAVI 12-leads ECG were analysed. We arbitrarily divided the patients into early and late PPM implantation (beyond the 3rd day after TAVI). The primary endpoint of the study was to identify electrocardiographic predictors of PPM implantation after TAVI, and the secondary endpoint was to identify other clinical or procedure-related predictive factors.

Results

 Of 431 patients who underwent TAVI, 77 (18%) required a PPM, and 30 (7%) had late PPM implantations. Pre-operative RBBB implies more than five-fold increase of the risk of PPM implantation after TAVI (OR 5,43, CI 2.11 - 13.99, P = 0.000), whereas the history of syncope is associated with a two-fold increase of the risk (OR 2.00, CI 1.01 - 3.96, P = 0.044), and maintains its predictive value also in the late PPM subgroup (OR 2.76, CI 1.11 – 6.82, P = 0.028).

Conclusions

 It is hard to predict the need of a PPM in the individual patients, but careful evaluation of pre-operative 12-lead ECG looking for pre-existing RBBB and an history of syncope, can individuate the group of patients with an increased risk of PPM requirement.

P1412 A new light to improve the view of the anatomical details during micro-invasive trans-ventricular repair of degenerative prolapse of mitral valve

BACKGROUND

Mitral valve repair is the preferred surgical treatment for severe mitral regurgitation due to degenerative leaflet prolapse. Within the growing era of transcatheter treatments for valvular heart disease, an innovative micro-invasive trans-ventricular beating-heart procedure was developed. Three-dimensional (3D) transoesophageal echocardiographic guidance is crucial to assist the operator in instrument navigation and chords positioning. 3D ultrasound technology is constantly evolving and a special light, that can be mobilized within the 3D images, has recently been invented. This light allows to illuminate the structures from different points of view and increase the definition of the anatomical details.

PURPOSE

To show the advantages of this new 3D image analysis technology, described above, through a sequence of intra-procedural images of a mitral valve repair by trans-ventricular polytetrafluoroethylene (ePTFE) chords implantation.

METHODS

The procedure is performed using a device that is introduced through a posterolateral ventriculotomy and it is advanced towards the mitral valve under real-time 3D transoesophageal guidance. The prolapsing segment, in this case central part of posterior leaflet (Fig. 1 A, B and C), is grasped with the jaw of the instrument (J in Fig. 1D), then the chords are implanted, tensioned and secured outside the ventricle. Figure 1A shows the pre-operative image of posterior leaflet prolapse with flail (P2 segment) and the light illuminates the valve from above. The broken chords (arrow in Fig. 1A) can be recognized with high definition. The light can also be placed on the valve plane (Fig. 1B) or below (Fig. 1C). When illumination occurs from the left ventricular side, the coaptation loss due to the P2 flail is highlighted (arrow in Fig. 1C). After placement, tensioning and securing the chords outside the ventricle, the prolapse disappears and the correct coaptation is re-established (Fig. 1E). The coaptation deficit is no longer visible, even with the light placed below the valve and it is possible to see the light coming out of the aortic valve (Ao), opened in systole, with mitral valve closed (Fig. 1F).

RESULTS

At the end of the procedure the residual mitral regurgitation was trivial and no loss of coaptation can be evidenced even with the light placed in the left ventricle (Fig. 1F).

CONCLUSIONS

This new light allows to improve the anatomical definition of 3D echocardiographic images, allows better visualization of the coaptation defects and can be used as a further verification of the result especially in cases of micro-invasive mitral repair.

Abstract P1412 Figure 1

P951 Intraprocedural echocardiographic technique to locate the insertion points of artificial chordae during transventricular beating heart mitral valve repair: ultrasound ""starry sky""

BACKGROUND

Mitral valve repair is the preferred surgical treatment for severe mitral regurgitation due to degenerative leaflet prolapse. Within the growing era of transcatheter treatments for valvular heart disease, an innovative micro-invasive trans-ventricular beating-heart procedure was developed. Three-dimensional transoesophageal echocardiographic guidance is crucial to assist the operator in instrument navigation and chords positioning. Indeed, it is important an equidistant chords placement on the leaflet to ensure a uniform force distribution on the prolapsing segment and to avoid damaging of the previously inserted chords.

PURPOSE

To propose an intraoperative three-dimensional echocardiographic technique that allows operators to see the exact location of the polytetrafluoroethylene (ePTFE) chords used for the mitral repair.

METHODS

The procedure is performed using a device that is introduced through a posterolateral ventriculotomy and it is advanced towards the mitral valve under real-time 3D transoesophageal guidance. The prolapsing segments are grasped with the jaw of the instrument and the chords are implanted to achieve the proper distribution of forces and then tensioned and secured outside the ventricle.

The proposed technique exploits the greater echogenicity of the artificial chord loop compared to native chords and leaflets. By lowering of the gains, remaining in the three-dimensional mitral valve surgical view, the signals of the native structures are attenuated, the underlying ventricular cavity appears black and the insertion points are visible as an intense signal on the virtual free edge of the leaflet treated.

Figure 1 shows the intraoperative sequence of images of a case performed at our centre. The images were acquired using real time single beat three-dimensional reconstruction. Figure 1A shows the surgical view of the native valve with prolapse of the P2-P3 scallops. Image 1B reveals the prolapsing leaflet grasping and device location. After gain lowering, it’s possible to see the intense signal of the positioned artificial chord (Figure 1C). It can also be noted how this position matches with the position of the device at the time of grasping. Image 1D shows the partial disappearance of the prolapse during the tensioning test after the positioning of a second chord in a more medial position. Figure 1E shows the correct position of the ePTFE chords. We can notice the second chord placed in a medial position from the first one. This view, with dark ventricular chamber and intense signals of chordae loops, looks like a "STARRY SKY".

RESULTS

This technique allows to locate the correct insertion points of the artificial chords during the procedure.

CONCLUSIONS

This is a simple technique to guide operators during trans-ventricular beating heart mitral valve repair with ePTFE chords.

Abstract P951 Figure 1

P1789Outcomes of different approaches for severe aortic stenosis: “"The Deferred-TAVI”, a multicentre study investigating medical and percutaneous therapy in the era of TAVI

Background

In the era of TAVI, also very high surgical risk patients can be treated and the importance of the Heart Team is to address the patient to the right therapy. In some cases due to comorbidities, lack of symptoms and patients' decision not always a final decision is achieved after the first clinical evaluation and the final strategy could be deferred for months.

Purpose

The study aims to analyze outcomes in patients with severe aortic stenosis differently treated according to the various approaches proposed by the Heart Team.

Methods

All the patients with a diagnosis of severe aortic stenosis considered at high and very high surgical risk were enrolled. Three international cardiology departments participated in this multicentre study. All the patients were divided into four groups according to the Heart Team decision of approach. Patients with indication to medical therapy only (DTO Drug therapy only), Patients first deferred from heart team decision, personal reasons or lack of symptoms and then addressed to medical therapy (D-DTO Deferred-Drug therapy only), Patients deferred and then addressed to TAVI within 3 months (D-TP Deferred TAVI Procedure), Patients with direct indication to TAVI (ITP Immediate TAVI procedure). Primary endpoint were overall survive at follow up comparing the differences between the four groups and the impact of the deferred strategy.

Results

795 patients were enrolled (80 DTO, 451 ITP, 264 initially deferred and then 155 D-DTO and 109 D-TP). Median follow-up was 465 days. Overall survive of the four groups at 1 year was 74% DTO, 73% D-DTO, 77% D-TP and 78% ITP, at 2 years 62% DTO, 38% D-DTO, 62% D-TP and 68% ITP, at 3 years 39% DTO, 11% D-DTO, 25% D-TP and 56% ITP (p≤0,001 at log rank test). At the multivariate analysis, compared to the referral group DTO, D-DTO was associated with higher mortality (HR=1,90; IC [95%]: 1,05–3,58; p=0,03 at 2 years; HR 1,66; IC [95%]: 1,01–2,76; p<0,05, at 3 years), while D-TP was not associated with lower mortality risk (HR 1,31 IC [95%]: 0,62–2,76; p=0,72 at 2 years, HR 1,37 IC [95%]: 0,77–2,44; p=0,77 at 3 years). ITP was associated with lower mortality risk only at 3 years (HR 0,60; IC [95%]: 0,42–0,99; p<0.05). Comparing the group deferred (D-DTO and D-TP) to the group not deferred (DTO and ITP), the deferred group was associated with higher mortality risk (HR 1,86; IC [95%]: 1,30–2.65; p=0,001 at 2 years, HR 2,21; IC [95%]: 1,61–3,05; p<0,001 at 3 years).

Conclusions

The Heart team decision on the approach of treatment strongly influence the survive of the patient. Compared to direct medical therapy, there is a higher risk of mortality for patients initially deferred and then treated with medical therapy and there is no survival benefit for patients initially deferred and then treated with TAVI. The choice of deferring the treatment of patients with severe aortic stenosis clearly decrease long term survive at follow up regardless the strategy of the approach.